Bilateral carpal tunnel syndrome – A review

Bilateral Idiopathic Carpal Tunnel Syndrome: Clinical-Functional Characterization and Efficacy of Two Combined Postoperative Physiotherapeutic Treatments

OBJECTIVE

To evaluate the efficacy of combined association instrument myofascial mobilization (IASTM) and stretching in patients with idiopathic bilateral carpal tunnel syndrome (CTS) operated on one hand and to analyze the response of the operated (OH) and non-operated (NH) hand according to the sequence of therapies. Research on these parameters has not yet been found in the literature.

METHODS

Randomized controlled crossover study with 43 participants using the objective and subjective outcome variables. Patients were randomly assigned to two groups: starting with stretching followed by IASTM and starting with IASTM followed by stretching. Then patients underwent surgery on the hand with more severe involvement and physical therapy rehabilitation was started 30 days after for a period of 4 weeks. After the 1-week interval the participants who started with stretching were referred to IASTM and vice versa, following the same previous patterns. The outpatient reassessments took place at 3 to 6 months. Crossover ANOVA and effect sizes were used as analysis methods.

RESULTS

Time was the most significant outcome for all variables both during therapies and at 6-month follow-up. Regarding response to the combined therapies between OH and NH, there were differences for both OH and NH, with the greatest impact on NH for the palmar grip and VAS variables. The treatment sequences were significant for pain on the NH and mental SF-12, suggesting that starting with IASTM followed by stretching had a superior outcome for these outcomes.

CONCLUSION

The combination of IASTM with stretching, used in the postoperative period of bilateral idiopathic CTS, proved to be supplementary, with significant results and large effect sizes for most of the outcomes assessed, both during the time of application of the therapies and in the 6-month follow-up for both hands, and may constitute a viable therapeutic alternative for this population.

Factors affecting contralateral wrist surgery after one carpal tunnel release in bilateral carpal tunnel syndrome

Carpal tunnel syndrome (CTS) can be bilateral, with varying incidence. Carpal tunnel release (CTR) in one wrist may relieve the symptoms of the contralateral wrist, avoiding the need for second surgery; conversely, the symptoms may persist or worsen, requiring contralateral surgery in some cases. The present study investigated whether surgical treatment was finally required for the non-operated CTS wrist, and in what cases non-operative treatment was possible. We compared baseline characteristics, risk factors and electrodiagnostic data between CTS patients who underwent only unilateral CTR and those who subsequently underwent bilateral surgery at various time intervals. This single-center retrospective study included 188 patients with bilateral CTS managed between 2010 and 2020; 137 patients (group 1, 73%) underwent only unilateral CTR, and 51 (group 2, 27%) subsequently underwent contralateral CTR. In group 1, contralateral CTS symptoms were assessed in 4 categories and compared to the presenting symptoms in the index wrist. There were no significant differences in age, gender, preoperative symptom duration, body status, addictive behavior, electrodiagnostic study or comorbidities, other than a higher rate of dialysis in group 2. The contralateral wrist showed partial or complete symptom relief in 57% of patients undergoing unilateral CTR. High BMI and history of diabetes were risk factors for persistent severe CTS or subsequent contralateral CTR.

The effectiveness of the median nerve neurodynamic mobilisation techniques in women with mild or moderate bilateral carpal tunnel syndrome: A single-blind clinical randomised trial

BACKGROUND

Carpal tunnel syndrome (CTS) is the most prevalent upper limb compression neuropathy. Surgical or nonsurgical treatment is recommended. Both mild and moderate CTS can be managed conservatively. Neurodynamic mobilisation techniques (NMTs) of the median nerve have not been widely studied, and conflicting findings exist.

METHODS/DESIGN

Sixty-two female patients with mild or moderate bilateral CTS were assigned one wrist to the treatment group (TG) and the other to the control group (CG). Both groups underwent carpal bone mobilisation. The TG underwent NMTs while the CG received a placebo elbow mobilisation not targeting the median nerve. The Numerical Rating Pain Scale, JAMAR Plus Digital Hand dynamometer and Functional Status Scale (FSS) were used to assess pain, grip strength and functional status.

DISCUSSION

Comparison of groups showed that NMTs at 5 weeks decreased pain intensity by 1.15 (p = 0.001) and by 2 (p ˂ 0.001) at 10 weeks. Difference in functional status was 0.45 at 5 weeks (p = 0.003) and 0.84 at 10 weeks (p = 0.003). The CG's grip strength improved by 0.59 (p = 0.05) after 5 weeks and 0.61 (p = 0.028) at 10 weeks. Both groups improved in all parameters over time.

CONCLUSION

When combined with carpal bone mobilisation, both NMTs and placebo elbow mobilisation seem to reduce pain intensity and improve grip strength and functional status. However, NMTs had better results in pain intensity and FSS.

CLINICAL IMPLICATIONS

Women with mild or moderate bilateral CTS may benefit from NMTs as a conservative treatment option.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR202201807752672, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=19340.

Characteristics of surgically treated Guyon canal syndrome: A multicenter retrospective study

Guyon canal (GC) syndrome is a rare peripheral neuropathy involving the distal part of the ulnar nerve. Several causes are associated with GC syndrome, including anatomic variations, space-occupying tumors, and trauma. Because of disease rarity, the only reported studies of GC syndrome are case series with small sample size. We conducted a multicenter study to identify the basic characteristics of patients with surgically treated GC syndrome and the risk factors for the disease. This retrospective multicenter study was conducted between January 2001 and December 2020. We screened 70 patients who underwent GC release surgery by seven hand surgeons at six institutes. A total of 56 patients were included in this study, including 38 patients (67.9%) who underwent isolated GC decompression and 18 (32.1%) who underwent combined peripheral nerve decompression. The mean patient age was 48.4 years (range: 20-89 years), and 40 patients (71.4%) were male. The average preoperative symptom duration was 18.5 months, and most patients were office workers. Ultrasound was positive for GC syndrome in 7/10 patients evaluated, CT in 2/5, MRI in 17/23, and electrodiagnostic studies in 35/44. The most common cause of GC syndrome was tumor (n = 23), followed by idiopathic (n = 17), trauma (n = 12), anatomic variants (n = 3), and inflammation (n = 3). In conclusion, most patients with GC syndrome in this study were male and had symptoms in one wrist. The most common cause of GC syndrome in this study was a tumor, including a ganglion cyst. Level of Evidence: Level IV case series.

Acupuncture and related therapies for carpal tunnel syndrome: A protocol for systematic review and Bayesian network meta-analysis

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common peripheral nerve compression syndrome of the upper limb. Plenty of studies showed the effects of acupuncture therapy on relieving pain and improving functional status for CTS patients. Diverse types of acupuncture therapies have been used in the treatment for CTS, but their relative treatment effects are poorly understood. This study will evaluate the effects of different acupuncture and related therapies for CTS by conducting a systematic review and Bayesian network meta-analysis (NMA).

METHODS

We will search randomized controlled trials (RCTs) of acupuncture and related therapies for CTS in MEDLINE (via PubMed), EMBASE, Web of Science, Cochrane Library, Chinese Biomedical Database, China National Knowledge Infrastructure, VIP Database, Wanfang Database, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Chinese Clinical Trial Register, and OpenGrey from inception to November 2021. Then, we will select eligible studies, extract data, and conduct risk of bias assessment using the Cochrane tool. Pairwise meta-analysis and Bayesian NMA will be performed in Stata 15.1 software and Aggregate Data Drug Information System 1.16.8 software. We will assess the quality of the evidence using the Confidence in Network Meta-Analysis application.

RESULTS

In this study, the treatment effects and safety of different acupuncture and related therapies for CTS will be evaluated.

CONCLUSION

This study will provide evidence for choosing the optimal acupuncture and related therapies in the treatment for CTS.

Mutations in COMP cause familial carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, affecting a large proportion of the general population. Genetic susceptibility has been implicated in CTS, but the causative genes remain elusive. Here, we report the identification of two mutations in cartilage oligomeric matrix protein (COMP) that segregate with CTS in two large families with or without multiple epiphyseal dysplasia (MED). Both mutations impair the secretion of COMP by tenocytes, but the mutation associated with MED also perturbs its secretion in chondrocytes. Further functional characterization of the CTS-specific mutation reveals similar histological and molecular changes of tendons/ligaments in patients’ biopsies and the mouse models. The mutant COMP fails to oligomerize properly and is trapped in the ER, resulting in ER stress-induced unfolded protein response and cell death, leading to inflammation, progressive fibrosis and cell composition change in tendons/ligaments. The extracellular matrix (ECM) organization is also altered. Our studies uncover a previously unrecognized mechanism in CTS pathogenesis.

Familial carpal tunnel syndrome (CTS) is common, but causal genes are not characterized. Here the authors report two CTS-related mutations in two large families that impair secretion of COMP in tenocytes, leading to ER stress-induced unfolded protein response, inflammation and fibrosis in patients and mouse models.

A comparison of the early outcomes of surgery in patients with unilateral and bilateral carpal tunnel syndrome using standard outcome measures

The Levine questionnaire is commonly used to assess the treatment outcomes of carpal tunnel syndrome (CTS). However, specific items in this questionnaire do not address symptoms or impairment in each hand separately. One concern is that patients with unilateral disease would experience greater improvement as a result of surgery than those with bilateral who have only one hand treated. The objective of this study was to compare the early outcomes of surgery for unilateral and bilateral CTS, after operation on only one hand, in order to determine if the disease in the untreated hand affects the subjective perception of treatment outcomes. A total of 372 patients, 186 with unilateral and 186 with bilateral CTS underwent minimally invasive carpal tunnel release under local anesthesia. None of the patients with bilateral CTS had the other hand operated on before the follow-up examination. The pre- and post-operative (at 3 months) measurements included subjective pain intensity in numeric rating scale and the Levine questionnaire. No statistically significant differences in declared pain intensity, as well as in the Levine symptom and function scores in patients with unilateral or bilateral CTS were noted. This suggests that subjective perception of the improvement experienced by patients as a result of surgery was independent of involvement of one or both of the patients' hands.

Occupational co-exposure to biomechanical factors and neurotoxic chemicals in a representative sample of French employees

Objectives

Musculoskeletal disorders, mainly carpal tunnel syndrome, represent a leading cause of compensation claims of workers worldwide. Despite this, and the fact that occupational exposures to biomechanical factors and neurotoxic chemicals have been individually associated with peripheral nerve damage, the prevalence of occupational co‐exposure to biomechanical factors and neurotoxic chemicals has rarely been explored. Therefore, our aim was to assess the prevalence of occupational co‐exposure to biomechanical factors and neurotoxic chemicals in a national representative sample of the French working population.

Methods

The study was based on the French representative cross‐sectional survey SUMER 2010. A total of 47 983 employees who had worked in their current job for at least one year were included. Occupational exposure to biomechanical factors and neurotoxic chemicals within the previous week of work were assessed using a questionnaire during face‐to‐face interviews with occupational physicians.

Results

Approximately 5% of male employees and 1% of female employees were co‐exposed to biomechanical factors and neurotoxic chemicals. This prevalence was up to 10% among male blue‐collar workers and 13%, 8%, and 6%, respectively, among male employees in the construction, agriculture, and industry sectors. Male employees under 30 years old, in apprenticeships, and working in small companies were more co‐exposed to biomechanical factors and neurotoxic chemicals than their counterparts.

Conclusions

Occupational co‐exposure to biomechanical factors and neurotoxic chemicals was observed in a significant proportion of French male employees, suggesting that further studies are required to investigate its potential adverse effects on peripheral neuropathies.

Cold effect in median nerve conductions in clinical carpal tunnel syndrome with normal nerve conduction studies

Clinical diagnosis of carpal tunnel syndrome (CTS) is confirmed by nerve conduction studies (NCS). In some cases, NCS may be normal. We aimed to demonstrate changes of distal motor latency (DML) and nerve conduction velocity (NCV) pathology of demyelination in entrapment neuropathy with cold application in case of clinical CTS with normal NCS. This prospective, cross-sectional, randomise, case-control involved 15 patients (25 hands) with clinically definite unilateral or bilateral CTS and normal nerve conduction studies (NCS), and 11 controls (22 hands). Ice pack was applied to median nerve trasse at wirst with monitoring skin temperature. NCS of median nerve were examinated again. Increases of DML, decrease of velocity of median nerve were observed in two groups after post-cooling. The change in NCV was greater than the change in DML. Cold effect was evident in DML and NCV in the patient group. This could be sign of the demyelination pathology. We think that cold application is influential to determine electrophysiologic abnormalities in clinic CTS with normal NCS.

Predictive factors of the neuropathic pain in patients with carpal tunnel syndrome and its impact on patient activity

AIM

To determine the predictive factors of the neuropathic pain in patients with carpal tunnel syndrome (CTS), and the impact of such neuropathic pain on patient's activity.

METHODS

Douleur Neuropathique 4 questionnaire, Short Form-Brief Pain Inventory test and Boston Carpal Tunnel Syndrome Questionnaire were completed and results were stratified according neuropathic pain and work activity of the patients.

RESULTS

69 of 90 patients with CTS had neuropathic pain (76.7%). Increasing by one the scores of numbness/tingling, pain intensity and neurologic affectation of the electromyogram meant increasing 3.3-, 2.7- and 4.4-times the risk of neuropathic pain, respectively.

CONCLUSION

These results will be useful for a better neuropathic pain evaluation in patients with CTS, allowing the appropriate treatment.

Brain remodeling after chronic median nerve compression in a rat model

Carpal tunnel syndrome is the most common compressive neuropathy, presenting with sensorimotor dysfunction. In carpal tunnel syndrome patients, irregular afferent signals on functional magnetic resonance imaging are associated with changes in neural plasticity during peripheral nerve injury. However, it is difficult to obtain multi-point neuroimaging data of the brain in the clinic. In the present study, a rat model of median nerve compression was established by median nerve ligation, i.e., carpal tunnel syndrome model. Sensory cortex remodeling was determined by functional magnetic resonance imaging between normal rats and carpal tunnel syndrome models at 2 weeks and 2 months after operation. Stimulation of bilateral paws by electricity for 30 seconds, alternating with 30 seconds of rest period (repeatedly 3 times), resulted in activation of the contralateral sensorimotor cortex in normal rats. When carpal tunnel syndrome rats received this stimulation, the contralateral cerebral hemisphere was markedly activated at 2 weeks after operation, including the primary motor cortex, cerebellum, and thalamus. Moreover, this activation was not visible at 2 months after operation. These findings suggest that significant remodeling of the cerebral cortex appears at 2 weeks and 2 months after median nerve compression.