Natural evolution of carpal tunnel syndrome in untreated patients

Point of care ultrasound combined with CTS-6 to diagnose idiopathic carpal tunnel syndrome

BACKGROUND

This study aimed to demonstrate the effectiveness of our new diagnostic chart using point of care ultrasound combined with CTS-6 for diagnosing idiopathic carpal tunnel syndrome.

METHODS

We conducted a retrospective analysis of the data of patients who visited our department and received point of care ultrasound combined with CTS-6 from 2020 to 2023. Data regarding age, sex, initial and final diagnosis, cross-sectional area of the median nerve, CTS-6 score, and electrodiagnostic severity were obtained and statistically analyzed.

RESULTS

Of the 177 wrists included in our study, 138 (78 %) were diagnosed with carpal tunnel syndrome, while 39 (22 %) were not (non-carpal tunnel syndrome). With our diagnostic method, 127 wrists (72 %) were diagnosed initially with carpal tunnel syndrome, 23 wrists (13 %) with non-carpal tunnel syndrome, and the rest 27 wrists (15 %) as borderline. Our initial diagnoses of carpal tunnel syndrome and non-carpal tunnel syndrome were maintained in all cases except for two. Cross-sectional area, CTS-6 score, and electrodiagnostic severity showed a positive correlation. A post hoc analysis showed that the new scoring system (CTS-6 score + 2 × cross-sectional area) with a cutoff value of 31.25 points showed a sensitivity as high as 95 % and a specificity of 100 %.

CONCLUSIONS

Our findings suggest that most suspected idiopathic carpal tunnel syndrome cases can be diagnosed correctly using the diagnostic chart. Although additional tools, including electrodiagnostic studies, may be needed for borderline cases, the use of point of care ultrasound combined with CTS-6 may be a recommendable first-line confirmatory test because point of care ultrasound and CTS-6 could be complementary tools, and this chart may be especially beneficial for atypical or outlier cases.

LEVEL OF EVIDENCE

Diagnostic III.

Risk of carpal tunnel syndrome among patients with osteoarthritis: a US population-based study

BACKGROUND

Carpal tunnel syndrome (CTS), an entrapment neuropathy caused by pressure of the median nerve, is a progressive condition that can lead to a decreased quality of life. Studies suggest an association between CTS and arthritis; however, previous studies examining osteoarthritis (OA) and CTS are limited in number, scope and study design. This study estimated the incidence and risk of CTS among patients with OA, both overall and by specific joints, in a large population-based cohort in the United States.

METHODS

Patients from the Optum claims database aged ≥ 45 years and diagnosed with OA between January 1, 2018, and December 31, 2022, were eligible for the OA cohort. The non-OA cohort included those without a diagnosis of OA at the index date and no history of OA for 12 months pre-index. Baseline characteristics were balanced using propensity score matching. The risk of CTS in the OA and non-OA cohort were evaluated using incidence rates and adjusted hazard ratios that were estimated using Cox regression.

RESULTS

After applying the inclusion/exclusion criteria, 3,610,240 of the 6,023,384 adults with a diagnosis of OA remained in the OA cohort. After propensity-score matching, each cohort included 1,033,439 individuals. The incidence rates for CTS per 1000 person-years were 7.35 (95% confidence interval [CI] 7.21-7.49) in the OA cohort and 1.44 (95% CI 1.38-1.50) in the non-OA cohort. The risk of developing CTS in patients with OA was ~ 4 times that of patients without (hazard ratio = 3.80; 95% CI 3.54-4.07). This increased risk was found across all OA joint types, with OA of the hand/wrist having the highest risk for CTS. Additionally, multiple OA joints presented a higher risk compared with a single affected joint.

CONCLUSIONS

OA increases the risk of CTS, but this is not limited to patients with hand/wrist OA, suggesting a systemic impact of OA on CTS. While the risk appears highest for patients with hand/wrist OA, patients with more distant affected joints like knee or hip also have an increased risk of CTS.

Decision for Carpal Tunnel Surgery: High-deductible Health Plans versus Traditional Health Plans

Background

Delay in surgical treatment for carpal tunnel syndrome (CTS) may result in long-term decreased functional outcomes. Few investigators have examined the relationship between type of health insurance plan and time to definitive treatment of CTS following diagnosis. We investigated the relationship between insurance type, treatment decision, and the time between diagnosis and surgery across groups.

Methods

This was a retrospective cohort study using the MarketScan Commercial Claims and Encounters Database 2011-2020. We used χ2 tests, linear regression, and logistic regression models to analyze demographic data and the time lag interval between CTS diagnosis and treatment.

Results

Overall, 28% of high-deductible health plan (HDHP) patients underwent carpal tunnel release, compared with 20% of traditional insurance patients (P < 0.001). HDHPs are defined by the internal revenue service as a deductible of $1400 for an individual or $2800 for a family per year. The odds of undergoing surgery versus no treatment for HDHP patients were 47% higher than traditional patients (P < 0.001). Among the patients who underwent surgery, HDHP patients underwent surgery 65 days earlier on average following diagnosis compared with traditional patients (P < 0.001).

Conclusions

Patients with HDHPs who receive a diagnosis of CTS are more likely to undergo surgery, with a shorter time lag between diagnosis and surgery. The results from this study call attention to differences in surgical decision-making between patients enrolled in different insurance plans.

Natural evolution of idiopathic carpal tunnel syndrome with respect to wrist and hand anthropometry: A prospective cohort study

OBJECTIVE

A greater wrist depth/width ratio and wrist depth/palm length ratio are known risk factors for carpal tunnel syndrome. We hypothesized that these parameters might also predict progression in patients who were not surgically treated.

METHODS

Seventy-eight patients with moderately severe idiopathic carpal tunnel syndrome of at least 10 months duration at recruitment, who declined surgical treatment and steroid injection, underwent repeated neurophysiological assessments after 3 years. A > 10% increase in median SNAP latency was taken as evidence of significant deterioration.

RESULTS

Patients with a wrist ratio ≥ 0.72 showed a statistically significant deterioration in SNAP latency from 5.46 (SD 2.09) to 7.16 (SD 1.56) ms and in SNAP amplitude from 30.19 (SD 13.8) to 16.62 (SD 14.42) µv. For those with a wrist-to-palm ratio ≥ 0.42, SNAP latency deteriorated from 5.27 (SD 1.21) to 7.1 (SD 1.52) ms, and amplitude from 32.78 (SD 13.76) to 19.45 (SD 16.62) µv. Patients with lower ratios did not show significant changes in any neurophysiological parameter. The relative risk of significant deterioration in SNAP latency in patients with a wrist ratio ≥ 0.72 was 2.04 (95% CI 1.27-3.27).

CONCLUSION

In untreated idiopathic carpal tunnel syndrome, patients with larger wrist and wrist-to-palm ratios are more likely to show neurophysiological progression.

Temporal Changes in Electrophysiological Parameters in Untreated Patients With Carpal Tunnel Syndrome

INTRODUCTION

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy worldwide. This study aimed to investigate the temporal changes in electrophysiological parameters in untreated patients with CTS.

METHODS

Patients were recruited among those with the symptoms of CTS who were referred to the electrophysiology laboratory of Niğde Ömer Halisdemir University Bor Physical Therapy and Rehabilitation Hospital in Niğde, Turkey. Forty-nine patients (78 hands) who had not received any sort of treatment for CTS and had prior electrophysiological examination postive for CTS were included. Laboratory records were reviewed retrospectively. Recent electrophysiological parameters of the patients were compared to their prior examinations using Wilcoxon signed-rank test and sign test was used to compare the change in the electrophysiological severity of the study hands between two examinations. One-way analysis of variance (ANOVA) was used to compare individual parameters of the median NCS among electrophysiological change groups (improved, deteriorated, and same).

RESULTS

The mean age was 50 ± 11 years, and 43 (88%) patients were female. The mean duration of time between the two electrophysiological examinations was 37 ± 20 months. Median sensory peak latency and median motor distal latency increased significantly in the second evaluation (p=0.005 and p=0.004, respectively). Median sensory conduction velocity decreased in the second examination (p=0.002). However, CTS severity determined electrophysiologically did not differ significantly in the two examinations (p=0.286).

CONCLUSION

Although there was a deterioration in electrophysiological parameters during a mean follow-up period of 37 months, the electrophysiological severity of the patients did not worsen.

Carpal Tunnel Syndrome: As Seen from the Perspective of the Patient

Carpal tunnel syndrome (CTS) is the most common nerve compression syndrome in the upper extremity and is one of the most common problems treated by hand surgeons. Despite its ubiquity-or perhaps because of it-there is a lack of unanimity regarding how best to treat CTS and what the options for treatment are. This study aimed to explore what patients find important when deciding on treatment of CTS in an effort to improve the physician-patient shared decision-making process.

Methods

An online crowdsourcing platform was used to recruit participants for this study. Study participants were first led through a clinical scenario in which the symptoms of CTS were explained. They were then asked a series of questions regarding what was important to them when deciding upon treatment. A Likert scale was used for responses.

Results

In total, 268 participant responses were included in the study. A majority of patients responded that all surveyed factors were either very important or important when considering treatment. The risk of surgery was most important, whereas postoperative pain was least important. The risk of surgery was significantly more important to patients than postoperative pain and time out of work. The cost of surgery was significantly more important to patients than postoperative pain.

Conclusions

Given the lack of consensus regarding an algorithm for the treatment of CTS, the patient's preference is increasingly important when formulating a treatment plan. The results of this study may better help physicians frame the discussion of treatment options for CTS with their patients.

Local corticosteroid injection versus placebo for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA in 1995 alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS many years, but its effectiveness is still debated.

OBJECTIVES

To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome compared to no treatment or a placebo injection.

SEARCH METHODS

We used standard, extensive Cochrane search Methods. The searches were 7 June 2020 and 26 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local injection of corticosteroid (LCI) into the wrist and one group that received a placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. requirement for carpal tunnel surgery, 7. improvement in quality of life and 8.

ADVERSE EVENTS

We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 14 trials with 994 participants/hands with CTS. Only nine studies (639 participants/hands) had useable data quantitatively and in general, these studies were at low risk of bias except for one quite high-risk study. The trials were conducted in hospital-based clinics across North America, Europe, Asia and the Middle East. All trials used participant-reported outcome measures for symptoms, function and quality of life. There is probably an improvement in symptoms measured at up to three months of follow-up favouring LCI (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.94 to -0.59; 8 RCTs, 579 participants; moderate-certainty evidence). Up to six months this was still evident favouring LCI (SMD -0.58, 95% CI -0.89 to -0.28; 4 RCTs, 234 participants/hands; moderate-certainty evidence). There is probably an improvement in function measured at up to three months favouring LCI (SMD -0.62, 95% CI -0.87 to -0.38; 7 RCTs, 499 participants; moderate-certainty evidence). We are uncertain if there is a difference in median nerve DML at up to three months of follow-up (mean difference (MD) -0.37 ms, 95% CI -0.75 to 0.02; 6 RCTs, 359 participants/hands; very low-certainty evidence). The requirement for surgery probably reduces slightly in the LCI group at one year (risk ratio 0.84, 95% CI 0.72 to 0.98; 1 RCT, 111 participants, moderate-certainty evidence). Quality of life, measured at up to three months of follow-up using the Short-Form 6 Dimensions questionnaire (scale from 0.29 to 1.0; higher is better) probably improved slightly in the LCI group (MD 0.07, 95% CI 0.02 to 0.12; 1 RCT, 111 participants; moderate-certainty evidence). Adverse events were uncommon (low-certainty evidence). One study reported 2/364 injections resulted in severe pain which resolved over "several weeks" and 1/364 injections caused a "sympathetic reaction" with a cool, pale hand that completely resolved in 20 minutes. One study (111 participants) reported no serious adverse events, but 65% of LCI-injected and 16% of the placebo-injected participants experienced mild-to-moderate pain lasting less than two weeks. About 9% of participants experienced localised swelling lasting less than two weeks. Four studies (229 participants) reported that they experienced no adverse events in their studies. Three studies (220 participants) did not specifically report adverse events.

AUTHORS' CONCLUSIONS

Local corticosteroid injection is effective for the treatment of mild and moderate CTS with benefits lasting up to six months and a reduced need for surgery up to 12 months. Where serious adverse events were reported, they were rare.

Diacutaneous Fibrolysis Intervention in Patients with Mild to Moderate Carpal Tunnel Syndrome May Avoid Severe Cases in Elderly: A Randomized Controlled Trial

BACKGROUND

Carpal Tunnel Syndrome (CTS) mainly affects adults of working age. The prevalence of severe cases is higher in elderly patients (>65 years old). Clinical guidelines recommend conservative treatment as the best option in the initial stages of CTS to avoid severe cases. Diacutaneous Fibrolysis (DF) has demonstrated to improve nerve conduction studies and mechanosensitivity. The main purpose was to quantify changes in the cross-sectional area (CSA) of the median nerve, transversal carpal ligament (TCL) thickness, numbness intensity, and the subjective assessment of clinical change after DF treatment in patients with CTS.

METHODS

a double-blind, randomized, placebo-controlled trial was designed. A number of 44 patients (60 wrists) with CTS were randomized to the DF group or the sham group. CSA and TCL thickness variables were registered by ultrasound. Clinical variables were assessed by the visual analogue scale and GROC scale. SPSS version 24.0 for MAC was used for statistical analysis. The group by time interaction between groups was analyzed using two-way repeated measures analysis of variance.

RESULTS

The DF group reduced CSA with a mean of 0.45 mm² (IC 95% 0.05 to 0.86) and TCL thickness with a mean reduction of 0.4 mm (IC 95% 0.6 to 2.1) compared to the sham group (p < 0.01, p < 0,03, respectively). Additionally, the DF group decreased the numbness intensity with a mean reduction of 3.47 (IC 95% 2.50 to 4.44, p < 0.01) and showed a statistically significant improvement on the GROC scale (p < 0.01).

CONCLUSIONS

DF treatment may significantly reduce CSA and TCL thickness, numbness intensity, and improved clinical perspective. DF applied in patients with mild to moderate CTS may prevent the progression of the disease as they age.

Response to local corticosteroid injections in carpal tunnel syndrome with normal conduction studies

INTRODUCTION

Nerve conduction studies (NCS) have been considered as the gold standard in carpal tunnel syndrome (CTS) diagnosis, despite correlation between clinical symptomatology and NCS severity has shown to be poor. In fact, clinical symptoms precede NCS changes in months or years. Few papers have been published about the clinical response to treatment of clinically typical CTS, but with normal NCS (NNCS).

OBJECTIVE

To compare the clinical response to local corticosteroid injections (LCI) in clinically typical CTS, with NNCS and abnormal NCS (ANCS).

METHOD

We included patients older than 18, with typical CTS symptoms (ongoing daily nocturnal pain/paresthesias in hand, at least during 3 months). Follow-up was done at 3, 6 and 12 months. Primary outcome was the visual analog scale for pain (p-VAS), comparing NNCS CTS wrists with ANCS CTS wrists. Statistic signification was established by the Student's t test, Mann-Whitney's "U", χ² test and Yates' correction.

RESULTS

We included 44 wrists in the NNCS group, and 83 in the ANCS group. There was no statistical significance between data in both groups, except in the 12-month follow-up, where the NNCS group achieved better results than the ANCS group in the 20% response (p=0.006). There was a trend toward a better 50% response in the 12-month follow-up.

CONCLUSIONS

Our data suggest that LCI are similarly effective in both CTS with NNCS and ANCS. Nonetheless, there is a mild better effect in NNCS than in ANCS at 12-month follow-up.

Occupational Therapists, Physiotherapists and Orthopaedic Surgeons Agree on the Decision for Carpal Tunnel Surgery

BACKGROUND

Therapist-led pathways have been proposed as waitlist management strategies prior to surgery for conditions such as carpal tunnel syndrome (CTS) in public hospitals. These models of care typically shift the initial care of patients and decision-making from surgeons to therapists and, have been shown to reduce the number of patients requiring surgery and improve wait-times. This occurs despite limited evidence of surgeon-therapist agreement on key decisions, such as the need for surgery. The purpose of this was study was to assess the agreement between therapists and orthopaedic surgeons regarding the need for surgery for patients who have CTS.

METHODS

This blinded inter-rated agreement study was embedded in a multicentre randomised parallel groups trial of 105 patients with CTS referred to four orthopaedic departments and waitlisted for an appointment. The trial evaluated the effect of a therapist-led care pathway on the need for surgery and outcomes related to symptoms and function. Patients were randomised to either remain on the orthopaedic waitlist or receive group education, a splint and home exercises. The decision on the need for surgery at 6 months was made by a member of the orthopaedic consultant team or by one of the 14 participating therapists. The therapists and surgeons were blinded to each other's decision. Agreement was determined using percentage agreement, kappa coefficients (k), prevalence-adjusted and bias-adjusted kappa (PABAK), and Gwet's first-order agreement coefficient (AC1).

RESULTS

Substantial agreement was seen between therapists and surgeons regarding the need for surgery (PABAK=0.74 (0.60-0.88)). Agreement was significantly associated with experience (P=.02). Therapists with advanced experience and scope of practice demonstrated perfect agreement with surgeons (PABAK=1.00 (95% CI: 1.00-1.00)). Mid-career therapists demonstrated substantial agreement (PABAK=0.67 (95% CI: 0.42-0.91)) and early-career therapists demonstrated fair agreement (PABAK=0.43 (95% CI: -0.04-0.90)).

CONCLUSION

Therapists with advanced scope of practice make decisions that are consistent with orthopaedic surgeons.

Update on Efficacy of Conservative Treatments for Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common upper extremity compression neuropathy. Non-operative interventions are usually the first-line treatments, and surgery is reserved for those that do not achieve a satisfactory symptom state by non-operative means. This narrative review summarizes the current evidence regarding the efficacy of orthoses, corticosteroid injections, platelet-rich plasma injections, Kinesio taping, neurodynamic techniques, gabapentin, therapeutic ultrasound, and extracorporeal shockwave therapy in people with CTS. While many trials suggest small short-term benefits, rigorous evidence of long-term patient-important benefits is limited. To improve the utility of healthcare resources, research in this area should focus on establishing efficacy of each treatment instead of comparing various treatments with uncertain benefits.

The long-term analgesic effectiveness of platelet-rich plasma injection for carpal tunnel syndrome: a cross-sectional cohort study

OBJECTIVE

Interest in perineural platelet-rich-plasma (PRP) injections for the treatment of carpal tunnel syndrome (CTS) has increased in recent years. However, evidence supporting the long-term effectiveness of PRP is lacking. Therefore, the aim of our cross-sectional cohort study was to investigate the long-term results of PRP injections for CTS.

METHODS

Eighty-one patients diagnosed with CTS of any grade who received a single PRP injection at least 2 years prior were enrolled. Through structured telephone interviews, all patients were asked of their post-injection outcomes compared to their pre-injection condition. Symptom relief ≥50%, compared to the pre-injection condition, was considered an effective outcome. Binary logistic regression was applied to analyze each baseline variable as a regressor for determining the prognostic outcome factors.

RESULTS

In total, 70% of patients reported positive outcomes ≥2 years post-injection. Shorter duration of symptoms before treatment (odds ratio: 0.991; 95% confidence interval [CI] 0.983-0.999; p = 0.023) and lower electrodiagnostic severity of CTS were the main prognostic factors for an effective outcome (mild grade vs. severe grade, odds ratio: 17.652; 95% CI 1.43-221.1; p = 0.025). Although there was a trend toward positive outcomes at longer follow-up durations (2-3 years vs. 3-4 years vs. 4-5 years), the difference was not statistically significant.

CONCLUSION

A single perineural PRP injection has a long-term analgesic effect on CTS, especially in mild-to-moderate cases.

Outcome predictors of platelet-rich plasma injection for moderate carpal tunnel syndrome

INTRODUCTION

Platelet-rich plasma (PRP) injection is effective for mild-to-moderate carpal tunnel syndrome (CTS), and physicians have been using PRP injections to treat CTS. However, the predictive factors of PRP injections have not been evaluated. This retrospective study sought to identify the predictive factors of PRP injections in patients with moderate CTS.

METHODS

Seventy-one patients with moderate CTS receiving single PRP injections were enrolled. The outcomes at the third- and sixth-month postinjection visits were categorised into good and poor groups according to the following: (1) good outcome, with visual analogue scale (VAS) score decrease ≧50% and (2) poor outcome, with VAS score decrease <50% of preinjection scores. Significant variables between groups were entered into a binary logistic regression to determine the predictive factors.

RESULTS

The baseline body weight (BW), distal motor latency (DML), sensory nerve conduction velocity (SNCV), and cross-sectional area (CSA) of the median nerve were significantly different between the groups in the third month. The odds ratios (ORs) of all features were significant, except for SNCV (BW, OR: 0.911; P = .016; DML, OR: 0.383; P = .028; CSA, OR: 0.694; P = .003), and they remained significant in the sixth month (BW, OR: 0.909; P = .004; DML, OR: 0.530; P = .011; CSA, OR: 0.828; P = .032).

CONCLUSION

Lower BW, DML, and CSA values of the median nerve predict better outcomes after perineural injection of PRP for moderate CTS at the 3- and 6-month follow-ups.

[Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]

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.

Response to Local Corticosteroid Injections in Carpal Tunnel Syndrome With Normal Conduction Studies

INTRODUCTION

Nerve conduction studies (NCS) have been considered as the gold standard in carpal tunnel syndrome (CTS) diagnosis, despite correlation between clinical symptomatology and NCS severity has shown to be poor. In fact, clinical symptoms precede NCS changes in months or years. Few papers have been published about the clinical response to treatment of clinically typical CTS, but with normal NCS (NNCS).

OBJECTIVE

To compare the clinical response to local corticosteroid injections (LCI) in clinically typical CTS, with NNCS and abnormal NCS (ANCS).

METHOD

We included patients older than 18, with typical CTS symptoms (ongoing daily nocturnal pain/paresthesias in hand, at least during 3 months). Follow-up was done at 3, 6 and 12 months. Primary outcome was the visual analog scale for pain (p-VAS), comparing NNCS CTS wrists with ANCS CTS wrists. Statistic signification was established by the Student's t test, Mann-Whitney's "U", χ2 test and Yates' correction.

RESULTS

We included 44 wrists in the NNCS group, and 83 in the ANCS group. There was no statistical significance between data in both groups, except in the 12-month follow-up, where the NNCS group achieved better results than the ANCS group in the 20% response (p=0.006). There was a trend toward a better 50% response in the 12-month follow-up.

CONCLUSIONS

Our data suggest that LCI are similarly effective in both CTS with NNCS and ANCS. Nonetheless, there is a mild better effect in NNCS than in ANCS at 12-month follow-up.

Long-term outcome after perineural injection with 5% dextrose for carpal tunnel syndrome: a retrospective follow-up study

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSION

Perineural injection therapy is a novel approach for treatment of carpal tunnel syndrome with safe and outstanding long-term effects.

Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management

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.

Laser Acupuncture for Carpal Tunnel Syndrome: A Single-Blinded Controlled Study

Objectives: This study aimed to compare the efficacy of laser acupuncture (LA) treatment with that of placebo LA treatment in patients with idiopathic, mild-to-moderate carpal tunnel syndrome (CTS), as measured by subjective symptom assessments and objective changes in nerve conduction studies (NCSs). Design: A randomized, single-blinded, controlled study. Settings: A Teaching Hospital in the Taichung, Taiwan between March 2013 and November 2013. Subjects: 84 consecutive treatment-naive patients with CTS. Interventions: Participants were randomly divided into two treatment arms: (1) LA, administered at traditional Chinese acu-points on the affected side, once a day, 5 times a week, for 4 weeks (N = 43); and (2) placebo LA, administered using the same device and protocol, with the LA device switched off (N = 41). Outcome measures: Patients completed the Global symptom score (GSS) at baseline and two and four weeks later. The primary outcome was changes in GSS. NCSs were performed at baseline and repeated at the end of the study as a secondary outcome. Results: There was a significantly greater reduction in GSS in the LA group than in the placebo group at week 2 (-9.30 ± 4.94 vs. -2.29 ± 4.27, respectively, P < 0.01) and at week 4 (-10.67 ± 5.98 vs. -2.90 ± 5.61, respectively, P < 0.01). However, NCSs did not show significant difference between the two groups. Conclusions: LA may be more effective than placebo LA in the treatment of mild-to-moderate idiopathic CTS in terms of subjective measurement. For patients who fear needle-based treatment, such as acupuncture or local injections, or those who do not opt for early surgical decompression, LA treatment can be considered as an effective and alternative form of acu-points stimulation therapy.

Resultado clínico y electrodiagnóstico en pacientes con liberación quirúrgica del síndrome del túnel del carpo

Introducción. La cirugía de síndrome del túnel del carpo (STC) es efectiva, aunque algunos reportes muestran satisfacción de solo el 75% luego de los procedimientos. La escala funcional HiOb es la que mejor se correlaciona con el estado neurofisiológico del nervio mediano.Objetivo. Determinar los resultados clínicos, funcionales y electrofisiológicos luego de una liberación quirúrgica en pacientes con STC.Materiales y métodos. Estudio analítico y descriptivo de pacientes con STC operados entre 2013 y 2014. Todos los individuos tenían pruebas clínicas y electrofisiológicas pre y post quirúrgicas.Resultados. Se estudiaron 36 pacientes con edad promedio de 49 años; los signos clínicos prequirúrgicos más frecuentes fueron Phalen y elevación de manos (91%). El seguimiento mínimo fue 6 meses. Hubo mejoría del dolor; de los signos de Tinel, de Phalen y de elevación de manos; en la escala HiOb, y en el Cuestionario de Boston, tanto en la función como en los síntomas. Los resultados electrofisiológicos mostraron mejoría en latencia distal motora del nervio mediano, latencia distal sensitiva del nervio mediano y delta sensitivo.Conclusiones. La liberación quirúrgica del STC es un procedimiento eficaz en la mejoría del dolor, los síntomas, las escalas funcionales y los hallazgos electrofisiológicos. El signo de Tinel prequirúrgico se asocia a peores resultados en el cuestionario de Boston.

Role of Biomechanical Factors in Resolution of Carpal Tunnel Syndrome Among a Population of Workers

OBJECTIVES

Identify if Carpal tunnel syndrome (CTS) symptoms vary by measured biomechanical exposures.

METHODS

A nested prospective cohort within a large, multicenter, 8-year cohort study. The CTS case definition was tingling/numbness in 2+ median nerve-served digits plus a nerve conduction study consistent with CTS. Workers were assigned to: (1) low (strain index [SI] less than or equal to 6.1), and (2) high (SI more than 6.1) job groups.

RESULTS

Among 1201 workers, 106 had CTS. Those in the high SI group became and remained symptom-free for at least 3 months, faster than the low SI group, adjusted hazard ratio (HR) = 2.07 (95% confidence interval [CI] = 1.21 to 3.56, P = 0.008). Only surgical release trended towards resolving CTS. Light duty had no impact, and job change was associated with delayed symptoms resolution.

CONCLUSIONS

High biomechanical exposures paradoxically predicted faster improvement in CTS and light duty did not result in symptom resolution.

Nerve hydrodissection for carpal tunnel syndrome: A prospective, randomized, double-blind, controlled trial

INTRODUCTION

In this study we explored the efficacy of nerve hydrodissection for mild-to-moderate carpal tunnel syndrome (CTS).

METHODS

Thirty-four participants were randomly assigned to an intervention group or a control group. One 5-ml dose of normal saline was injected into the intracarpal and subcutaneous regions in subjects of both groups, respectively. The primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score. Secondary outcomes were cross-sectional area of the median nerve and electrophysiological studies. Assessments were performed before the injection and at 1, 2, 3, and 6 months postintervention.

RESULTS

Compared with the control group, the intervention group showed significantly greater improvement at the second and third posttreatment months according to BCTQ severity score and at all time-points for cross-sectional area of the median nerve (P < 0.01).

DISCUSSION

Our study demonstrates the therapeutic effects of nerve hydrodissection for mild-to-moderate CTS. Muscle Nerve 59:174-180, 2019.

Determinants of Remission in Medically Treated Carpal Tunnel Syndrome: Study from Central India

Background:

The factors associated with the spontaneous remission (SR) of symptoms in carpal tunnel syndrome (CTS) are not well known.

Objectives:

To look for determinants of SR in medically treated, electrophysiologically proven patients of CTS.

Methods:

We revisited the medical records and nerve conduction study data of 130 hands with CTS and divided them into two groups as per the absence or persistence of the symptoms when contacted after a median time lapse of 3 years following the diagnosis.

Results:

SR occurred in 46.1% of the hands. Higher odds of SR were linked with female gender, symptoms restriction to lateral fingers, symptom duration <10 months, mildly delayed median motor and sensory distal latencies, and median sensory amplitude >20 μV. We developed a seven-point scale, on which a score of ≥4 had a strong association (odds ratio 4.31) with SR.

Discussion and Conclusion:

No single risk factor, standalone, can predict SR in patients with CTS, which could lead to an invasive treatment (Surgery or local injection) to them. We propose that patients scoring ≥4 on our 7 point scale should be treated medically for the initial 10 months after the symptom onset.

Gradual Onset Diseases: Misperception of Disease Onset

PURPOSE

Gradual onset diseases (eg, carpal tunnel syndrome, cubital tunnel syndrome, and trapeziometacarpal arthrosis) tend to go unnoticed for years. When a slowly progressive disease transitions from asymptomatic to symptomatic, it may seem like an acute event. The primary aim of this study was to determine the percentage of patients who perceive the slowly progressive disease as having started within 1 year. We also hypothesized that (1) there would be no factors associated with perception of an onset of disease within 1 year, more specifically among patients with advanced disease; and (2) there would be no difference in a decision to pursue operative treatment between patients who perceived the onset of the disease to be recent and those who perceived it to be long-standing.

METHODS

In this retrospective study, we reviewed the medical records of 732 patients newly diagnosed with carpal tunnel syndrome (n = 114), cubital tunnel syndrome (n = 276), or trapeziometacarpal arthrosis (n = 342), for the onset of symptoms. Multiple factors were assessed for (1) association with perception of disease onset within 1 year, and (2) choice for operative treatment in bivariate and multivariable analyses.

RESULTS

A total of 69% of all subjects and 68% of patients with advanced disease perceived the disease as having started within 1 year. A perceived provocation (such as an injury or surgery) was associated with a perception of recent onset. A decision to pursue operative treatment was not different between the 2 groups.

CONCLUSIONS

Slowly progressive diseases are often misperceived as relatively new.

CLINICAL RELEVANCE

Effective communication strategies are important to ensure that people make choices consistent with their values and not based on misconceptions.

Injection versus Decompression for Carpal Tunnel Syndrome-Pilot trial (INDICATE-P)-protocol for a randomised feasibility study

Background

Carpal tunnel syndrome (CTS) is the commonest peripheral nerve disorder in the UK, with over 52,996 carpal tunnel decompressions performed in 2011. By 2030, this figure is estimated to double. Whilst evidence supports conservative measures for mild symptoms, and early surgery for severe symptoms, controversy remains over the most appropriate management for patients that present with moderate disease, with regard to early surgery or late surgery following steroid injection. Injection versus Decompression for Carpal Tunnel Syndrome-Pilot trial (INDICATE-P) is a feasibility study for a multicentre, randomised controlled trial (INDICATE) to determine whether patients over the age of 18 with moderate CTS should undergo early surgical decompression of the median nerve or a single steroid injection (followed by later surgery if required).

Methods/design

INDICATE-P is a feasibility study for an open (non-blinded) randomised controlled pilot trial. Eligible participants will be adults with a clinical diagnosis of moderate CTS. This is defined as symptoms disturbing sleep or restricting activities of daily living or work, despite a 2-week trial of night splints. Participants will be randomised to one of two possible interventions: surgical decompression or a single steroid injection (followed by surgery later if required). Clinical outcome measures will be captured by postal questionnaire at 1, 3, 6 and 12 months post-randomisation. In order to improve the study design for the main INDICATE trial, feasibility data will also be collected to identify difficulties in recruitment and retention, to gain patient feedback on questionnaires and to confirm the suitability of the proposed outcome measures.

Discussion

The INDICATE-P feasibility study will contribute to the design and execution of the INDICATE trial, which will seek to assess the safety and effectiveness of two approaches to treatment for patients over 18 years of age with moderate CTS: early carpal tunnel decompression or a single steroid injection (followed by later surgery).

The use of FloSeal haemostatic sealant in the management of epistaxis: a prospective clinical study and literature review

INTRODUCTION It is standard practice in the UK that if conservative measures or chemical cautery fail to control epistaxis, patients receive nasal packing which is often uncomfortable, requires admission and has well documented associated morbidity. Our study aims to evaluate the use of FloSeal haemostatic sealant in managing patients with epistaxis. MATERIALS AND METHODS Patients were identified from those referred with active epistaxis. A successful outcome was defined as complete haemostasis with FloSeal alone, with no further significant bleeding requiring admission or further interventions in the subsequent 7 days. Patients reported satisfaction using a ten-point visual analogue scale. Ear, nose and throat doctors recorded patient demographics, time to prepare FloSeal, length of stay, need for further treatment and adverse events on an electronic database. RESULTS 30 patients were enrolled in the study. The mean time to prepare FloSeal was 5 minutes. The success rate of FloSeal was 90%. The mean length of stay was 2.75 hours. The mean patient satisfaction with FloSeal was 8.4/10. No adverse events occurred. DISCUSSION FloSeal was found to be effective in controlling anterior epistaxis. There was a single case of posterior epistaxis which required operative management. The literature largely supports FloSeal in anterior epistaxis, but indicates sphenopalatine artery ligation as the definitive management of posterior epistaxis. CONCLUSIONS Our data support the use of FloSeal in patients with anterior epistaxis not controlled with conservative measures or chemical cautery. It was found to be easy to use, is well tolerated by patients and is efficient in financial terms.

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Background

NHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.

Objectives

We aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.

Methods

We used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.

Results

There was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.

Conclusions

Policy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance

This randomized controlled study addressed whether sonographic needle guidance affected the outcomes of corticosteroid injection for symptomatic carpal tunnel syndrome. Seventy-seven symptomatic carpal tunnels were randomized to injection by either (1) conventional anatomic landmark palpation-guided injection or (2) sonographic image-guided injection, each using a two-step technique where 3 ml of 1% lidocaine was first injected to hydrodissect and hydrodisplace critical intra-carpal tunnel structures followed by injection with 80 mg of triamcinolone acetonide (2 ml). Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, total cost, and cost per responder were determined. There were no complications in either treatment group. Relative to conventional anatomic landmark palpation-guided methods, sonographic guidance for injection of the carpal tunnel resulted in 77.1% reduction in injection pain (p<0.01), a 63.3% reduction in pain scores at outcome (p<0.014), 93.5% increase in the responder rate (p<0.001), 84.6% reduction in the non-responder rate (p<0.001), a 71.0% increase in therapeutic duration (p<0.001), and a 59.3% ($150) reduction in cost/responder/year for a hospital outpatient (p<0.001). However, despite improved outcomes, cost per patient per year was significantly increased for an outpatient in a physician's office and was neutral for a hospital outpatient. Sonographic needle guidance significantly improves the performance and clinical outcomes of injection of the carpal tunnel and is cost-effective for a hospital-based practice, but based on current reimbursements, it significantly increases overall costs for medical care delivered in a non-hospital-based physician practice.

A comparison of the results of carpal tunnel release in patients in different age groups

BACKGROUND AND PURPOSE

The age of the patient at the onset of the disease may influence its course and outcome of the treatment. The objective of this study was to compare outcomes of carpal tunnel release in patients in different age ranges.

MATERIAL AND METHODS

The records from the register of patients with carpal tunnel syndrome who were operated on in the authors' department over a period of two years (between 2009 and 2011) were analyzed. A total of 386 patients with carpal tunnel syndrome, 322 female (83%) and 64 male (17%) with a mean age of 57 (range: 30-81) years were divided into three sub-groups according to their age: 40 years or less (n = 28), 41-65 years (n = 248) and over 65 years (n = 73). All patients received mini-open carpal tunnel release. The results were assessed at 6 months after the operation by the Levine questionnaire and measurements of grip and pinch strengths as well as sensation of a light touch by the filament test.

RESULTS

At the six-month follow-up, all patients showed significant resolution of symptoms as assessed by the Levine symptom score (from 3.3 to 1.4) and significant improvement of the dexterity of the hand, as assessed by the Levine function score (from 3.0-3.2 to 1.6-1.8). All patients showed significant improvement of sensation of a light touch and in-crease of grip and pinch strengths. However, patients older than 60 years showed less improvement of the total grip strength of the hand.

CONCLUSION

Patients with carpal tunnel syndrome at any age may expect a similar benefit from surgery.

[Neurography for diagnosing carpal tunnel syndrome]

BACKGROUND

A number of evidence-based guidelines now recommend that a nerve conduction study should be used to confirm the existence of carpal tunnel syndrome before any surgery takes place.

METHOD

The article is based on a search in PubMed, a personal literature archive (1980-2011) and long clinical experience of neurological and neurophysiological diagnostics.

RESULTS

Both motor and sensory nerve fascicles must be tested after adequate warming up. An extended nerve conduction study with supplementary tests to compare velocities and latencies in median and ulnar nerves, increases the diagnostic precision. Given normal or mild findings, surgery can usually be avoided as the first choice of treatment, because many patients with mild carpal tunnel syndrome recover spontaneously.

INTERPRETATION

The gold standard for diagnosis of carpal tunnel syndrome should be a combination of a clinical examination and a nerve conduction study.

The results of carpal tunnel release for carpal tunnel syndrome diagnosed on clinical grounds, with or without electrophysiological investigations: a randomized study

We compared the results of carpal tunnel release in patients with the diagnosis of carpal tunnel syndrome based on only clinical grounds and those diagnosed on clinical and electrophysiological grounds. Ninety-three patients, 83 women (89%) and ten men (11%), meeting the criteria of 'typical' carpal tunnel syndrome, were randomly assigned to receive carpal tunnel release with (n = 45, 48%) or without (n = 48, 52%) nerve conduction studies. Patients were followed-up at 1 and 6 months, by assessments that included the Levine scores, filament tests, grip and pinch strength. No significant differences in Levine scores were found at the 1 and 6 months assessments. Statistically significant differences were noted in three-point pinch strength and sensation; however, they were not of clinical importance. The results of the study show that the results of carpal tunnel release in patients with typical symptoms are no better after nerve conduction studies and, therefore, nerve conduction studies can be omitted.

A randomized clinical trial of acupuncture versus oral steroids for carpal tunnel syndrome: a long-term follow-up

We prospectively followed up patients with carpal tunnel syndrome (CTS) in our previous study for 1 year. A total of 77 consecutive patients with electrophysiologically confirmed mild-to-moderate idiopathic CTS were randomized and assigned into 2 treatment arms: 1) 2 weeks of prednisolone 20 mg daily followed by 2 weeks of prednisolone 10 mg daily (n = 39); and 2) acupuncture administered in 8 sessions over 4 weeks (n = 38). In the current study, the patients were further followed up at 7 and 13 months using Global symptom score (GSS) assessments and nerve conduction studies repeated again at 13 months. When comparing with baseline levels, the percentages of patients with treatment failure, moderate improvement, and good improvement were significantly different between the 2 groups at month 7 [10.5, 2.6, and 86.8% for the acupuncture group and 33.3, 7.7, and 59% for the steroid group, respectively (P = .014)] and month 13 [15.8, 2.6, and 81.6% versus 51.3, 0, and 48.7%, respectively (P = .002)]. The acupuncture group had a significantly better improvement in GSS, distal motor latencies and distal sensory latencies when compared to the steroid group throughout the 1-year follow-up period (P < .01). Furthermore, significant correlation was observed between changes of GSS (month 13-baseline) and all parameters of the electrophysiological assessments except for compound muscle action potential amplitude.

PERSPECTIVE

This article demonstrates that short-term acupuncture treatment may result in long-term improvement in mild-to-moderate idiopathic CTS. Acupuncture treatment can be considered as an alternative therapy to other conservative treatments for those who do not opt for early surgical decompression.

Carpal lock and the volar-supporting orthosis in mild and moderate carpal tunnel syndrome

OBJECTIVE

The carpal lock, which is a hand/wrist orthosis that supports the dorsal aspect of the hand, was used in patients with mild-moderate carpal tunnel syndrome, and its clinical and electrophysiological effectiveness was compared with that of a volar-supporting orthosis.

DESIGN

Nerve conduction study and clinical evaluation of 24 patients (41 hands) with mild or moderate carpal tunnel syndrome were performed before and 3 mos after the use of the carpal lock or the volar-supporting orthosis.

RESULTS

Significant improvement was observed in electrophysiological parameters and clinical outcomes after use of both orthoses. There was no statistically significant difference between the two groups. Patients in the carpal lock group used the orthosis 89.6% of the prescribed time, whereas those in the volar-supporting orthosis group used the orthosis 79.2% of the prescribed time (P < 0.05).

CONCLUSIONS

The carpal lock may be used as an alternative to the volar-supporting orthosis.

Carpal tunnel syndrome: long-term nerve conduction studies in 261 hands

OBJECTIVE

To compare a long-term carpal tunnel syndrome (CTS) on nerve conduction studies (NCS) in hands treated non-surgically.

METHOD

We retrospectively selected 261 symptomatic CTS hands (166 patients), all of them confirmed by NCS. In all cases, at least 2 NCS were performed in an interval greater than 12 months. Cases with associated polyneuropathy were excluded. NCS parameters for CTS electrodiagnosis included a sensory conduction velocity (SCV) < or =46.6 m/s (wrist to index finger, 14 cm) and distal motor latency (DML) > or =4.25 ms (wrist to APB, 8 cm).

RESULTS

92.8% were women; mean age was 49 years (20-76); the mean interval between NCS was 47 months (12-150). In the first exam, the median sensory nerve action potential (SNAP) and the compound action muscular potential were absent in 9.8% and 1.9%, respectively. In the second/last exam, SCV worsened in 54.2%, remained unchanged in 11.6% and improved in 34.2%. SNAP amplitude worsened in 57.7%, remained unchanged in 13.1% and improved in 29.2%. DML worsened in 52.9%, remained unchanged in 7.6% and improved in 39.5%. Overall, NCS parameters worsened in 54.9%, improved in 34.3% and remained unchanged in 10.8%.

CONCLUSION

Long-term changing in NCS of CTS hands apparently were not related to clinical symptomatology and could lead to some difficulty in clinical correlation and prognosis. Aging, male gender and absent SNAP were more related to NCS worsening, regardless the mean interval time between the NCS.

Current options for nonsurgical management of carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common of the entrapment neuropathies. Surgical decompression is commonly performed and has traditionally been considered the defnitive treatment for CTS. Conservative treatment options include physical therapy, bracing, steroid injections and alternative medicine. While CTS is often progressive, patients may get better without formal treatment. The resolution of symptoms is not necessarily related to the severity of the clinical findings and self-limited activity is common. The current literature suggests that bracing and corticosteroid injections may be useful in the nonsurgical treatment of CTS, although the benefits may be short term. There is limited evidence regarding the efficacy of other treatments, such as therapy, exercise, yoga, acupuncture, lasers and magnets, and further studies are needed. Surgery is recommended for progressive functional deficits and significant pain.

Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation

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.

A systematic review of anti-inflammatories for mild to moderate carpal tunnel syndrome

The purpose of this study was to evaluate anti-inflammatory drugs in the medium- and long-term management of mild to moderate carpal tunnel syndrome (CTS). The authors conducted a systematic review of the literature on the effectiveness of steroidal and nonsteroidal anti-inflammatory drugs for mild and moderate cases of CTS. There were included only randomized, double-blind clinical trials. Six publications referring to five trials were included in the review. No study on nonsteroidal anti-inflammatory drugs met our inclusion criteria. Although neurophysiological studies have not shown great differences resulting from the application of corticosteroids, the symptomatic benefit provided by such drugs is clear. In the short term, local infiltration provides better results than systemic administration of corticosteroids. Over a 1-year period, however, this difference does not persist. Further double-blind randomized trials evaluating therapeutic efficacy for a longer follow-up period are required to provide stronger evidence for both steroidal and nonsteroidal anti-inflammatories.

Severity scoring in carpal tunnel syndrome helps predict the value of conservative therapy

A prospective study was performed to assess the outcome of conservative treatment of carpal tunnel syndrome and to establish the predictive value of preoperative Boston carpal tunnel questionnaire scores. Sixty-seven patients with 101 symptomatic hands underwent an evidence-based education and conservative therapy regime prior to surgery. All patients were scored using the Boston carpal tunnel questionnaire at presentation and at 3 months. Fifty-eight of 67 patients completed both assessments providing a complete assessment of 89 symptomatic hands. The mean Boston carpal tunnel questionnaire scores improved significantly from 2.45 to 2.12 and throughout the duration of the study 73% of patients improved with conservative treatment and 14% did not require surgery. Severity scoring at presentation was predictive of outcome with conservative therapy. This work suggests that the Boston carpal tunnel questionnaire can be used to identify patients who are likely to respond to conservative treatment.