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Slouma M, Ben Dhia S, Cheour E, Gharsallah I. Acroparesthesias: An Overview. Curr Rheumatol Rev 2024; 20:115-126. [PMID: 37921132 DOI: 10.2174/0115733971254976230927113202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/09/2023] [Accepted: 08/18/2023] [Indexed: 11/04/2023]
Abstract
Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.
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Affiliation(s)
- Maroua Slouma
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Siwar Ben Dhia
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Elhem Cheour
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
- Pain Treatment Center, La Rabta Hospital, Tunis, Tunisia
| | - Imen Gharsallah
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
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2
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Lefaucheur JP. Assessment of autonomic nervous system dysfunction associated with peripheral neuropathies in the context of clinical neurophysiology practice. Neurophysiol Clin 2023; 53:102858. [PMID: 36966708 DOI: 10.1016/j.neucli.2023.102858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023] Open
Abstract
Peripheral neuropathies may involve the small diameter nerve fibers of the autonomic nervous system. In the presence of clinical signs compatible with dysautonomia, it is very difficult to affirm that these signs are really linked to an alteration in postganglionic autonomic innervation, and not to a lesion of the central nervous system or to a direct damage to the tissues and innervated organs. Also, in the context of the investigation of peripheral neuropathies, there is an interest in performing objective and quantitative assessment of distal autonomic innervation. The corresponding autonomic tests are mainly based on the exploration of sudomotor or vasomotor disorders of the limb extremities. In this article, we provide an overview of the various tests available for the study of the autonomic nervous system in clinical practice, including vasomotor reactivity tests, in particular based on laser Doppler techniques, and sudomotor tests, based on axon-reflexes produced by iontophoresis of cholinergic drugs or on the simpler measurement of electrochemical skin conductance by the Sudoscan® device.
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3
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Paradoxical Changes of Cutaneous Microcirculation and Sympathetic Fibers of Rat Hind Limbs after Sciatic Nerve Compression. Plast Reconstr Surg 2023; 151:245-254. [PMID: 36696318 DOI: 10.1097/prs.0000000000009842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Recent studies show evidence that surgical nerve decompression could improve cutaneous blood flow (CBF), which might benefit ulcer healing. However, the change of CBF and sympathetic fibers after nerve compression is poorly understood. In the current study, a unilateral sciatic nerve compression model was created in Sprague-Dawley rats. METHODS A laser Doppler imaging system was applied to assess the CBF of the regions below the ankles. Immunohistochemistry and transmission electron microscopy were used to investigate the histopathologic changes of sympathetic fibers in sciatic nerve samples. RESULTS Laser Doppler imaging revealed decreased CBF of both the lesional limb and the contralesional limb, which occurred earlier in the lesional side, indicating an enhanced sympathetic tone on vasomotor function. Intraneural density of sympathetic fibers decreased on both sides and the ultrastructure of unmyelinated fibers of both sides degenerated in a nonsynchronized manner. CONCLUSIONS The study revealed nonsynchronized reduced CBF of bilateral hind limbs with paradoxically degenerated and diminished sympathetic fibers in bilateral sciatic nerves after unilateral sciatic nerve compression. These results may validate the importance of and broaden the indications for surgical nerve decompression in preventing or treating foot ulcers.
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Mathew A, John T. Efficiency of 90-Min Extended EMLA-Induced Stimulated Skin-Wrinkling Test in the Diagnosis of Carpal Tunnel Syndrome. Ann Indian Acad Neurol 2022; 25:92-99. [PMID: 35342267 PMCID: PMC8954309 DOI: 10.4103/aian.aian_305_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/07/2021] [Accepted: 08/25/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Previous researchers have used a 30-min eutectic mixture of local anesthetic (EMLA) test, which assesses the sympathetically mediated vasomotor function, in diagnosing carpal tunnel syndrome (CTS). However, its specificity was low, limiting its clinical diagnostic utility. In this study, we assessed the efficiency of 90-min extended EMLA-induced stimulated skin-wrinkling (SSW) test in CTS diagnosis. Methods: A cross-sectional study was designed among patients clinically diagnosed with CTS. Hands of healthy volunteers and the asymptomatic hands of selected patients served as control. The Boston symptom severity scale (SSS) and the neuropathic pain severity inventory (NPSI) were used to assess symptom severity, and nerve conduction study (NCS) was used to assess electrophysiological severity. EMLA-induced SSW was visually graded after 90 min of application and correlated with symptom and NCS severities. Results: Forty-two symptomatic hands and 30 asymptomatic hands were enrolled as cases and controls, respectively. The diagnostic efficiency of the extended EMLA test was found to be 83.4% for digit 2 and 87.3% for the lateral 4 digits (mean), whereas the diagnostic efficiency of standard NCS was 88.1%. Boston SSS and NPSI were better correlated with EMLA positivity than NCS positivity. A linear regression analysis showed negative correlation of wrinkling grade with NCS grade. Conclusion: With its improved diagnostic efficiency, the 90-min extended EMLA test can feasibly be used as an alternative to NCS, especially in general practice settings. Its potential clinical utility should be explored in a large population of CTS patients showing varying clinical and electrophysiological severities.
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5
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Chang YW, Chen CJ, Wang YW, Chiu V, Lin SK, Horng YS. Influence of temperature on sonographic images of the median nerve for the diagnosis of carpal tunnel syndrome: a case control study. BMC Med Imaging 2021; 21:163. [PMID: 34742241 PMCID: PMC8571853 DOI: 10.1186/s12880-021-00700-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background In addition to nerve conduction studies (NCSs), ultrasonography has been widely used as an alternative tool for diagnosing carpal tunnel syndrome (CTS). Although the results of NCSs are influenced by local skin temperature, few studies have explored the effects of skin temperature on ultrasonography of the median nerve. Since swelling and intraneural blood flow of the median nerve might be influenced by local temperature changes, the aim of this study was to evaluate the cross-sectional area (CSA) and intraneural blood flow of the median nerve under three skin temperatures (30 °C, 32 °C, 34 °C). Methods Fifty patients with CTS and 50 healthy volunteers were consecutively recruited from a community hospital. Each participant received physical examinations and NCSs and underwent ultrasonography, including power Doppler, to evaluate intraneural vascularity. Results The CSA of the median nerve in the CTS patients was significantly larger than that in the healthy controls at all three temperatures. However, significant differences in the power Doppler signals of the median nerve between the two studied groups were observed only at 30 and 32 °C, not at 34 °C. Conclusion The significant difference in the intraneural vascularity of the median nerve between the patients with CTS and the healthy subjects was lost at higher temperatures (34 °C). Therefore, the results of power Doppler ultrasonography in diagnosing CTS should be cautiously interpreted in patients with a high skin temperature or those who reside in warm environments.
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Affiliation(s)
- Yi-Wei Chang
- Department of Physical Medicine and Rehabilitation, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist., New Taipei City, 231, Taiwan, ROC.,Department of Medicine, Tzu Chi University, Hualien, Taiwan, ROC.,Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Chii-Jen Chen
- Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC
| | - You-Wei Wang
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan, ROC
| | - Valeria Chiu
- Department of Physical Medicine and Rehabilitation, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist., New Taipei City, 231, Taiwan, ROC.,Department of Medicine, Tzu Chi University, Hualien, Taiwan, ROC
| | - Shinn-Kuang Lin
- Department of Medicine, Tzu Chi University, Hualien, Taiwan, ROC.,Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan, ROC
| | - Yi-Shiung Horng
- Department of Physical Medicine and Rehabilitation, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist., New Taipei City, 231, Taiwan, ROC. .,Department of Medicine, Tzu Chi University, Hualien, Taiwan, ROC.
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6
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Schmid AB, Fundaun J, Tampin B. [Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]. Schmerz 2021; 35:419-433. [PMID: 34505948 DOI: 10.1007/s00482-021-00584-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potenzial mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.
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Affiliation(s)
- Annina B Schmid
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford University, West Wing Level 6, OX3 9DU, Oxford, Großbritannien.
| | - Joel Fundaun
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford University, West Wing Level 6, OX3 9DU, Oxford, Großbritannien.,High Country Physical Therapy, Laramie, WY, USA
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Westaustralien, Australien.,School of Physiotherapy and Exercise Science, Curtin University, Westaustralien, Australien.,Fakultät Wirtschafts- und Sozialwissenschaften, Hochschule Osnabrück, Osnabrück, Deutschland
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7
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Bargiel P, Czapla N, Prowans P, Kotrych D, Ziętek P, Lusina D, Łęgosz P, Petriczko J. Thermography in the diagnosis of carpal tunnel syndrome. Open Med (Wars) 2021; 16:175-182. [PMID: 33585693 PMCID: PMC7862996 DOI: 10.1515/med-2021-0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 09/19/2020] [Accepted: 10/07/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Carpal tunnel syndrome (CTS) is a condition caused by chronic compression of the median nerve. The diagnosis is made mainly on the basis of clinical image and confirmed with electrodiagnostic testing (electromyography and nerve conduction study); however, these methods do not always aid in reaching the diagnosis of CTS. Moreover, they are invasive examinations, unpleasant for the patient and have to be performed by a qualified physician. AIM An evaluation of the usefulness of dynamic thermography in the diagnosis of CTS. MATERIAL AND METHODS Forty patients were included in the study group. CTS was diagnosed based on clinical examination and electromyography. Forty healthy volunteers were included in the control group. Each of the participants was examined thrice with dynamic thermography. The patient's hands were first cooled down and then a thermal camera measured their return to normal temperature. The measurement was repeated on the dorsal and volar aspects of each hand. RESULTS The results obtained in the study show that a relief of symptoms after carpal tunnel release does not correlate with thermal image. Moreover, the return to normal hand temperature was faster in the control group. In patients with unilateral CTS, no difference was observed in thermographic images of the affected and healthy hands. CONCLUSIONS Dynamic thermography can be useful in confirming CTS diagnosis.Dynamic thermography does not allow for objective assessment of patient's complaints in the postoperative period.This method has currently limited clinical application. Due to complexity, it presently serves mainly scientific purposes.
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Affiliation(s)
- Piotr Bargiel
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, ul. Unii Lubelskiej 1, 71-252, Szczecin, Poland
| | - Norbert Czapla
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, ul. Unii Lubelskiej 1, 71-252, Szczecin, Poland
| | - Piotr Prowans
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, ul. Unii Lubelskiej 1, 71-252, Szczecin, Poland
| | - Daniel Kotrych
- Department of Orthopaedics, Traumatology and Orthopaedic Oncology, Pomeranian Medical University, Szczecin, Poland
| | - Paweł Ziętek
- Department of Orthopaedics, Traumatology and Orthopaedic Oncology, Pomeranian Medical University, Szczecin, Poland
| | - Dariusz Lusina
- Department of Orthopaedics, Traumatology and Orthopaedic Oncology, Pomeranian Medical University, Szczecin, Poland
| | - Paweł Łęgosz
- Department of Orthopaedics and Traumatology, Medical University of Warsaw, Warsaw, Poland
| | - Jan Petriczko
- Department of Plastic, Endocrine and General Surgery, Pomeranian Medical University, ul. Unii Lubelskiej 1, 71-252, Szczecin, Poland
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8
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Beaziz J, Lazareth I. Bilateral palmar cyanosis associated with primitive carpal tunnel syndrome. JOURNAL DE MÉDECINE VASCULAIRE 2020; 45:354-356. [PMID: 33248540 DOI: 10.1016/j.jdmv.2020.10.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/02/2020] [Indexed: 11/20/2022]
Affiliation(s)
- J Beaziz
- Department of dermatology, Saint-Joseph hospital, 185, rue Raymond-Losserand, 75014 Paris, France.
| | - I Lazareth
- Department of vascular medicine, Saint-Joseph hospital, Paris, France
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9
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Ridderström M, Svantesson M, Thorell O, Magounakis T, Minde J, Olausson H, Nagi SS. High prevalence of carpal tunnel syndrome in individuals with rare nerve growth factor-beta mutation. Brain Commun 2020; 2:fcaa085. [PMID: 32954334 PMCID: PMC7472894 DOI: 10.1093/braincomms/fcaa085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/15/2020] [Accepted: 06/03/2020] [Indexed: 11/12/2022] Open
Abstract
In Sweden, a large family with a point mutation in the nerve growth factor-beta gene has previously been identified. The carriers of this mutation have reduced small-fibre density and selective deficits in deep pain and temperature modalities. The clinical findings in this population are described as hereditary sensory and autonomic neuropathy type V. The purpose of the current study was to investigate the prevalence of carpal tunnel syndrome in hereditary sensory and autonomic neuropathy type V based on clinical examinations and electrophysiological measurements. Furthermore, the cross-sectional area of the median nerve at the carpal tunnel inlet was measured with ultrasonography. Out of 52 known individuals heterozygous for the nerve growth factor-beta mutation in Sweden, 23 participated in the current study (12 males, 11 females; mean age 55 years; range 25–86 years). All participants answered a health questionnaire and underwent clinical examination followed by median nerve conduction study in a case–control design, and measurement of the nerve cross-sectional area with ultrasonography. The diagnosis of carpal tunnel syndrome was made based on consensus criteria using patient history and nerve conduction study. The prevalence of carpal tunnel syndrome in the hereditary sensory and autonomic neuropathy group was 35% or 52% depending on whether those individuals who had classic symptoms of carpal tunnel syndrome but negative nerve conduction studies were included or not. Those who had a high likelihood of carpal tunnel syndrome based on classic/probable patient history with positive nerve conduction study had a significantly larger median nerve cross-sectional area than those who had an unlikely patient history with negative nerve conduction study. The prevalence of carpal tunnel syndrome was 10–25 times higher in individuals heterozygous for the nerve growth factor-beta mutation than the general Swedish population. Further studies are needed to better understand the underlying pathophysiological mechanisms.
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Affiliation(s)
| | - Mats Svantesson
- Department of Clinical Neurophysiology, Linköping University, Linköping, Sweden
| | - Oumie Thorell
- Department of Clinical Neurophysiology, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Center for Social and Affective Neuroscience, Linköping University, Linköping, Sweden.,Department of Integrative Physiology, School of Medicine, Western Sydney University, Sydney, Australia
| | | | - Jan Minde
- Department of Orthopaedics, Gällivare Hospital, Gällivare, Sweden.,Division of Orthopaedics, Department of Surgery and Perioperative Science, Umeå University Hospital, Umeå, Sweden
| | - Håkan Olausson
- Department of Clinical Neurophysiology, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Center for Social and Affective Neuroscience, Linköping University, Linköping, Sweden
| | - Saad S Nagi
- Department of Clinical Neurophysiology, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Center for Social and Affective Neuroscience, Linköping University, Linköping, Sweden.,Department of Integrative Physiology, School of Medicine, Western Sydney University, Sydney, Australia
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10
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Schmid AB, Fundaun J, Tampin B. Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain Rep 2020; 5:e829. [PMID: 32766466 PMCID: PMC7382548 DOI: 10.1097/pr9.0000000000000829] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/04/2020] [Accepted: 05/30/2020] [Indexed: 12/18/2022] Open
Abstract
Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.
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Affiliation(s)
- Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
| | - Joel Fundaun
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
- High Country Physical Therapy, Laramie, WY, USA
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Western Australia, Australia
- Faculty of Business Management and Social Sciences, Hochschule Osnabrück, University of Applied Sciences, Osnabrück, Germany
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11
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Triki L, Zouari HG, Kammoun R, Kammoun F, Kammoun I, Masmoudi K, Lefaucheur JP. A reappraisal of small- and large-fiber damage in carpal tunnel syndrome: New insights into the value of the EMLA test for improving diagnostic sensitivity. Neurophysiol Clin 2017; 47:427-436. [DOI: 10.1016/j.neucli.2017.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 11/25/2022] Open
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12
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Borchers AT, Gershwin ME. The clinical relevance of complex regional pain syndrome type I: The Emperor's New Clothes. Autoimmun Rev 2016; 16:22-33. [PMID: 27666818 DOI: 10.1016/j.autrev.2016.09.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023]
Abstract
The management of patients with chronic pain is a nearly daily challenge to rheumatologists, neurologists, orthopedic surgeons, pain specialists and indeed a issue in nearly every clinical practice. Among the myriad of causes of pain are often included a unique syndrome, generally referred to as complex regional pain syndrome type I (CRPS). Unfortunately CRPS I has become a catch all phase and there are serious questions on whether it exists at all; this has led to an extraordinary number of poorly defined diagnostic criteria. It has also led to an etiologic quagmire that includes features as diverse as autoimmunity to simple trauma. These, in turn, have led to overdiagnosis and often overzealous use of pain medications, including narcotics. In a previous paper, we raised the issue of whether CRPS type I reflected a valid diagnosis. Indeed, the diagnostic criteria for CRPS I, and therefore the diagnosis itself, is unreliable for a number of reasons: 1) the underlying pathophysiology of the signs and symptoms of CPRS I are not biologically plausible; 2) there are no consistent laboratory or imaging testing available; 3) the signs and symptoms fluctuate over time without a medical explanation; 4) the definitions of most studies are derived from statistical analysis with little consideration to required sample size, i.e. power calculations; 5) interobserver reliability in the assessment of the signs and symptoms are often only fair to moderate, and agreement on the diagnosis of "CRPS I" is poor. Even physicians who still believe in the concept of "CRPS I" admit that it is vastly overdiagnosed and has become a diagnosis of last resort, often without a complete differential diagnosis and an alternative explanation. Finally, one of the most convincing arguments that there is no clinical entity as "CRPS I" comes from the enormous heterogeneity in sign and symptom profiles and the heterogeneity of pathophysiological mechanisms postulated. This observation is underscored by the diversity of responses among "CRPS I" patients to essentially all treatment modalities. It has even led to the concept that the signs and symptoms of CRPS can spread throughout the body, as if it is an infectious disease, without any medical plausible explanation. If true progress is to be made in helping patients with pain, it will require entirely new and different concepts and abandoning CRPS I as a legitimate diagnosis.
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Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States.
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13
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Galea LA, Mercieca A, Sciberras C, Gatt R, Schembri M. Evaluation of Sympathetic Vasomotor Fibres in Carpal Tunnel Syndrome Using Continuous Wave Doppler Ultrasonography. ACTA ACUST UNITED AC 2016; 31:306-10. [PMID: 16487634 DOI: 10.1016/j.jhsb.2005.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Revised: 12/19/2005] [Accepted: 12/21/2005] [Indexed: 02/07/2023]
Abstract
Sympathetic vasomotor fibres carried by the median nerve and ulnar nerve innervate their respective sensory territories. The sympathetic vasomotor fibres of the median nerve were evaluated in patients with carpal tunnel syndrome and in healthy volunteers using continuous wave Doppler ultrasonography. The pulsatility index of the radialis indicis artery and the radial palmar digital artery of the little finger were measured at baseline and after stimulation. The maximal increase in the pulsatility index of each artery was measured. This was significantly lower for the radialis indicis artery in the CTS group than in the healthy controls. However, there was no significant difference in the maximal increase in pulsatility index of the radial palmar digital artery of the little finger between both groups. Sympathetic vasomotor fibres of the median nerve are affected in carpal tunnel syndrome. Continuous wave Doppler ultrasonography is easy to use and should be investigated further as a possible diagnostic tool for the confirmation of carpal tunnel syndrome.
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Affiliation(s)
- L A Galea
- Department of Orthopaedics and Department of Surgery, St. Luke's Hospital, Guardamangia, Malta.
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14
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Wilder-Smith EP, Lirong L, Seet RCS, Lim ECH. Symptoms Associated with Electrophysiologically Verified Carpal Tunnel Syndrome in Asian Patients. ACTA ACUST UNITED AC 2016; 31:326-30. [PMID: 16487635 DOI: 10.1016/j.jhsb.2005.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 12/23/2005] [Accepted: 12/29/2005] [Indexed: 11/27/2022]
Abstract
Sensory symptoms are crucial for the diagnosis of carpal tunnel syndrome (CTS). We have studied the spectrum of sensory symptoms in 67 cases of neurophysiologically confirmed CTS in Singapore and investigated the correlation of semi-quantitative clinical (‘Historical-Objective’) and neurophysiological (‘Bland’) scales. The range of sensory symptoms was large. The more frequent use of the terms ‘woodenness’ and ‘aching’ rather than ‘pins and needles’ suggests racial and cultural differences in symptom expression, or recognition of previously ignored descriptors. ‘Numbness’ (97%) was the most common descriptive symptom, followed by ‘tingling’ (81%), ‘tightness’ (60%), ‘aching’ (45%), ‘woodenness’ (39%) and ‘pins and needles’ (33%). Less common were ‘deadness’ (27%), prickling (24%), and cramp-like pain (18%). Uncommon sensations included ‘jabbing’ (10%), ‘shooting pain’ (10%), ‘stabbing’ (9%), ‘tight-band like pressure’ (9%), ‘cold’ (8%), ‘crushing’ (6%) and ‘burning’ (6%). The semi-quantitative clinical and neurophysiological scales correlated well (Pearson 0.645, P<0.001).
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15
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Baselgia LT, Bennett DL, Silbiger RM, Schmid AB. Negative Neurodynamic Tests Do Not Exclude Neural Dysfunction in Patients With Entrapment Neuropathies. Arch Phys Med Rehabil 2016; 98:480-486. [PMID: 27449322 PMCID: PMC5324720 DOI: 10.1016/j.apmr.2016.06.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 06/22/2016] [Accepted: 06/26/2016] [Indexed: 12/13/2022]
Abstract
Objective To examine differences in somatosensory phenotypes of patients with positive and negative neurodynamic tests and compare these with healthy participants. Design Case-control study. Setting University department. Participants Patients with electrodiagnostically confirmed carpal tunnel syndrome (CTS) (n=53) and people without CTS (n=26) participated in this study (N=79). Patients with CTS were subgrouped according to the results of the upper limb neurodynamic tests biasing the median nerve into patients with positive or negative neurodynamic tests. Interventions Not applicable. Main Outcome Measure All participants underwent quantitative sensory testing in the median innervated territory of their hand. Results Only 46% of patients with CTS had positive neurodynamic tests. No differences were identified between groups for pain thresholds (P>.247). However, patients with CTS had increased mechanical (P<.0001) and thermal detection thresholds (P<.0001) compared with people without CTS. Patients with negative neurodynamic tests had a more pronounced vibration detection deficit (mean, 7.43±0.59) than people without CTS (mean, 7.89±0.22; P=.001). Interestingly, warm detection was the only domain differentiating positive (mean, 4.03°C±2.18°C) and negative neurodynamic test groups (6.09°C±3.70°C, P=.032), with patients with negative neurodynamic tests demonstrating increased loss of function. Conclusions Patients with negative neurodynamic tests seem to have a more severe dysfunction of the unmyelinated fiber population. Our findings suggest that neurodynamic tests should not be used in isolation to judge neural involvement. Rather, they should be interpreted in the context of loss of function tests of the small fiber domain.
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Affiliation(s)
- Larissa T Baselgia
- Institute of Physiotherapy, Zurich University of Applied Sciences ZHAW, Winterthur, Switzerland
| | - David L Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Headington, UK
| | | | - Annina B Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Headington, UK; School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, Australia.
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Halac G, Demir S, Yucel H, Niftaliyev E, Kocaman G, Duruyen H, Kendirli T, Asil T. Splinting is effective for night-only symptomatic carpal tunnel syndrome patients. J Phys Ther Sci 2015; 27:993-6. [PMID: 25995540 PMCID: PMC4434031 DOI: 10.1589/jpts.27.993] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 11/28/2014] [Indexed: 11/30/2022] Open
Abstract
[Purpose] Carpal tunnel syndrome is the most common entrapment neuropathy of the median
nerve. Splinting is one of the most used conservative treatment methods for carpal tunnel
syndrome. The aim of this study was to show the effectiveness of splinting in carpal
tunnel syndrome patients who were divided into two groups according to their level of
symptoms. [Subjects and Methods] A total of 40 carpal tunnel syndrome patients were
divided into 2 groups based on having symptoms only at night or during the day were
included in this study. These two groups were compared at the end of a 3-months splinting
therapy in terms of improvement of severity of symptoms, functional capacity, pain level,
and electrophysiological findings. [Results] Pain levels of both groups were similar at
baseline. After splinting, pain levels of night-only symptomatic patients were lower than
those of sustained symptomatic ones. No differences were found in symptom severity,
functional capacity, and the electrophysiological findings in either group after the
splinting. [Conclusion] The results of this study show that splinting alone may be
sufficient to decrease the pain for night-only symptomatic patients. Combined therapy
methods may be needed for sustained symptomatic patients.
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Affiliation(s)
- Gulistan Halac
- Department of Neurology, Medical Faculty, Bezmialem Vakif University, Turkey
| | - Saliha Demir
- Department of Physical Medicine and Rehabilitation, Medical Faculty, Bezmialem Vakif University, Turkey
| | - Hulya Yucel
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakif University, Turkey
| | - Elvin Niftaliyev
- Department of Neurology, Medical Faculty, Bezmialem Vakif University, Turkey
| | - Gulsen Kocaman
- Department of Neurology, Medical Faculty, Bezmialem Vakif University, Turkey
| | - Humeyra Duruyen
- Department of Neurology, Medical Faculty, Bezmialem Vakif University, Turkey
| | - Tansel Kendirli
- Department of Neurology, GATA Haydarpasa Teaching Hospital, Turkey
| | - Talip Asil
- Department of Neurology, Medical Faculty, Bezmialem Vakif University, Turkey
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Schmid AB, Bland JDP, Bhat MA, Bennett DLH. The relationship of nerve fibre pathology to sensory function in entrapment neuropathy. ACTA ACUST UNITED AC 2014; 137:3186-99. [PMID: 25348629 PMCID: PMC4240296 DOI: 10.1093/brain/awu288] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The impact of peripheral entrapment neuropathies on target innervation remains unknown. Using quantitative sensory testing, neurophysiology and skin biopsies, Schmid et al. demonstrate that carpal tunnel syndrome affects large fibres and their nodal complexes, but is also associated with a reduction in the number and functioning of small sensory axons. Surprisingly little is known about the impact of entrapment neuropathy on target innervation and the relationship of nerve fibre pathology to sensory symptoms and signs. Carpal tunnel syndrome is the most common entrapment neuropathy; the aim of this study was to investigate its effect on the morphology of small unmyelinated as well as myelinated sensory axons and relate such changes to somatosensory function and clinical symptoms. Thirty patients with a clinical and electrophysiological diagnosis of carpal tunnel syndrome [17 females, mean age (standard deviation) 56.4 (15.3)] and 26 age and gender matched healthy volunteers [18 females, mean age (standard deviation) 51.0 (17.3)] participated in the study. Small and large fibre function was examined with quantitative sensory testing in the median nerve territory of the hand. Vibration and mechanical detection thresholds were significantly elevated in patients with carpal tunnel syndrome (P < 0.007) confirming large fibre dysfunction and patients also presented with increased thermal detection thresholds (P < 0.0001) indicative of C and Aδ-fibre dysfunction. Mechanical and thermal pain thresholds were comparable between groups (P > 0.13). A skin biopsy was taken from a median nerve innervated area of the proximal phalanx of the index finger. Immunohistochemical staining for protein gene product 9.5 and myelin basic protein was used to evaluate morphological features of unmyelinated and myelinated axons. Evaluation of intraepidermal nerve fibre density showed a striking loss in patients (P < 0.0001) confirming a significant compromise of small fibres. The extent of Meissner corpuscles and dermal nerve bundles were comparable between groups (P > 0.07). However, patients displayed a significant increase in the percentage of elongated nodes (P < 0.0001), with altered architecture of voltage-gated sodium channel distribution. Whereas neither neurophysiology nor quantitative sensory testing correlated with patients’ symptoms or function deficits, the presence of elongated nodes was inversely correlated with a number of functional and symptom related scores (P < 0.023). Our findings suggest that carpal tunnel syndrome does not exclusively affect large fibres but is associated with loss of function in modalities mediated by both unmyelinated and myelinated sensory axons. We also document for the first time that entrapment neuropathies lead to a clear reduction in intraepidermal nerve fibre density, which was independent of electrodiagnostic test severity. The presence of elongated nodes in the target tissue further suggests that entrapment neuropathies affect nodal structure/myelin well beyond the focal compression site. Interestingly, nodal lengthening may be an adaptive phenomenon as it inversely correlates with symptom severity.
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Affiliation(s)
- Annina B Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, Headington, UK School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD 4072, Australia
| | - Jeremy D P Bland
- Department of Clinical Neurophysiology, Kent and Canterbury Hospital, CT1 3NG, Canterbury Kent, UK
| | - Manzoor A Bhat
- Department of Physiology, Centre for Biomedical Neuroscience, School of Medicine, University of Texas Health Science Centre, San Antonio, TX, USA
| | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, Headington, UK
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Local and remote immune-mediated inflammation after mild peripheral nerve compression in rats. J Neuropathol Exp Neurol 2013; 72:662-80. [PMID: 23771220 DOI: 10.1097/nen.0b013e318298de5b] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
After experimental nerve injuries that extensively disrupt axons, such as chronic constriction injury, immune cells invade the nerve, related dorsal root ganglia (DRGs), and spinal cord, leading to hyperexcitability, raised sensitivity, and pain. Entrapment neuropathies, such as carpal tunnel syndrome, involve minimal axon damage, but patients often report widespread symptoms. To understand the underlying pathology, a tube was placed around the sciatic nerve in 8-week-old rats, leading to progressive mild compression as the animals grew. Immunofluorescence was used to examine myelin and axonal integrity, glia, macrophages, and T lymphocytes in the nerve, L5 DRGs, and spinal cord after 12 weeks. Tubes that did not constrict the nerve when applied caused extensive and ongoing loss of myelin, together with compromise of small-, but not large-, diameter axons. Macrophages and T lymphocytes infiltrated the nerve and DRGs. Activated glia proliferated in DRGs but not in spinal cord. Histologic findings were supported by clinical hyperalgesia to blunt pressure and cold allodynia. Tubes that did not compress the nerve induced only minor local inflammation. Thus, progressive mild nerve compression resulted in chronic local and remote immune-mediated inflammation depending on the degree of compression. Such neuroinflammation may explain the widespread symptoms in patients with entrapment neuropathies.
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Schmid AB, Nee RJ, Coppieters MW. Reappraising entrapment neuropathies--mechanisms, diagnosis and management. ACTA ACUST UNITED AC 2013; 18:449-57. [PMID: 24008054 DOI: 10.1016/j.math.2013.07.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/10/2013] [Accepted: 07/13/2013] [Indexed: 12/13/2022]
Abstract
The diagnosis of entrapment neuropathies can be difficult because symptoms and signs often do not follow textbook descriptions and vary significantly between patients with the same diagnosis. Signs and symptoms which spread outside of the innervation territory of the affected nerve or nerve root are common. This Masterclass provides insight into relevant mechanisms that may account for this extraterritorial spread in patients with entrapment neuropathies, with an emphasis on neuroinflammation at the level of the dorsal root ganglia and spinal cord, as well as changes in subcortical and cortical regions. Furthermore, we describe how clinical tests and technical investigations may identify these mechanisms if interpreted in the context of gain or loss of function. The management of neuropathies also remains challenging. Common treatment strategies such as joint mobilisation, neurodynamic exercises, education, and medications are discussed in terms of their potential to influence certain mechanisms at the site of nerve injury or in the central nervous system. The mechanism-oriented approach for this Masterclass seems warranted given the limitations in the current evidence for the diagnosis and management of entrapment neuropathies.
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Affiliation(s)
- Annina B Schmid
- The University of Queensland, Division of Physiotherapy, School of Health and Rehabilitation Sciences, Brisbane (St Lucia), Australia; University of Oxford, Nuffield Department of Clinical Neurosciences, Oxford, United Kingdom.
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Ping Ng KW, Ong JJY, Nyein Nyein TD, Liang S, Chan YC, Lee KO, Wilder-Smith EP. EMLA-Induced Skin Wrinkling for the Detection of Diabetic Neuropathy. Front Neurol 2013; 4:126. [PMID: 24032026 PMCID: PMC3759298 DOI: 10.3389/fneur.2013.00126] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/20/2013] [Indexed: 01/12/2023] Open
Abstract
Objective: To determine the usefulness of Eutectic Mixture of Local Anesthetic (EMLA)-induced stimulated skin wrinkling (SSW) to detect diabetic sensorimotor polyneuropathy (DSPN). Research Design and Methods: Two hundred and ten diabetics were prospectively recruited (mean age 58.5 ± 12.7 years) from a large tertiary center from 2009 to 2011. EMLA was applied to the tips of digits 2, 3, and 4 and the degree of wrinkling graded. Diabetic Neuropathy Symptom (DNS) score, nerve conduction studies (NCS), Semmes–Weinstein monofilament (SWMF) tests, and vibratory perception thresholds (VPTs) testing were chosen as comparative clinical standards to diagnose length-dependent DSPN. Results: Inter-rater agreement for two examiners of SSW was high, with Cohen’s weighted κ of 0.912 for the right hand, and 0.823 for the left. K measure of agreement of SSW with the NCS, DNS scores, SWMF testing, and VPT testing was 0.486, 0.243, 0.289, and 0.395 respectively. SSW was able to distinguish between normal and abnormal NCS and DNS results, with median scores of 3.333 vs. 1.667 (p < 0.0005); and 3.167 vs. 2.000 (p < 0.0005) respectively. Following receiver operating characteristic-analysis, at a cut-off point of <3 for an abnormal SSW test, sensitivity of SSW test for diagnosing DSPN using NCS as a reference standard was 81.3%, and specificity was 67.0%, on par with other testing methods. Conclusion: SSW shows comparable sensitivity to other methods for detecting DSPN. Given its low cost and easy administration, SSW can be considered a useful alternative screening method for diagnosing diabetic neuropathy.
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Affiliation(s)
- Kay Wei Ping Ng
- Division of Neurology, Department of Medicine, National University Hospital , Singapore
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Marchalik D, Lipsky A, Petrov D, Harvell JD, Milgraum SS. Dermatologic Presentations of Orthopedic Pathologies. Am J Clin Dermatol 2012; 13:293-310. [DOI: 10.2165/11595880-000000000-00000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ghasemi-Esfe AR, Morteza A, Khalilzadeh O, Mazloumi M, Ghasemi-Esfe M, Rahmani M. Color Doppler ultrasound for evaluation of vasomotor activity in patients with carpal tunnel syndrome. Skeletal Radiol 2012; 41:281-6. [PMID: 21479858 DOI: 10.1007/s00256-011-1149-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 02/23/2011] [Accepted: 02/23/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with carpal tunnel syndrome (CTS) have a variety of vasomotor symptoms. Here, we aimed to study the vasomotor activity of the radialis indicis (RI) artery (median nerve territory) and the radial palmar digital (RPD) artery of the little finger (ulnar nerve territory) before and after sympathetic stimulation in CTS patients using color Doppler ultrasound. METHODS We performed a cross-sectional study of 46 consecutive CTS patients plus 36 healthy controls. All patients underwent electromyography studies and were classified into mild and moderate/severe groups according to electrodiagnostic findings. Color Doppler examination of the RI artery and the RPD artery of the little finger were performed with the participants in a relaxed sitting position and after a deep breath followed by a cough (sympathetic stimulation). The pulsatility index (PI) was recorded at the point of maximal change in waveform, before and after this stimulus. RESULTS The PI of RI artery was significantly lower (p < 0.01) in CTS patients than healthy controls, both before and after stimulation. The changes in PI of RI artery after stimulation were significantly lower in CTS patients than healthy controls (1.18 ± 0.37 vs. 5.41 ± 0.87; p < 0.001). The same pattern was seen for PI of RI artery when comparing patients with mild vs. moderate/severe CTS. No difference was found in PI of RPD artery of the 5th finger between patients vs. controls and between patients with mild vs. moderate/severe CTS, both before and after stimulation. CONCLUSIONS We showed that color Doppler ultrasound can readily determine impaired vasomotor activity in CTS patients.
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Affiliation(s)
- Ahmad Reza Ghasemi-Esfe
- Advanced Diagnostic and Interventional Radiology Research Center, Medical Imaging Center, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Dynamic Doppler evaluation of the radial and ulnar arteries in patients with carpal tunnel syndrome. AJR Am J Roentgenol 2011; 197:W817-20. [PMID: 22021527 DOI: 10.2214/ajr.11.6559] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate the blood flow characteristics of the radial and ulnar arteries of the hands of patients with carpal tunnel syndrome (CTS) either in the neutral position or in provocative positions using color Doppler imaging. SUBJECTS AND METHODS Subjects with relevant complaints of CTS and positive Tinel sign and/or Phalen maneuver were recruited. Nerve conduction studies were performed to confirm the diagnosis of CTS. Forty-four hands of 22 patients with CTS (bilateral involvement) and 24 hands of 12 healthy volunteers were included in the study. Pulsed and color Doppler evaluations with the hands in the neutral, Phalen, and reverse Phalen positions were performed of the radial and ulnar arteries using a 5-13-MHZ linear-array transducer (Logiq 9). RESULTS All of the CTS patients and control subjects were women; their mean ages were 50.77 ± 7.69 (SD) and 46.42 ± 4.32 years, respectively. When hands were evaluated in the neutral position, the flow volume, peak systolic velocity, end-diastolic velocity, and diameter values of both the radial and ulnar arteries were significantly greater in patients with CTS than in control subjects (all p < 0.05). When compared with the measurements obtained with hands at the neutral position, the decreases in the amount of blood flow during the Phalen and reverse Phalen maneuvers were significantly greater in the CTS group than the control group. The amount of blood flow decrease was not correlated with the disease duration. CONCLUSION Blood flow in the hands of CTS patients differs from that of healthy individuals both at rest and during certain hand movements. Future studies, also with simultaneous monitoring of sympathetic innervation, could be beneficial to confirm the association between blood flow and the sympathetic nerves of the hand.
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Tamburin S, Cacciatori C, Praitano ML, Cazzarolli C, Foscato C, Fiaschi A, Zanette G. Median nerve small- and large-fiber damage in carpal tunnel syndrome: a quantitative sensory testing study. THE JOURNAL OF PAIN 2010; 12:205-12. [PMID: 20797919 DOI: 10.1016/j.jpain.2010.06.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 05/31/2010] [Accepted: 06/25/2010] [Indexed: 12/21/2022]
Abstract
UNLABELLED We explored the contribution of median nerve small (Aδ, C)-and large (Aβ)-fiber damage to the severity and topographic distribution of sensory symptoms in carpal tunnel syndrome (CTS) and the timing of fiber damage across CTS stages. We recruited 106 CTS patients. After selection, 49 patients were included. They underwent electrodiagnostic and quantitative sensory testing (QST) study and were asked on the severity of Boston Carpal Tunnel Questionnaire (BCTQ) Symptoms Severity Scale, daytime pain (DP), night pain and paresthesia, on the distribution of hand symptoms, and the presence of proximal symptoms. BCTQ Symptoms Severity Scale and DP severity was significantly correlated with Aδ-fiber damage. Small-fiber QST measures were impaired in electrodiagnostic-negative CTS patients and did not change across CTS neurographic stages. QST findings were not correlated to the topographical distribution of symptoms. Aδ-fiber damage contributes to CTS symptoms and in particular to DP. Night pain and paresthesia might be ascribed to ectopic fiber discharges secondary to median nerve enhanced mechanosensitivity. Small-fiber damage takes place earlier than large fiber. Median nerve fiber involvement does not directly contribute to extraterritorial symptoms spread. Our data may help understanding CTS pathophysiology and explain the well-known discrepancy between CTS symptoms and electrodiagnostic findings. PERSPECTIVE We explored the involvement of median nerve small and large fibers in carpal tunnel syndrome (CTS). We found a significant correlation between Aδ-fiber function and CTS symptoms. Small-fiber involvement took place in milder disease stages. These findings could help reconcile the discrepancy between CTS symptoms and electrodiagnostic data.
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Affiliation(s)
- Stefano Tamburin
- Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Verona, Italy.
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Uchiyama S, Itsubo T, Nakamura K, Kato H, Yasutomi T, Momose T. Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation. J Orthop Sci 2010; 15:1-13. [PMID: 20151245 DOI: 10.1007/s00776-009-1416-x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Accepted: 09/22/2009] [Indexed: 12/31/2022]
Abstract
The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.
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Affiliation(s)
- Shigeharu Uchiyama
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Japan
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Long-term skin temperature measurements – A practical diagnostic tool in complex regional pain syndrome. Pain 2008; 140:8-22. [DOI: 10.1016/j.pain.2008.07.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 06/30/2008] [Accepted: 07/03/2008] [Indexed: 11/22/2022]
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Kuwabara S, Tamura N, Yamanaka Y, Misawa S, Isose S, Bae JS, Hattori T, Asahina M. Sympathetic sweat responses and skin vasomotor reflexes in carpal tunnel syndrome. Clin Neurol Neurosurg 2008; 110:691-5. [PMID: 18485585 DOI: 10.1016/j.clineuro.2008.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Revised: 03/30/2008] [Accepted: 04/05/2008] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate cutaneous sympathetic functions in carpal tunnel syndrome (CTS) using sympathetic sweat responses (SSwRs) and skin vasomotor reflexes (SVmRs). METHODS In 29 hands (20 patients) with idiopathic CTS, SSwRs were recorded with a sudorometer from the thenar eminence, and SVmRs were used to measure cutaneous blood flow using a Doppler flowmeter placed on the index finger tip. Normal data were obtained from 15 volunteers of similar age. RESULTS SSwRs or SVmRs were abnormal in 23 (80%) hands; SSwRs were absent in 38%, whereas SVmRs were abnormally decreased in 59%. Autonomic symptoms were present in 18 (62%) hands; finger edema (38%) and dry hand (35%) were frequent symptoms. Autonomic symptoms, and abnormal SSwRs and SVmRs did not correlate with results of nerve conduction studies. CONCLUSIONS Skin sudomotor or vasomotor sympathetic function is frequently impaired in CTS. Susceptibility to compression ischemia may be different in sympathetic unmyelinated and large myelinated fibers.
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Affiliation(s)
- Satoshi Kuwabara
- Department of Neurology, Chiba University School of Medicine, Chiba, Japan.
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Wilder-Smith EP, Seet RCS, Lim ECH. Diagnosing carpal tunnel syndrome—clinical criteria and ancillary tests. ACTA ACUST UNITED AC 2006; 2:366-74. [PMID: 16932587 DOI: 10.1038/ncpneuro0216] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 04/24/2006] [Indexed: 12/31/2022]
Abstract
Damage to the median nerve within the carpal tunnel gives rise to carpal tunnel syndrome (CTS), which is associated with a wide spectrum of symptoms. The predominant classic symptoms are nocturnal pain of the hand, and sensory disturbances within the distribution of the median nerve, both of which are characteristically relieved by hand movements. Ancillary tests, including nerve conduction studies (NCS) and imaging techniques, are mainly indicated when the classic defining features are absent. NCS are less accurate in the early stages of CTS, and in younger patients. Imaging tests (ultrasound and MRI), while still having a lower diagnostic accuracy than NCS, are proving to be useful for explaining persistence of symptoms following surgical relief. Supplementary tests of small nerve fiber function and measurement of intracarpal pressure might, in the future, improve early recognition of CTS, especially in the absence of well-defined symptoms.
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