ABSTRACT
Introduction: We estimated the lifetime prevalence and incidence of carpal tunnel release (CTR) and identified risk factors for CTR. Methods: The study population consisted of individuals ...aged ≥30 years living in Finland during 2000–2001 (N = 6,256) and was linked to the Finnish Hospital Discharge Register from 2000 to 2011. Results: Lifetime prevalence of CTR was 3.1%, and incidence rate was 1.73 per 1,000 person‐years. Female sex (adjusted hazard ratio HR = 1.8, 95% confidence interval CI 1.2–2.8), age of 40–49 years (HR = 2.5, CI 1.7–3.8 compared with other age groups), education (HR = 0.6, CI 0.4–0.9 for high level vs. low/medium level), obesity (HR = 1.7, CI 1.2–2.5 for body mass index ≥30 vs. < 30 kg/m2), and hand osteoarthritis (HR = 2.4, CI 1.4–3.9) were associated with incidence of CTR. Discussion: CTR is a common surgical procedure, performed on 1.9% of men and 4.1% of women during their lifetimes. Obesity and hand osteoarthritis are associated with an increased risk of CTR. Muscle Nerve 58: 497–502, 2018
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.
Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of ...illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity.
What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale?
One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings.
After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 95% confidence interval 7.7 to 15), longer duration of symptom episodes (OR 4.5 95% CI 3.3 to 6.2), nocturnal numbness in spite of splint immobilization (OR 3.2 95% CI 2.3 to 4.3), constant numbness (OR 2.5 95% CI 1.9 to 3.4), positive Tinel and positive Phalen test results (OR 2.2 95% CI 1.6 to 2.9), and older age (OR 1.6 95% CI 1.2 to 2.1).
Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability.
Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability.
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
Purpose
Regarding surgical indications for carpal tunnel syndrome (CTS), the hypothesis that the recovery processes of subjective symptoms differ among pain, sensory, and motor symptoms and correlate ...with recovery in objective nerve conduction studies was examined in the present study.
Methods
The global symptom score (GSS) is a method used to assess clinical outcomes and covers subjective symptoms, including pain (pain and nocturnal awakening), sensory (numbness and paresthesia), and motor (weakness/clumsiness) symptoms. The relationships between long-term changes in GSS and recovery in nerve conduction studies were investigated.
Results
Forty patients (40 hands) were included (mean age 65 years; 80% female; 68% with moderate CTS: sensory nerve conduction velocity < 45 m/s and motor nerve distal latency > 4.5 ms). Pain and nocturnal awakening rapidly subsided within 1 month after surgery and did not recur in the long term (median 5.6 years). Paresthesia significantly decreased 3 months after surgery and in the long term thereafter. Weakness/clumsiness significantly decreased at 1 year. Sensory nerve distal latency, conduction velocity, and amplitude significantly improved 3 months and 1 year after surgery, and correlated with nocturnal awakening in the short term (3 months) in moderate CTS cases. The patient satisfaction rate was 91%.
Conclusion
Rapid recovery was observed in pain and nocturnal awakening, of which nocturnal awakening correlated with the recovery of sensory nerve conduction velocity. Patients with pain symptoms due to moderate CTS may benefit from surgical release.
This follow-up study of the INSTinCTS (INjection vs SplinTing in Carpal Tunnel Syndrome) trial compared the effects of corticosteroid injection (CSI) and night splinting (NS) for the initial ...management of mild-to-moderate CTS on symptoms, resource use and carpal tunnel surgery, over 24 months.
Adults with mild-to-moderate CTS were randomized 1:1 to a local corticosteroid injection or a night splint worn for 6 weeks. Outcomes at 12 and 24 months included the Boston Carpal Tunnel Questionnaire (BCTQ), hand/wrist pain intensity numeric rating scale (NRS), the number of patients referred for and undergoing CTS surgery, and healthcare utilization. A cost-utility analysis was conducted.
One hundred and sixteen participants received a CSI and 118 a NS. The response rate at 24 months was 73% in the CSI arm and 71% in the NS arm. By 24 months, a greater proportion of the CSI group had been referred for (28% vs 20%) and undergone (22% vs 16%) CTS surgery compared with the NS group. There were no statistically significant between-group differences in BCTQ score or pain NRS at 12 or 24 months. CSI was more costly mean difference £68.59 (95% CI: -120.84, 291.24) with fewer quality-adjusted life-years than NS over 24 months mean difference -0.022 (95% CI: -0.093, 0.045).
Over 24 months, surgical intervention rates were low in both groups, but less frequent in the NS group. While there were no differences in the clinical effectiveness of CSI and NS, initial treatment with CSI may not be cost-effective in the long-term compared with NS.
Background
Diagnostic delay of hereditary transthyretin amyloidosis (ATTRv, v for variant) prevents timely treatment and, therefore, concurs to the mortality of the disease. The aim of the present ...study was to explore with nerve ultrasound (US) possible red flags for early diagnosis in ATTRv patients with carpal tunnel syndrome (CTS) and/or polyneuropathy and in pre-symptomatic carriers.
Methods
Patients and pre-symptomatic carriers with a TTR gene mutation were enrolled from seven Italian centers. Severity of CTS was assessed with neurophysiology and clinical evaluation. Median nerve cross-section area (CSA) was measured with US in ATTRv carriers with CTS (TTR-CTS). One thousand one hundred ninety-six idiopathic CTS were used as controls. Nerve US was also performed in several nerve trunks (median, ulnar, radial, brachial plexi, tibial, peroneal, sciatic, sural) in ATTRv patients with polyneuropathy and in pre-symptomatic carriers.
Results
Sixty-two subjects (34 men, 28 women, mean age 59.8 years ± 12) with TTR gene mutation were recruited. With regard to CTS, while in idiopathic CTS there was a direct correlation between CTS severity and median nerve CSA (
r
= 0.55,
p
< 0.01), in the subgroup of TTR-CTS subjects (16 subjects, 5 with bilateral CTS) CSA did not significantly correlate with CTS severity (
r
= − 0.473). ATTRv patients with polyneuropathy showed larger CSA than pre-symptomatic carriers in several nerve sites, more pronounced at brachial plexi (
p
< 0.001).
Conclusions
The present study identifies nerve morphological US patterns that may help in the early diagnosis (morpho-functional dissociation of median nerve in CTS) and monitoring of pre-symptomatic TTR carriers (larger nerve CSA at proximal nerve sites, especially at brachial plexi).
To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical ...and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome.
We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452.
Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 SD 0·81) than the night splint group (2·29 0·75; adjusted mean difference −0·32; 95% CI −0·48 to −0·16; p=0·0001). No adverse events were reported.
A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care.
Arthritis Research UK.
Current non-surgical treatment for peripheral entrapment neuropathy is considered insignificant and unsustainable; thus, it is essential to find an alternative novel treatment. The technique of ...perineural injection therapy using 5% dextrose water has been progressively used to treat many peripheral entrapment neuropathies and has been proven to have outstanding effects in a few high-quality studies. Currently, the twentieth edition of Harrison's Principles of Internal Medicine textbook recommends this novel injection therapy as an alternative local treatment for carpal tunnel syndrome (CTS). Hence, this novel approach has become the mainstream method for treating CTS, and other studies have revealed its clinical benefit for other peripheral entrapment neuropathies. In this narrative review, we aimed to provide an insight into this treatment method and summarize the current studies on cases of peripheral entrapment neuropathy treated by this method.
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