Perineural injection therapy with 5% dextrose water is progressively becoming a mainstream method for treating carpal tunnel syndrome. However, its long-term outcome is still unknown. Hence, the ...purpose of this retrospective study was to investigate the long-term outcome after perineural injection therapy using 5% dextrose water.
A total of 185 patients diagnosed with carpel tunnel syndrome at least 1 year post-therapy were enrolled. All the patients underwent ultrasound-guided perineural injection therapy using 10 ml of 5% dextrose water at the outpatient department. In a structured telephone interview, the patients were asked about the outcome post-therapy compared with pre-injection. A symptom relief ≥50% indicated effective outcome, and a symptom relief <50% was indicative of a poor outcome.
In total, 88.6% patients reported an effective outcome, and 11.4% rated the outcome as poor, after a mean of 2.2 injections with a mean of 1-3 years' post-injection follow-up. The outcome was significantly related with severity level, and the patients that reported a poor outcome had a significantly higher incidence of severe grade compared with those who reported an effective outcome (52.4% vs 31.7%, P = 0.03). Patients with mild, moderate and severe grades, respectively, required an average of 1.7 (0.1), 2.4 (0.2) and 2.6 (0.3) injections to reach an effective outcome (P = 0.006) (severe vs mild, P = 0.008; moderate vs mild, P = 0.062).
Perineural injection therapy is a novel approach for treatment of carpal tunnel syndrome with safe and outstanding long-term effects.
Patient-reported outcome measures (PROMs) are frequently used to assess treatment outcomes for hand and wrist conditions. To adequately interpret these outcomes, it is important to determine whether ...a statistically significant change is also clinically relevant. For this purpose, the minimally important change (MIC) was developed, representing the minimal within-person change in outcome that patients perceive as a beneficial treatment effect. Prior studies demonstrated substantial differences in MICs between condition-treatment combinations, suggesting that MICs are context-specific and cannot be reliably generalized. Hence, a study providing MICs for a wide diversity of condition-treatment combinations for hand and wrist conditions will contribute to more accurate treatment evaluations.
(1) What are the MICs of the most frequently used PROMs for common condition-treatment combinations of hand and wrist conditions? (2) Do MICs vary based on the invasiveness of the treatment (nonsurgical treatment or surgical treatment)?
This study is based on data from a longitudinally maintained database of patients with hand and wrist conditions treated in one of 26 outpatient clinics in the Netherlands between November 2013 and November 2020. Patients were invited to complete several validated PROMs before treatment and at final follow-up. All patients were invited to complete the VAS for pain and hand function. Depending on the condition, patients were also invited to complete the Michigan Hand outcomes Questionnaire (MHQ) (finger and thumb conditions), the Patient-rated Wrist/Hand Evaluation (PRWHE) (wrist conditions), or the Boston Carpal Tunnel Questionnaire (BCTQ) (nerve conditions). Additionally, patients completed the validated Satisfaction with Treatment Result Questionnaire at final follow-up. Final follow-up timepoints were 3 months for nonsurgical and minor surgical treatment (including trigger finger release) and 12 months for major surgical treatment (such as trapeziectomy). Our database included 55,651 patients, of whom we excluded 1528 who only required diagnostic management, 25,099 patients who did not complete the Satisfaction with Treatment Result Questionnaire, 3509 patients with missing data in the PROM of interest at baseline or follow-up, and 1766 patients who were part of condition-treatment combinations with less than 100 patients. The final sample represented 43% (23,749) of all patients and consisted of 36 condition-treatment combinations. In this final sample, 26% (6179) of patients were managed nonsurgically and 74% (17,570) were managed surgically. Patients had a mean ± SD age of 55 ± 14 years, and 66% (15,593) of patients were women. To estimate the MIC, we used two anchor-based methods (the anchor mean change and the MIC predict method), which were triangulated afterward to obtain a single MIC. Applying this method, we calculated the MIC for 36 condition-treatment combinations, comprising 22 different conditions, and calculated the MIC for combined nonsurgical and surgical treatment groups. To examine whether the MIC differs between nonsurgical and surgical treatments, we performed a Wilcoxon signed rank test to compare the MICs of all PROM scores between nonsurgical and surgical treatment.
We found a large variation in triangulated MICs between the condition-treatment combinations. For example, for nonsurgical treatment of hand OA, the MICs of VAS pain during load clustered around 10 (interquartile range 8 to 11), for wrist osteotomy/carpectomy it was around 25 (IQR 24 to 27), and for nerve decompression it was 21. Additionally, the MICs of the MHQ total score ranged from 4 (nonsurgical treatment of CMC1 OA) to 15 (trapeziectomy with LRTI and bone tunnel), for the PRWHE total score it ranged from 2 (nonsurgical treatment of STT OA) to 29 (release of first extensor compartment), and for the BCTQ Symptom Severity Scale it ranged from 0.44 (nonsurgical treatment of carpal tunnel syndrome) to 0.87 (carpal tunnel release). An overview of all MIC values is available in a freely available online application at: https://analyse.equipezorgbedrijven.nl/shiny/mic-per-treatment/. In the combined treatment groups, the triangulated MIC values were lower for nonsurgical treatment than for surgical treatment (p < 0.001). The MICs for nonsurgical treatment can be approximated to be one-ninth (IQR 0.08 to 0.13) of the scale (approximately 11 on a 100-point instrument), and surgical treatment had MICs that were approximately one-fifth (IQR 0.14 to 0.24) of the scale (approximately 19 on a 100-point instrument).
MICs vary between condition-treatment combinations and differ depending on the invasiveness of the intervention. Patients receiving a more invasive treatment have higher treatment expectations, may experience more discomfort from their treatment, or may feel that the investment of undergoing a more invasive treatment should yield greater improvement, leading to a different perception of what constitutes a beneficial treatment effect.
Our findings indicate that the MIC is context-specific and may be misleading if applied inappropriately. Implementation of these condition-specific and treatment-specific MICs in clinical research allows for a better study design and to achieve more accurate treatment evaluations. Consequently, this could aid clinicians in better informing patients about the expected treatment results and facilitate shared decision-making in clinical practice. Future studies may focus on adaptive techniques to achieve individualized MICs, which may ultimately aid clinicians in selecting the optimal treatment for individual patients.
Carpal tunnel syndrome, the most common entrapment neuropathy of the upper extremity, is caused by compression of the median nerve as it travels through the carpal tunnel. Classically, patients with ...the condition experience pain and paresthesias in the distribution of the median nerve, which includes the palmar aspect of the thumb, index and middle fingers, and radial half of the ring finger. Additional clues include positive physical examination findings, such as the flick sign, Phalen maneuver, and median nerve compression test. Although patients with typical symptoms and signs of carpal tunnel syndrome do not need additional testing, ultrasonography and electrodiagnostic studies are useful to confirm the diagnosis in atypical cases and rule out other causes. If surgical decompression is planned, electrodiagnostic studies should be obtained to determine severity and surgical prognosis. Conservative treatment may be offered initially to patients with mild to moderate carpal tunnel syndrome. Options include splinting, corticosteroids, physical therapy, therapeutic ultrasound, and yoga. Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are not effective therapies. Local corticosteroid injection can provide relief for more than one month and delay the need for surgery at one year. Patients with severe carpal tunnel syndrome or whose symptoms have not improved after four to six months of conservative therapy should be offered surgical decompression. Endoscopic and open techniques are equally effective, but patients return to work an average of one week earlier with endoscopic repair.
Background
The aim of the present study was to investigate the correlation of the neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio with the severity of idiopathic carpal tunnel ...syndrome (CTS).
Methods
A total of 407 patients with idiopathic CTS (neurophysiologically 150 mild, 144 moderate, and 113 severe) and 206 subjects without CTS were included (control group).
Results
There was a positive correlation between the severity of CTS and NLR (r = 0.224; P < 0.001), age (r = 0.333; P < 0.001), and body mass index (r = 0.251; P < 0.001). A 1‐unit increase in NLR level was associated with an approximately 1.7‐fold higher incidence of CTS (P = 0.002; odds ratio = 1.668; 95% confidence interval = 1.199‐2.319).
Conclusions
Our results suggest that neurophysiologically more severe CTS is associated with higher NLR levels. The role of systemic inflammation in CTS should be investigated in further studies.
Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder worldwide. The epidemiology and risk factors, including family burden, for developing CTS are multi-factorial. Despite much ...research, its intricate pathophysiological mechanism(s) are not fully understood. An underlying subclinical neuropathy may indicate an increased susceptibility to developing CTS. Although surgery is often performed for CTS, clear international guidelines to indicate when to perform non-surgical or surgical treatment, based on stage and severity of CTS, remain to be elucidated. Neurophysiological examination, using electrophysiology or ultrasonography, performed in certain circumstances, should correlate with the history and findings in clinical examination of the person with CTS. History and clinical examination are particularly relevant globally owing to lack of other equipment. Various instruments are used to assess CTS and treatment outcomes as well as the effect of the disorder on quality of life. The surgical treatment options of CTS - open or endoscopic - offer an effective solution to mitigate functional impairments and pain. However, there are risks of post-operative persistent or recurrent symptoms, requiring meticulous diagnostic re-evaluation before any additional surgery. Health-care professionals should have increased awareness about CTS and all its implications. Future considerations of CTS include use of linked national registries to understand risk factors, explore possible screening methods, and evaluate diagnosis and treatment with a broader perspective beyond surgery, including psychological well-being.
Carpal tunnel syndrome (CTS) is the most common compressive neuropathy. Patients who have unilateral symptoms are frequently found to have bilateral CTS by electrodiagnostic (EDx) study. We aimed to ...(a) study the prevalence and identify the predictive factors for bilateral CTS diagnosed by EDx; and (b) develop a model to predict bilateral CTS.
The retrospective clinical and EDx data of patients with CTS were collected and analyzed using the Chi-squared test and multiple logistic regression analysis. A model was fitted, and the best cutoff point determined. Calibration and discrimination performance of the model were performed.
A total of 327 patients with a mean age of 50.0 years were enrolled. Most were women (82.6%), and the most common presenting symptom was hand numbness (93.6%). The median duration of symptoms was 60 days. The prevalence of bilateral CTS was 80.7%. In the multivariate analysis, the predictive factors for bilateral CTS were the presence of bilateral symptoms (AOR 6.7 95%CI 3.1-14.3), thenar muscle weakness (AOR 3.9 95%CI 1.3-11.6), and age ≥ 45 years (AOR 2.5 95%CI 1.3-4.6). The logistic regression model was fitted, and the best cutoff point determined. The area under the receiver operating curve (AUC) was 0.76. The respective optimism-corrected C index and Somers' D was 0.762 and 0.524.
The prevalence of bilateral CTS was 80.7%. Our findings suggest bilateral CTS was predicted with adequate diagnostic accuracy by bilateral symptoms, age ≥ 45 years, and thenar muscle weakness.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Introduction: The purpose of this study was to develop an evidence‐based guideline for the use of neuromuscular ultrasound in the diagnosis of carpal tunnel syndrome (CTS). Methods: Two questions ...were asked: (1) What is the accuracy of median nerve cross‐sectional area enlargement as measured with ultrasound for the diagnosis of CTS? (2) What added value, if any, does neuromuscular ultrasound provide over electrodiagnostic studies alone for the diagnosis of CTS? A systematic review was performed, and studies were classified according to American Academy of Neurology criteria for rating articles of diagnostic accuracy (question 1) and for screening articles (question 2). Results: Neuromuscular ultrasound measurement of median nerve cross‐sectional area at the wrist is accurate and may be offered as a diagnostic test for CTS (Level A). Neuromuscular ultrasound probably adds value to electrodiagnostic studies when diagnosing CTS and should be considered in screening for structural abnormalities at the wrist in those with CTS (Level B). Muscle Nerve 46: 287–293, 2012
Depression and pain catastrophizing are aspects of the patient's mindset that have been shown to be important in relation to the outcome of carpal tunnel release. However, other factors of the ...patient's mindset have been understudied, such as treatment expectations and illness perceptions. The aim of the present study was to investigate the influence of these mindset aspects on outcome of carpal tunnel release, in addition to psychological distress and pain catastrophizing.
A total of 307 patients with carpal tunnel syndrome who visited outpatient hand surgery clinics and who completed online questionnaires regarding demographic and psychosocial characteristics and carpal tunnel syndrome severity were included. The patient mindset was measured with the Patient Health Questionnaire-4, the Pain Catastrophizing Scale, the Credibility Expectancy Questionnaire, and the Brief Illness Perception Questionnaire. Hierarchical linear regression models were used to examine the relation between self-reported severity 6 months after carpal tunnel release, as measured with the Boston Carpal Tunnel Questionnaire, and psychosocial aspects of mindset, adjusting for preoperative Boston Carpal Tunnel Questionnaire score, patient characteristics, and comorbidities.
Independent associations with better self-reported outcome were found for higher treatment expectations (β = -0.202; p < 0.001) and illness comprehensibility (β = -0.223; p < 0.001). The additional explained variance in Boston Carpal Tunnel Questionnaire scores by the patient's mindset was 13.2 percent (psychological distress and pain catastrophizing together, 2.1 percent; treatment expectations and illness perceptions together, 11.1 percent).
Treatment outcome expectations and comprehensibility of illness are both independently associated with the outcome of carpal tunnel release, showing the importance of these aspects of the patient's mindset for the outcome of carpal tunnel release.
Risk, III.
Although carpal tunnel syndrome (CTS) is the most common form of peripheral entrapment neuropathy, its pathogenesis remains largely unknown. An estimated heritability index of 0.46 and an increased ...familial occurrence indicate that genetic factors must play a role in the pathogenesis.
We report on a family in which CTS occurred in subsequent generations at an unusually young age. Additional clinical features included brachydactyly and short Achilles tendons resulting in toe walking in childhood. Using exome sequencing, we identified a heterozygous variant (c.5009T>G; p.Phe1670Cys) in the fibrillin-2 (
) gene that co-segregated with the phenotype in the family. Functional assays showed that the missense variant impaired integrin-mediated cell adhesion and migration. Moreover, we observed an increased transforming growth factor-β signalling and fibrosis in the carpal tissues of affected individuals. A variant burden test in a large cohort of patients with CTS revealed a significantly increased frequency of rare (6.7% vs 2.5%-3.4%, p<0.001) and high-impact (6.9% vs 2.7%, p<0.001)
variants in patient alleles compared with controls.
The identification of a novel
variant (p.Phe1670Cys) in a unique family with early onset CTS, together with the observed increased frequency of rare and high-impact
variants in patients with sporadic CTS, strongly suggest a role of
in the pathogenesis of CTS.
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