Carpal tunnel syndrome: updated evidence and new questions

Prognostic indicators of postoperative objective improvement in carpal tunnel syndrome: A retrospective study

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy affecting the upper limb, with surgical intervention as the primary treatment. This study aims to identify predictive factors influencing postoperative motor and sensory recovery following carpal tunnel release (CTR).

METHODS

A retrospective analysis was conducted on 95 patients (117 hands), with objective outcomes measured by tip pinch strength and two-point discrimination (2PD) six months postoperatively. Motor recovery was defined as the recovery rate of tip pinch strength ≥ 1.2, while sensory recovery was defined as 2PD < 6 mm. Predictive factors such as age, gender, body mass index, comorbidities, and preoperative physical strength were analyzed using univariate and multivariate logistic regression.

RESULTS

Our study showed that younger patients (<73 years) and those patients with better preoperative sensory function had better significant postoperative sensory recovery (age: OR 5.5p = 0.003, 2PD: OR 3.3p = 0.042). Preoperative pinch strength was a significant predictor of motor recovery, while the presence of diabetes mellitus was associated with poorer sensory recovery. Although subjective measures such as the Quick DASH and visual analog scale improved postoperatively, they did not correlate with objective motor and sensory recovery.

CONCLUSIONS

These findings suggested the importance of preoperative differences in pinch strength, sensory function and age in predicting postoperative prognosis in patients with CTS. Understanding these prognostic factors may help clinicians to provide patients with different measures of subjective improvement and to manage their expectations.

Exercise interventions for treating work-related complaints of the arm, neck or shoulder in adults

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of exercise interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults. The outcomes of interest are pain, function, work outcomes, adverse events, quality of life, healthcare use and injury recurrence.

Anatomical variations and their association with carpal tunnel syndrome: a comparison with healthy controls

PURPOSE

The prevalence of carpal tunnel syndrome (CTS) as the foremost upper extremity entrapment neuropathy is well-documented. The present study aimed to evaluate the prevalence of anatomical variations in the carpal tunnel and their potential role as risk factors for CTS.

METHODS

Data from 447 CTS patients who underwent median nerve decompression between 2018 and 2019 were retrospectively analyzed. As a control group, 200 hands from 103 age- and sex-matched asymptomatic volunteers were further investigated.

RESULTS

Anatomical variations identified through ultrasound in 19.7% of CTS hands and 16.0% of controls. Specifically, 10.3% of CTS hands had persistent median arteries, while 14.3% had bifid median nerves. Both variations occurred in 4.9% of CTS patients. In the control group, 13.0% had persistent median arteries and 11.0% had bifid median nerves, with both found in 8.0%.

CONCLUSIONS

Anatomical variations were found in both, CTS patients and controls, but their prevalence did not differ significantly between groups, suggesting they are not independent risk factors for CTS.

Multimodal Deep Learning for Grading Carpal Tunnel Syndrome: A Multicenter Study in China

RATIONALE AND OBJECTIVES

Ultrasound (US)-based deep learning (DL) models for grading the severity of carpal tunnel syndrome (CTS) are scarce. We aimed to advance CTS grading by developing a joint-DL model integrating clinical information and multimodal US features.

MATERIALS AND METHODS

A retrospective dataset of CTS patients from three hospitals was randomly divided into the training (n=680) and internal validation (n=173) sets. An external validation set was prospectively recruited from another hospital (n=174). To further test the model's generalizability, cross-vendor testing was conducted at three additional hospitals utilizing different US systems in the external validation set 2 (n=224). An US-based model was developed to grade CTS severity utilizing multimodal sonographic features, including cross-sectional area [CSA], echogenicity, longitudinal nerve appearance, and intraneural vascularity. A joint-DL model (CTSGrader) was constructed integrating sonographic features and clinical information. Diagnostic performance of both models was verified based on electrophysiological results. In the validation sets, the better-performing model was compared to two junior and two senior radiologists. Additionally, the radiologists' diagnostic performance with artificial intelligence (AI) assistance was evaluated in external validation sets.

RESULTS

CTSGrader achieved areas under the curve (AUCs) of 0.951, 0.910, and 0.897 in the validation sets. The accuracies of CTSGrader were 0.849, 0.833, and 0.827, which were higher than those of US-based model (all p<.05). It outperformed two junior and one senior radiologists (all p<.05) and was equivalent to 1 senior radiologist (all p>.05). With its assistance, the accuracies of two junior and one senior radiologists were improved (all p<.05).

CONCLUSION

The joint-DL model (CTSGrader) developed in our study outperformed the single-modality model. The AI-aided strategy suggested its potential to support clinical decision-making for grading CTS severity.

Comparison of the establishment of a rabbit model of carpal tunnel syndrome under ultrasound-guided and landmark-guided methods

A simple and feasible rabbit model of carpal tunnel syndrome (CTS) was established using an animal experimental study. Twenty-four New Zealand white rabbits were randomized into a normal group (Group C), a glucose injection model group (Groups N-M) and an ultrasound-guided injection model group (Groups U-M). Each group consisted of 8 rabbits.Electrophysiological and ultrasound examinations were performed before sampling. Hematoxylin-eosin (H&E) staining and electron microscopy were performed to observe the neuropathological changes. During electrophysiological testing 1 week after modeling, the amplitudes of the sensory nerve conduction velocity (SNCV), distal motor latency (DML) and compound muscle action potential (CMAP ) in the U-M group were significantly different compared to the C group and the N-M group (P < 0.05). Five weeks after modeling, the amplitudes of the SNCV, DML and CMAP in the U-M group and the C group were significantly different (P < 0.05). These differences were statistically significant compared to the DML and CMAP in the N-M group (P < 0.05), and the changes in these parameters were more significant than the results 1 week after modeling (P < 0.05). The difference in CMAP amplitude between the N-M group and C group was statistically significant (P < 0.05), but the other parameters were not significantly different (P > 0.05). Compared to the original modeling method, four injections of 0.3 ml of 10% glucose solution under ultrasound guidance reduced the time required to establish the disease model and increased the stability of the model. Therefore, this technique is a simple and feasible method for establishing a model of rabbit carpal tunnel syndrome.

Effectiveness of Comprehensive Video Datasets: Toward the Development of an Artificial Intelligence Model for Ultrasonography-Based Severity Diagnosis of Carpal Tunnel Syndrome

OBJECTIVES

Advances in diagnosing carpal tunnel syndrome (CTS) using ultrasonography (US) and artificial intelligence (AI) aim to replace nerve conduction studies. However, a method for accurate severity diagnosis remains unachieved. We explored the potential of comprehensive video data formats for constructing an effective model for diagnosing CTS severity.

METHODS

We studied 75 individuals (52 with CTS) from 2019 to 2022, categorizing them into 3 groups based on disease severity. We recorded 132 US videos of carpal tunnel during finger movement. Features of the median nerve (MN) were extracted from automatically segmented US video frames, from which 3 datasets were created: a comprehensive video dataset with full information, a key metrics dataset, and an initial frame dataset with the least information. We compared the accuracy of machine learning algorithms for classifying CTS severity into 3 groups across these datasets using 63-fold cross-validation.

RESULTS

The cross-sectional area of the MN correlated with severity (P < .05) but MN displacement did not. The algorithm using the comprehensive video dataset exhibited the highest sensitivity (1.00) and accuracy (0.75).

CONCLUSIONS

Our study demonstrated that utilizing comprehensive video data enables a more accurate US-based diagnosis of CTS severity. This underscores the value of capturing the patterns of MN deformation and movement, which cannot be captured by representative metrics such as medians or maximums. By further developing an AI model based on our findings, a simpler and painless method for assessing CTS severity can be achieved.

Exploring Subtypes Based on Depression and Anxiety in Preoperative Patients With Carpal Tunnel Syndrome: A Two-Step Cluster Analysis

Background Although a growing body of literature supports the importance of depression and anxiety, the assessment of these modifiable factors has not been considered in recent clinical practice guidelines for patients with carpal tunnel syndrome (CTS). This study aimed to classify patients with CTS into preoperative subgroups using cluster analysis based on the Japanese versions of the Self-Rating Depression Scale (SDS) and Pain Anxiety Symptom Scale-20 (PASS-20). Outcome measures were also compared for each cluster. Methods Data from 65 patients with CTS were analyzed. The SDS and PASS-20 psychological parameters were grouped using the K-means cluster method, according to Ward's method. Sociodemographic, disease-related, physical, psychological, and disability outcomes were compared between the clusters. Results A three-cluster solution, which categorized patients into "psychologically normal," "only depression," and "psychologically impaired" clusters, was selected. Upper extremity disability in the "psychologically impaired" cluster was more severe compared to that in other clusters. Conclusions We provided evidence for the detection of depression and anxiety in patients with CTS at a preoperative period.

Elasticity Characteristics of Thenar Muscles in Carpal Tunnel Syndrome

OBJECTIVE

Measurement of thenar muscle elasticity by ultrasound shear wave elastography (SWE) may be useful for the diagnosis and evaluation of carpal tunnel syndrome (CTS), but there is a paucity of information on SWE of the thenar muscles in patients with CTS. The purpose of this study was to investigate the elasticity of the thenar muscles in patients with CTS.

METHODS

Twenty-two adult patients with a referral diagnosis of CTS (27 hands) and 20 healthy volunteers as a control (20 dominant hands) participated in this study. The elastic modulus of the thenar muscles was measured with SWE in two conditions, rest and pinch. The elastic modulus and percent change between the two conditions for each muscle were compared between groups.

RESULTS

The elastic modulus of the abductor pollicis brevis (APB) in the patient group was lower than that in the control group at rest (20.6 ± 5.6 kPa vs. 25.0 ± 8.5 kPa; p = 0.034). However, the elastic modulus (87.9 ± 49.0 kPa vs. 62.5 ± 28.5 kPa; p = 0.044) and percent change (373.3 ± 336.4% vs. 169.2 ± 116.0%; p = 0.006) of the APB in the patient group were higher than those in the control group with pinch. For the opponens pollicis and adductor pollicis, there was no significant difference in the elastic modulus between groups.

CONCLUSION

Patients with CTS showed differences in SWE of the APB. Future studies need to investigate the accuracy of SWE in diagnosing CTS and assessing prognosis.

The causal relationship between thyroid dysfunction and carpal tunnel syndrome: A Mendelian randomization study

Mendelian randomization was used to investigate the causal relationship between thyroid dysfunction (including hypothyroidism and hyperthyroidism) and carpal tunnel syndrome. Genetic loci independently associated with hypothyroidism and hyperthyroidism were selected as instrumental variables from pooled data from genome-wide association studies. Inverse variance weighting (IVW) was used to analyze the causal effect, supplemented by weighted median and MR-Egger. Heterogeneity test, pleiotropy testing and leave-one-out analysis were used to analyze the sensitivity test to explore the robustness of the results. Both hypothyroidism and hyperthyroidism increase the risk of carpal tunnel syndrome (hypothyroidism: IVW, OR = 1.04, 95% CI = 1.01-1.08, P = .017; hyperthyroidism: IVW, OR = 1.08, 95% CI = 1.05-1.12, P = 9.218E-06, no pleiotropy was found in both tests. Patients with thyroid dysfunction have an increased risk of carpal tunnel syndrome.

Supportive care for systemic amyloidosis: International Society of Amyloidosis (ISA) expert panel guidelines

Systemic amyloidosis refers to a group of protein misfolding disorders resulting in organ deposition with amyloid, leading to organ dysfunction, ultimately resulting in organ failure and death if not successfully treated. Treatment is type-specific and aimed at the underlying source of the misfolded protein. In the past decades, treatments have become increasingly available across the various amyloidosis types with improved response rates and longer survival. Supportive care measures are an integral part of care for patients with systemic amyloidosis to improve symptom burden and quality of life, reduce healthcare costs, and potentially prolong survival while type-directed therapy takes effect. In these guidelines, we provide supportive care recommendations across eight areas of interest in systemic amyloidosis: cardiology, nephrology, peripheral neuropathy, central nervous system involvement, autonomic neuropathy, gastroenterology, coagulopathy and bleeding, nutrition and hematology. These guidelines were developed on behalf of the International Society of Amyloidosis (ISA) by experts in the above fields and provide the best available evidence and expertise for supportive care in these rare disorders.

Carpal tunnel dimensions following osteopathic manipulation utilizing dorsal carpal arch muscle energy: a pilot study

CONTEXT

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. When mild to moderate in severity, nonoperative treatments including osteopathic manipulative treatment (OMT) have been found to be effective. Studies have been carried out to quantify the mechanism of such treatments with cadaver studies, magnetic resonance imaging (MRI), and ultrasound.

OBJECTIVES

This pilot project investigated the mechanism of a previously undescribed technique of nonoperative carpal tunnel treatment, dorsal carpal arch muscle energy (DCA-ME), which focuses on the dorsal arch (trapezium, trapezoid, capitate, and hamate bones) manipulating the bones to redome the arch, round the tunnel, and increase its volume. Although the actual effectiveness of such manipulation in the treatment of CTS can only be assessed and quantified in patients with the disorder, this initial study was carried out to see if it was feasible for physical changes following DCA-ME to be quantified with ultrasound.

METHODS

A pilot study of 25 healthy volunteers with no prior history of CTS or related disorders was undertaken to quantify anatomical changes in carpal tunnel dimensions following OMT of the nondominant wrist, utilizing DCA-ME. The subjects were randomly assigned to either the OMT group (n=14) or the control group (n=11). The control group underwent a sham manipulation. Pre- and postultrasound measurements of carpal tunnel dimensions were made. The study employed a two-group, pre-/postmanipulation design to evaluate the anatomical changes resulting from the OMT manipulation compared to those following the control sham manipulation.

RESULTS

Comparison of the OMT and control groups revealed a mean increase in carpal tunnel depth from 0.45 mm ± 0.13 mm pre-OMT to 0.48 mm ± 0.13 mm post-OMT (p=0.0146, Cohen's d=0.214, 95 % CI 0.0068 to 0.0517). There was also a mean increase in cross-sectional area from 1.83 mm2 ± 0.56 mm2 pre-OMT to 1.98 mm2 ± 0.59 mm2 post-OMT (p=0.0058, Cohen's d=0.260, 95 % CI 0.0517 to 0.2490). There was no significant difference in canal width (p=0.5973) or transverse carpal ligament length (p=0.2673) following OMT intervention. The control group, which received the sham procedure, demonstrated no significant differences in the transverse carpal ligament length, carpal tunnel width, depth, or cross-sectional area before and after the sham intervention.

CONCLUSIONS

Ultrasound measurements at the narrowest section of the carpal tunnel before and after DCA-ME OMT of healthy asymptomatic wrists demonstrated a significant increase in cross-sectional area as well as depth, with no significant change in the length of the transverse carpal ligament, suggesting that the cause of the increased volume is an alteration of dorsal arch shape. A limitation of the study is the small sample size, inclusion of only healthy wrists, the short period of time between manipulation and measurements, and the difficulty of assuring the same level and angle of ultrasound measurements.

Research trends and hotspots in the surgical treatment of peripheral nerve injuries of the upper limb from 2000 to 2024: a bibliometric visualization study

Purpose

Surgical treatment plays a crucial role in the management of peripheral nerve injuries of the upper limb, but little bibliometric analysis has been conducted on it. This study was aimed to examine the global trends and hotspots in the field of Peripheral nerve injuries of the upper limb.

Methods

Publications on the surgical treatment of peripheral nerve injuries of the upper limb in the Web of Science database were collected between 2000 to 2024. CiteSpace and VOSviewer software was applied to visualize and analyze publications, countries, institutions, journals, authors, references, and keywords.

Results

A total of 751 articles were collected, the most active countries in this field were the United States and China. The authors with the most publications were Mackinnon, Susan E from the United States, and Xu WD and Gu YD from China. JOURNAL OF HAND SURGERY AMERICAN VOLUME was the journal with the most published. Based on keywords, the current research hotspots primarily revolved around nerve transfer, brachial plexus and reconstruction.

Conclusion

The results of this bibliometric study provide clinical trends and hotspots in the surgical treatment of peripheral nerve injuries of the upper limb over the past 24 years, which may help researchers to identify clinical trends and explore new treatment in the field of peripheral nerve injuries.

Updates on Common Mononeuropathies

This article provides an overview of the most common mononeuropathies. It includes a description of the neuroanatomy and function of each nerve which allows clinical localization of the lesion. It also describes the clinical presentation, findings in electrodiagnostic studies, updates in imaging including neuromuscular ultrasound and magnetic resonance neurography, and recommended treatment. While mononeuropathies may be part of polyneuropathy, this scenario is beyond the scope of this article. The most common mononeuropathy is carpal tunnel syndrome. Its prevalence in the United States is estimated at 50 per 1,000. The second most common entrapment neuropathy is ulnar neuropathy at the elbow. The incidence was calculated as 20.9% in a 2005 study. The most common compressive neuropathy of the lower extremity is peroneal neuropathy. Other common mononeuropathies included in this article are radial neuropathy, tibial neuropathy, and femoral neuropathy.

Smoking may be a risk factor for carpal tunnel syndrome: Insights from Mendelian randomization analysis

INTRODUCTION

It is currently uncertain whether smoking is a risk factor for carpal tunnel syndrome (CTS). This study aims to elucidate association between smoking and CTS using Mendelian randomization (MR) analysis.

METHODS

This study was a secondary analysis of publicly available GWAS data, using four smoking phenotypes (smoking initiation, smoking status, lifetime smoking, and never smoking) as exposures, and two CTS datasets (discovery and validation sets) as outcomes for MR analysis. The discovery set (n=480201) was used to explore the causal relationship between smoking and CTS, while the validation set (n=385304) was used to confirm the results. The effects of smoking on CTS were assessed using inverse variance weighted (IVW), MR-Egger, and weighted median methods. Cochran's Q test was used to detect heterogeneity, and MREgger to test for pleiotropy. Finally, a meta-analysis was performed on the IVW results from both the discovery and validation sets.

RESULTS

IVW results showed that in both the discovery and validation sets, smoking initiation, smoking status, and lifetime smoking are risk factors for CTS. The summary results from the meta-analysis are as follows: smoking initiation (OR=1.17; 95% CI: 1.08-1.27, p<0.001), smoking status (OR=1.87; 95% CI: 1.56-2.24, p<0.001), and lifetime smoking (OR=2.46; 95% CI: 2.03-3.00, p<0.001). Conversely, never smoking is a protective factor against CTS, with the summary result of the meta-analysis being: OR=0.55; 95% CI: 0.42-0.71, p<0.001.

CONCLUSIONS

Based on genetic evidence, smoking may be a risk factor for CTS. Further clinical trials are needed to confirm this causal relationship.

Diagnostic Value of Measurements of Median Nerve Diameter at the Site of the Maximal Stenosis in Carpal Tunnel Syndrome

Introduction

Ultrasonography is increasingly used to diagnose the carpal tunnel syndrome (CTS). Most frequently, the enlargement of the nerve cross-sectional area (CSA) at the tunnel inlet serves to confirm the diagnosis. Recent research has shown that the nerve diameter is decreased within the tunnel, when measured at the level of pisiforme or capitatum. The stenosis index (SI), which uses the ratio of the diameter of median nerve at the tunnel inlet to the diameter within the tunnel (SI diameter), was proposed as the diagnostic marker of CTS. In this study, we compared the diameter of the median nerve measured at the site of maximal stenosis (DMS) between patients with CTS and controls. Additionally, we investigated the diagnostic utility of the modified SI, which uses the ratio of CSA at the inlet to the diameter within the tunnel (SI CSA).

Methods

Forty-eight patients (72 hands) with CTS and 18 asymptomatic controls (28 hands) underwent electrodiagnostic testing and ultrasonography.

Results

CSA at the inlet was larger in patients, whereas DMS showed only trend towards being smaller in CTS. CTS was also associated with more distal localization of maximal stenosis. Both SI diameter and SI CSA were higher in patients, however the discriminative effect of SI CSA was stronger. SI diameter, SI CSA, CSA at the inlet and DMS correlated with the electrodiagnostic severity grade of CTS. The post-hoc analysis revealed that patients with moderate and severe electrodiagnostic grade of CTS have smaller DMS, whereas patients with mild CTS did not differ from controls.

Conclusion

DMS seems to have only limited diagnostic potential in mild CTS, but it may be a marker of more advanced cases. CTS may be associated with the distal shift of DMS. SI CSA may have significant diagnostic potential in CTS.

Photobiomodulation in carpal tunnel syndrome with pain, strength, and functionality analysis: a systematic review and meta-analysis

BACKGROUND

Carpal tunnel syndrome (CTS) is characterized as a compressive neuropathy of the median nerve and has several treatments, including photobiomodulation, which can be performed with low-intensity laser therapy (LLLT) and light-emitting diodes (LEDs).

PURPOSE

To carry out a literature review on the effectiveness of low-intensity laser therapy (LLLT) in CTS.

METHODS

This study is characterized by being a systematic review with metaanalysis. The databases included were PubMed, Embase, Cochrane, the Physiotherapy Evidence Database (PEDro), Scopus and LILACS. Also, gray literature: Google Scholar, OpenGrey and CAPES Theses and Dissertations Catalog. The search was carried out in all databases on October 11, 2023 and updated on June 06, 2024. The risk of bias was assessed using the Cochrane tool, RoB 2, by two blinded reviewers and conflicts were resolved by consensus. The outcomes of interest were pain intensity (Visual analogue scale), strength (handgrip and pinch) and hand functionality (Boston questionnaire, Levine questionnaire, Purdue Pergboard Test). Statistical analysis was carried out using RevMan 5.4.1. Continuous results were expressed as standard mean differences (95% CI), with p-value of < 0.05 considered statistically significant. The value of the I2 statistical test was calculated to test for heterogeneity between studies. A random effects model was adopted.

RESULTS

13 randomized controlled trials were selected from 1.613 records. In the general bias analysis, two studies (15,4%) were considered to have some relevant problems that could interfere with the quality of the study, and three (23,1%) were identified as having a high risk of bias, eight studies (61,5%) were classified as having a low risk of bias. In the meta-analysis, it was possible to observe that there were no advantages of the laser for pain (p = 0.08), nor for handgrip strength (p = 0.11), but it did produce improvements in functionality.

CONCLUSION

It is concluded that LLLT is an effective therapeutic modality in the treatment of CTS, improving functionality; however, despite the studies pointing to advantages for the modality in reducing pain and improving grip strength, the meta-analysis did not show this result. Even so, there is a need for more clinical trials are needed to standardize dosimetry, mainly because the primary studies showed clinical advantages of PBM.

REGISTRATION

Open Science Framework (OSF)- https://doi.org/10.17605/OSF.IO/HQCRP .

Diagnostic Dilemmas in Carpal Tunnel Syndrome and Cervical Spine Disorders: A Comprehensive Review

Carpal tunnel syndrome (CTS) and cervical spondylosis (CS) are both common diseases, yet differentiation between the two is sometimes necessary. However, there are few evidence-based reviews on the differentiation of these conditions. This review examined the literature on the diagnosis of CTS and CS, focusing on how to distinguish between them. The analysis is divided into four categories: clinical symptoms, physical examination, diagnostic imaging, and electrodiagnosis. A total of 281 studies are reviewed, revealing a major issue: the inclusion criteria for defining each disease varies widely across studies. Understanding this limitation, the conclusion drawn is that no single clinical symptom, test, or imaging evaluation can be deemed uniquely reliable for diagnosing CTS or CS. Therefore, it is essential to apply the most up-to-date knowledge, conduct thorough examinations, and perform necessary tests for each patient to achieve a confident and accurate diagnosis.

Combination of morphological and multiparametric MR neurography enhances carpal tunnel syndrome diagnosis and evaluation

This study aimed to investigate the diagnostic and evaluative significance of combining median nerve (MN) morphological measurements with diffusion tensor imaging (DTI) and T2 mapping metrics for carpal tunnel syndrome (CTS). Morphological and multiparametric magnetic resonance neurography (MRN), along with clinical evaluation, were conducted on 33 CTS patients and 32 healthy controls. The MRN metrics included fractional anisotropy (FA), apparent diffusion coefficient (ADC), axial diffusivity (AD), radial diffusivity (RD), T2 value, cross-sectional area (CSA) and MN flattening ratio (MNFR) at both the pisiform bone and hamate bone levels. Differences in MRN metrics between the above two levels (Delta FA, Delta ADC, Delta AD, Delta RD and Delta T2) were calculated. T-tests, multivariable regression, and receiver operating characteristic (ROC) curve analyses were used to compare and classify patients with CTS and controls. The correlations between MRN metrics and clinical characteristics were analyzed. Comparisons were also made between MRN metrics in patients with and without significant symptom improvement after treatment. FA, AD, T2 value, and CSA at the pisiform bone level were identified as independent predictors of CTS. The combination of these metrics improved diagnostic performance (AUC 0.922, sensitivity 84.85% and specificity 90.62%). Delta ADC, Delta AD, and Delta T2 correlated with function Boston scores. The T2 value at hamate bone level, along with Delta AD and FA, correlated with visual analogue score (VAS). CSA and Delta T2 had higher AUCs for classifying patients with and without significant symptom improvement after treatment. These findings suggest that combining MN morphological and multiparametric MRN metrics can enhance the diagnostic performance of CTS and has the potential to provide an objective and quantitative basis for further study of the degree of entrapment and prognosis.

Preoperative Physiotherapy Effects on Hand Function and Quality of Life in Carpal Tunnel Syndrome: 3 - & 6 - month randomized controlled trial

INTRODUCTION

Carpal Tunnel Syndrome (CTS) is a prevalent upper limb mononeuropathy that often leads to delayed surgical intervention, resulting in prolonged symptoms and reduced quality of life.

AIM

To describe the effect of a three-session treatment involving nerve mechanical interface mobilization and self-mobilization combined with education in hand function, symptoms, and quality of life of pre-surgical CTS patients at 3 and 6-months follow-ups; 3) A randomized clinical trial was performed in 42 preoperative CTS patients. Patients were randomized into an experimental group, receiving a three-session intervention of education, diacutaneous fibrolysis, and self-mobilization, or a control group receiving standard care. Primary outcomes included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, while secondary outcomes assessed paresthesia, mechanosensitivity of the median nerve, mechanical threshold with the Semmes Weinstein monofilament, pinch strength, and quality of life, with the short-form-36 & EuroQol-5D.

RESULTS

The cohort were predominantly severe CTS patients with associated comorbidities. Statistical improvements were shown for experimental group compared to control group in DASH at 6-month follow-up (p = 0.035; η2 = 0.12). Paraesthesia intensity, mechanosensitivity, and quality of life were also significantly improved in the experimental group compared to control group at both 3- and 6-months (p < 0.05). The same occurred for pinch strength at 6 months (p < 0.05). No significant differences were found in mechanical threshold (p > 0.05); 5) The treatment effectively improved hand function, symptoms, and quality of life in preoperative CTS patients, offering a viable alternative during delays in surgical procedures. Nerve mechanical interface treatment could not only help mild to severe CTS patients but might be relevant for severe CTS patients with associated comorbidities.

Comparison of the Impact of Out-of-plane and In-plane Injection Approaches on Injection Pain and Functionality in Patients With Carpal Tunnel Syndrome Undergoing Ultrasound-guided Injection: A Patient- and Assessor-blinded Randomized Study

OBJECTIVES

To compare the out-of-plane (OP) and in-plane (IP) approaches for carpal tunnel syndrome (CTS) in terms of pain during injection and postinjection adverse effects, and to investigate whether these approaches led to any difference in terms of pain/numbness, symptom severity, functionality, and median nerve cross-sectional area and to examine the relationship of these parameters with the pain during injection.

DESIGN

Patient/assessor-blinded randomized study.

SETTING

Hospital outpatient clinic.

PARTICIPANTS

Fifty patients with mild-to-moderate CTS.

INTERVENTIONS

The participants were randomized into OP and IP (both n=25) ultrasound-guided injection groups.

MAIN OUTCOME MEASURES

Each patient reported the pain felt during the injection at 1 hour thereafter, and also any adverse effects at 4 weeks after injection. Before and 4 weeks after injection, patients used a visual analog scale to indicate pain/numbness; symptom severity and functionality were assessed using the Boston Carpal Tunnel Syndrome Questionnaire. The cross-sectional area of the median nerve was also obtained.

RESULTS

The average pain during injection was 2.64±0.82 in the IP group and 1.96±0.86 in the OP group (P=.017). Postinjection adverse effects were similar between the 2 groups (P<.05). After injection, the percentage change in symptom severity was 49.8±11.8 in the IP group and 40.6±11.5 in the OP group (P=.008). In the IP group, day preinjection pain/numbness, night pain/numbness percentage change scores, and symptom severity percentage change scores were moderately correlated with the pain during injection (r=.439, .469, and .429, respectively).

CONCLUSIONS

IP injection caused greater pain during injection than OP injection and led to greater reduction in symptom severity at 1 month after injection. In that group, injection pain was associated with the baseline day pain score, change in night pain score, and change in symptom severity score.

Comparing scissors and scalpels to a novel surgical instrument: a biomechanical sectioning study

BACKGROUND

This study introduces a novel surgical instrument to reduce iatrogenic nerve injuries during procedures such as carpal tunnel and ulnar nerve decompression surgery. These injuries often result from direct damage to surrounding tissues by surgical instruments, whose designs have remained largely unchanged over the past decades. The novel device is a modified surgical forceps that has a deployable surgical scalpel that runs along a groove on the forceps. This design protects important anatomical structures while allowing fast dissection and cutting of fascial layers.

METHODS

The process used to develop a novel instrument included computer-aided design (CAD) modeling, 3D printing for prototyping, and the fabrication of an aluminum prototype. Biomechanical testing was performed with the novel device, iris scissors, bandage scissors, and a scalpel on an MTS Static Materials Test System. The peak force to slide-cut, number of cut attempts, and percentage cut on first attempt were compared between the prototype and traditional surgical tools. The materials cut in testing were Ace™ bandage, stockinette, and gauze. Statistical analyses were performed using Welch's t-tests and Fisher's exact tests.

RESULTS

Compared to conventional bandage and iris scissors, the novel surgical instrument required significantly less force to cut through an Ace™ bandage, stockinette, and gauze (p < 0.01). The number of cuts required to transect those same materials with the novel device was comparable to that of the scalpel and bandage scissors. Additionally, while there were no differences between the novel device and the other devices for an Ace™ bandage and stockinette, the novel device tended to cut a greater percentage of gauze in one pass than did the iris scissors.

CONCLUSION

The novel surgical instrument designed in this study required less force compared to conventional scissors, demonstrated cutting efficiency similar to that of a scalpel blade, and had more safety features than either instrument. This study highlights the value of collaboration between biomedical engineering and orthopedic surgery departments on innovation in medical technology, through which new technologies with improved design and functionality demonstrate the potential to reduce iatrogenic injuries.

Mediators of the association between educational attainment and carpal tunnel syndrome: A 2-sample, 2-step Mendelian randomization study

To clarify the causal relationship and potential mediators between educational attainment and carpal tunnel syndrome (CTS), as well as to evaluate whether educational attainment, cognition, and intelligence independently exert causal effects on CTS, we employed univariable Mendelian randomization (MR), multivariable MR, reverse MR, and 2-step MR approaches. Our research demonstrates that educational attainment exerts an independent causal effect on CTS, with this causal relationship being unidirectional. Five mediators were identified as significant influencers within the causal pathways connecting educational attainment and CTS. Targeting these mediators may be beneficial in the prevention of CTS.

Carpal Tunnel Syndrome in Elite Female Tug-of-War Athletes: Prevalence and Risk Factor Analysis

Background: Tug-of-War (TOW) games involve repetitive hand movements and vigorous force, raising the risk of peripheral neuropathy in the upper extremities. The prevalence of carpal tunnel syndrome (CTS) in TOW athletes remains unclear. We hypothesize that elite female TOW athletes have a higher prevalence of CTS than the general population. Methods: Twenty-nine female TOW athletes were recruited from a national team and participated in the study. CTS was clinically diagnosed by history taking and physical examination. Nerve conduction studies (NCS) were additionally performed to confirm CTS. Results: Twelve athletes were clinically diagnosed with CTS; however, only nine were confirmed by NCS. Ten athletes were diagnosed with subclinical CTS by NCS, while seven were classified as truly-non-CTS by both clinical assessment and NCS. The prevalence of CTS and subclinical CTS among the athletes was found to be 33.3% and 37.0%, respectively, significantly higher than 2.7% in the general population by electrodiagnosis. The body weight (p = 0.025) of the athletes with CTS and subclinical CTS was significantly different from those of the athletes without CTS. Conclusions: Our observations revealed a higher prevalence of CTS among elite female TOW athletes, with body weight being a risk factor. The forceful grasping and pulling of the rope may contribute to the development of CTS.

A Rare Case of Carpal Tunnel Syndrome Due to Subepineural Hematoma of Median Nerve: Diagnosis and Surgical Management

Carpal tunnel syndrome (CTS) is a common neuropathy with various underlying causes, posing diagnostic and management challenges for healthcare providers. The condition is typically associated with repetitive strain, idiopathic factors, or anatomical variations, leading to the compression of the median nerve within the carpal tunnel. We describe a case of a 46-year-old male who presented with recurrent CTS symptoms one year after a successful carpal tunnel release surgery. The symptoms resurfaced following a minor wrist trauma, leading to pain, numbness, and hand weakness. Despite initial conservative management, including immobilization and NSAIDs, the symptoms persisted. Further investigation and exploratory surgery revealed a rare subepineural hematoma of the median nerve, which was subsequently drained, resulting in immediate and lasting symptom relief. This case demonstrates the importance of considering uncommon etiologies such as subepineural hematomas in patients with recurrent CTS and underscores the need for a thorough diagnostic approach to ensure effective treatment.

Values and Diagnostic Accuracy of Electrodiagnostic Findings in Carpal Tunnel Syndrome Based on Age, Gender, and Diabetes

BACKGROUND

Appropriate cut-off values and diagnostic accuracy (DA) [sensitivity, specificity, predictive values, positive (PPV) and negative (NPV)] of electrodiagnostic findings for carpal tunnel syndrome (CTS) based on age, gender, and diabetes mellitus (DM) were not reported.

METHODS

In a retrospective study, we described the latency difference values and DA of comparative latency studies COLS [median to ulnar through palmar difference (palmdiff) and ring difference study (ringdiff), median to radial through thumb difference study (thumbdiff), and combined sensory index (CSI)] among non-CTS and CTS groups based on age, DM, and gender.

RESULTS

We included 632 patients (228 without CTS and 404 with CTS). For PPV > 90% and NPV > 50%, the best cut-offs among patients without DM, were 0.5ms, 0.8-1 ms, 1.4 ms, and 2 ms for palmdiff, thumbdiff, CSI (age < 60 years), and CSI (age > 60 years), respectively. The best cut-offs among patients with DM were 0.5 ms, 1.2 ms, 0.8 ms, 1.0-1.2 ms, 1.8 ms, 1-1.2 ms, 3.0 ms, and 3.5 ms for palmdiff (age < 50 years), palmdiff (age > 50 years), thumbdiff (age < 40 years), thumbdiff (age 40-59 years), thumbdiff (age > 60 years), CSI (age < 50 years), CSI (age 50-59 years), and CSI (age > 60 years), respectively.

CONCLUSION

The cut-off values of COLS to confirm CTS and their DA were different according to age and DM.

Understanding the Mechanosensitivity of the Median Nerve in Pre-Surgical Carpal Tunnel Syndrome Patients: A Correlational Study

(1) Background: Neurodynamic tests are recommended for the diagnosis of entrapment neuropathies such as carpal tunnel syndrome (CTS). However, their association with clinical variables in severe patients or patients with associated comorbidities is poorly documented. This study aims to analyze the association between the mechanosensitivity of the median nerve and symptoms, function and psycho-social variables in moderate and severe carpal tunnel syndrome patients with comorbidities; (2) Methods: Correlational study. In total, 42 pre-surgical patients (24 females; 59.1 ± 12.7 years) included in the Spanish Public Healthcare System with an electrodiagnostic of CTS were selected. Sociodemographic variables and clinical features (symptoms, function, sensitivity and quality of life evaluated with the 36-item Short Form Survey (SF-36) and the Medical Outcomes Study Sleep Scale (MOS-sleep) were recorded. Upper Limb Neurodynamic Test 1 was used to evaluate neural mechanosensitivity; (3) Results: The 81% had a severe CTS and 78.6% had some comorbidity. The average time from the first medical visit to the surgeon's visit was 365.5 days. Median nerve mechanosensitivity correlated weakly with the SF-36 subscale, General Health, (Spearman's rho = 0.367) and MOS sleep scale, Awaken Short of Breath or with headache dimension (Spearman's rho = -0.353) and moderately with SF-36 subscale, Social Functioning (Spearman's rho = 0.553); (4) Conclusions: No associations were observed for median nerve mechanosensitivity, except for quality of life and sleep. Both social determinants and clinical variables should be considered when examining and treating these patients.

Updates in diagnostic tools for diagnosing nerve injury and compressions

Predicting prognosis after nerve injury and compression can be challenging, even for the experienced clinician. Although thorough clinical assessment can aid diagnosis, we cannot always be precise about long-term functional recovery of either motor or sensory nerves. To evaluate the severity of nerve injury, surgical exploration remains the gold standard, particularly after iatrogenic injury and major nerve injury from trauma, such as brachial plexus injury. Recently, advances in imaging techniques (ultrasound, magnetic resonance imaging [MRI] and MR neurography) along with multimodality assessment, including electrodiagnostic testing, have allowed us to have a better preoperative understanding of nerve continuity and prediction of nerve health and possible recovery. This article outlines the current and potential roles for clinical assessment, exploratory surgery, electrodiagnostic testing ultrasound and MRI in entrapment neuropathies, inflammatory neuritis and trauma. Emphasis is placed on those modalities that are improving in diagnostic accuracy of nerve assessment before any surgical intervention.

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder worldwide. The epidemiology and risk factors, including family burden, for developing CTS are multi-factorial. Despite much research, its intricate pathophysiological mechanism(s) are not fully understood. An underlying subclinical neuropathy may indicate an increased susceptibility to developing CTS. Although surgery is often performed for CTS, clear international guidelines to indicate when to perform non-surgical or surgical treatment, based on stage and severity of CTS, remain to be elucidated. Neurophysiological examination, using electrophysiology or ultrasonography, performed in certain circumstances, should correlate with the history and findings in clinical examination of the person with CTS. History and clinical examination are particularly relevant globally owing to lack of other equipment. Various instruments are used to assess CTS and treatment outcomes as well as the effect of the disorder on quality of life. The surgical treatment options of CTS - open or endoscopic - offer an effective solution to mitigate functional impairments and pain. However, there are risks of post-operative persistent or recurrent symptoms, requiring meticulous diagnostic re-evaluation before any additional surgery. Health-care professionals should have increased awareness about CTS and all its implications. Future considerations of CTS include use of linked national registries to understand risk factors, explore possible screening methods, and evaluate diagnosis and treatment with a broader perspective beyond surgery, including psychological well-being.

Comparison of local versus intramuscular steroid injection in patients with carpal tunnel syndrome: A prospective open label randomized clinical trial

AIM

This study compared the efficacy and safety of local corticosteroid injection (LCI) vs intramuscular (IM) corticosteroid injection in mild to moderate carpal tunnel syndrome (CTS).

METHODS

This is an open labeled, randomized controlled trial conducted during December 2021 to August 2023. Eighty-six patients with CTS were randomized in 1:1 ratio to receive either single 40 mg methylprednisolone (MP) injection at the wrist (LCI arm), or single 40 mg MP intramuscular injection (IM arm) in the deltoid. Primary outcome was absolute Symptom Severity Scale (SSS) at 3 months. Secondary outcomes were SSS score at 1-month, Functional Status Scale (FSS) score at 1 and 3 months, and recurrence at 3 months and injection site pain assessed on visual analog (VAS) scale.

RESULTS

Median age was 45 (range 22 - 80) years, and 86 % were females. Baseline characteristics were comparable between groups. Mean SSS score at 3 months was similar in two arms (1.72 ± 0.71 vs 2.0 ± 0.93) with mean difference (MD) -0.03 (-0.31 to 0.25, p = 0.83) after adjusting for baseline SSS scores. LCI, however, resulted in significantly better SSS (1.48 ± 0.51 vs 1.88 ± 0.69, adjusted p = 0.04), and FSS scores (1.57 ± 0.44 vs 1.80 ± 0.66, adjusted p = 0.03) at 1 month compared to IM arm. Response rate (67.4 % vs 55.8 %; p = 0.30) and recurrence rate (17.1 % vs 22.6 %, p = 0.74) at 3 months were similar. Injection site pain was severe in LCI arm[median 5 (range 3 - 8) vs median 3 (range 2 - 6)].

CONCLUSIONS

In patients with mild to moderate CTS, LCI resulted in better improvement in the BCTQ scores at 1 month compared to IM steroid. However, 3-month's outcome was similar. Intramuscular steroid injection was better tolerated.

Neuromuscular manifestations of wild type transthyretin amyloidosis: a review and single center's experience

Transthyretin amyloidosis (ATTR) is a condition defined by accumulation of insoluble transthyretin amyloid deposits in multiple organs, especially in the peripheral nerve and heart muscle. ATTR may result from transthyretin mutations (variant ATTR or ATTRv) or may occur with normal transthyretin genotype (wild type ATTR or ATTRwt). ATTRwt was previously known as "senile amyloidosis" and causes cardiomyopathy which may lead to heart failure with a preserved ejection fraction, affecting predominantly elderly men. The exact prevalence of ATTRwt in the general population remains unclear, but its occurrence may be underestimated in women. It was observed that a proportion of ATTRwt cardiomyopathy patients may develop slowly progressing neuropathy that is milder and indolent in comparison with typical progressive neuropathy associated with ATTRv. Furthermore, the causality of neuropathy is often uncertain in patients with ATTRwt. Neuropathy symptoms, including distal sensory loss, unsteadiness and (neuropathic) pain are common in elderly patients with multiple potential causes, and as ATTRwt patients are typically older, relatively high prevalence of peripheral neuropathy is expected with frequent comorbidities. Relatively high prevalence of ATTRwt in elderly population contrasts few documented cases of neuropathy caused by ATTRwt, and there is uncertainty whether ATTRwt neuropathy is an infrequent occurrence or a significant manifestation of multisystemic ATTRwt. We review neurologic and musculoskeletal manifestations of ATTRwt and present clinical features of a single center cohort of ATTRwt patients with suspected peripheral neuropathy.

Safety and Efficacy of Ultrasound-Guided Perineural Hydrodissection as a Minimally Invasive Treatment in Carpal Tunnel Syndrome: A Systematic Review

Ultrasound-guided perineural hydrodissection (HD) is a novel technique that has been found to be effective in providing mechanical release of perineural adhesions and decompression of the nerve, reducing inflammation and edema and restoring its physiological function. It has a significant impact on chronic neuropathic pain (20 ± 4 weeks with VAS < 5 or VAS diminished by 2 points after the procedure). Carpal tunnel syndrome (CTS) is a common entrapment mononeuropathy, and its distribution is typically innervated by the median nerve. Patients with mild or moderate CTS may benefit from nonsurgical treatments or conservative therapies. This review was conducted following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Four investigators assessed each title, abstract, and full-text article for eligibility, with disagreements being resolved by consensus with two experienced investigators. The qualitative assessment of the studies was carried out using the modified Oxford quality scoring system, also known as the modified Jadad score. Furthermore, risk of possible biases was assessed using the Cochrane collaboration tool. The results of this review suggest that US-guided HD is an innovative, effective, well-tolerated, and safe technique (11 out of 923 patients had collateral or side effects after the procedure). However, further studies comparing all drugs and with a larger sample population are required to determine the most effective substance.

A revised electrodiagnosis-based severity classification for carpal tunnel syndrome

BACKGROUND

An electrodiagnostic evaluation is conducted to diagnose carpal tunnel syndrome (CTS) and evaluate its severity.

OBJECTIVE

This study proposes a revised approach for classifying the severity of electrophysiological findings for patients with CTS.

METHODS

This retrospective cross-sectional study included patients with CTS confirmed through electrodiagnostic evaluations. Based on the Stevens' classification, the patients were divided into three groups (mild/moderate/severe). A new intermediate group was defined to identify patients with normal motor nerve conduction studies and abnormal electromyographic results. CTS pain was evaluated using a numeric rate scale. Physical examinations and sonographic evaluation were performed to detect anatomical abnormalities.

RESULTS

Overall, 1,069 CTS hands of 850 CTS patients were included. The mean age was 57.9 ± 10.8 years, and 336 (39.5%) were men. There were 522 (48.8%) mild cases; 281 (26.3%) moderate cases; and 266 (24.9%) severe cases. In the severe group, 49 cases were reclassified into the intermediate group. The median cross-sectional area in the intermediate group significantly differed from that in the severe group. However, the pain score significantly differed from that of the moderate group.

CONCLUSION

The intermediate CTS group showed clinical features that were intermediate to those of the moderate and severe CTS groups.

Transthyretin amyloid deposition in ligamentum flavum (LF) is significantly correlated with LF and epidural fat hypertrophy in patients with lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is a degenerative disease characterized by intermittent claudication and numbness in the lower extremities. These symptoms are caused by the compression of nerve tissue in the lumbar spinal canal. Ligamentum flavum (LF) hypertrophy and spinal epidural lipomatosis in the spinal canal are known to contribute to stenosis of the spinal canal: however, detailed mechanisms underlying LSS are still not fully understood. Here, we show that surgically harvested LFs from LSS patients exhibited significantly increased thickness when transthyretin (TTR), the protein responsible for amyloidosis, was deposited in LFs, compared to those without TTR deposition. Multiple regression analysis, which considered age and BMI, revealed a significant association between LF hypertrophy and TTR deposition in LFs. Moreover, TTR deposition in LF was also significantly correlated with epidural fat (EF) thickness based on multiple regression analyses. Mesenchymal cell differentiation into adipocytes was significantly stimulated by TTR in vitro. These results suggest that TTR deposition in LFs is significantly associated with increased LF hypertrophy and EF thickness, and that TTR promotes adipogenesis of mesenchymal cells. Therapeutic agents to prevent TTR deposition in tissues are currently available or under development, and targeting TTR could be a potential therapeutic approach to inhibit LSS development and progression.

Effects of high-intensity laser therapy on pain, functional status, hand grip strength, and median nerve cross-sectional area by ultrasonography in patients with carpal tunnel syndrome

The aim of this study was to evaluate the effects of high intensity laser therapy (HILT) on pain, functional status, hand grip strength, and median nerve cross-sectional area by ultrasonography in patients with carpal tunnel syndrome. Sixty patients who were diagnosed with carpal tunnel syndrome were included in the study. The patients observed during the research were randomly divided into two groups with 30 patients in each group. Splint+ exercise and HILT (pulsed mode with a power of 8.0 W and energy density of 8 J/cm2 for 1.40 minutes for every 25 cm2, continuous mode with a power of 3.0 W and energy density of 80 J/cm2 for 11 minutes for each 25 cm2; total 10 sessions 5 days a week) were applied for 2 weeks for the first group, and splint+exercise and sham laser treatment were applied for 2 weeks for the second group. Randomization was undertaken with the assistance of a computer-generated random number table before beginning the treatment processes. The patients were evaluated with the determined scales before the treatment, at the end of the treatment, and at the 3rd month. Hydraulic hand dynamometer was used to measure hand grip strength, visual analog scale (VAS) for pain, Boston CTS Questionnaire to assess function, and ultrasonography to measure median nerve cross-sectional area. The impact of time on the change in VAS levels was found to be of statistical significance within each group of patients (p<0.001), but between-group comparisons did not yield significant results (p<0.454). The effects of time on variations in Boston CTS Questionnaire scores were found to have been of statistical significance for both groups (p<0.001), but significance was not subsequently observed when the results of the two groups were compared on a between-group basis (p=0.226 and p=0.973 for the FSS and SSS, respectively). While time had a statistically significant effect on the change in hand grip strength for both groups (p=0.000), between-group comparisons statistical significance finding in favor of HILT was found in the early period (p=0.012). The time-group association patterns of the groups showed significant difference (p=0.025). While time had a statistically significant effect on the changes in the median cross-sectional areas of the nerve for the patients of both treatment groups (p<0.001), between-group comparisons yielded no findings of statistical significance (p=0.438). The time-group relationship patterns of the groups were found to reflect statistical significance (p=0.001). In conclusion, the results of the research presented here have confirmed that hand grip strength may increase and the median nerve's cross-sectional area may decrease upon the application of high-intensity laser for individuals experiencing CTS. However, this effect was demonstrated here only in the short-term and the evidence was not maintained through the course of follow-up of a longer duration.

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: Neuropathic Pain Associated or Not with a Nociplastic Condition

Carpal tunnel syndrome (CTS) has been traditionally classified as primarily a neuropathic condition with or without pain. Precision medicine refers to an evidence-based method of grouping patients based on their susceptibility to biology, prognosis of a particular disease, or in their response to a specific treatment, and tailoring specific treatments accordingly. In 2021, the International Association for the Study of Pain (IASP) proposed a grading system for classifying patients into nociceptive, neuropathic, or nociplastic phenotypes. This position paper presents data supporting the possibility of subgrouping individuals with specific CTS related-pain into nociceptive, neuropathic, nociplastic or mixed-type phenotypes. Carpal tunnel syndrome is a neuropathic condition but can also be comorbid with a nociplastic pain condition. The presence of extra-median symptoms and the development of facilitated pain processing seem to be signs suggesting that specific CTS cases can be classified as the nociplastic pain phenotype. The clinical responses of therapeutic approaches for the management of CTS are inconclusive. Accordingly, the ability to identify the predominant pain phenotype in patients with CTS could likely be problematic for producing efficient treatment outcomes. In fact, the presence of a nociplastic or mixed-type pain phenotype would explain the lack of clinical effect of treatment interventions targeting the carpal tunnel area selectively. We propose a clinical decision tree by using the 2021 IASP classification criteria for identifying the predominant pain phenotype in people with CTS-related pain, albeit CTS being a priori a neuropathic pain condition. The identification of a nociplastic-associated condition requires a more nuanced multimodal treatment approach to achieve better treatment outcomes.

Use of Iontophoresis with Corticosteroid in Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

BACKGROUND

Carpal tunnel syndrome is a neuropathy that affects the median nerve. The aim of this review is to synthesize the evidence and perform a meta-analysis on the effects of iontophoresis in people with carpal tunnel syndrome.

METHODS

The search was carried out using PubMed, Web of Science, Scopus, CINHAL Complete, Physiotherapy Evidence Database, and SciELO. The methodological quality was evaluated using PEDro. A standardized or mean difference meta-analysis (Hedge's g) using a random-effects model was calculated.

RESULTS

Seven randomized clinical trials using iontophoresis for electrophysiological, pain, and functional outcomes were included. The mean of PEDro was 7/10. No statistical differences were obtained for the median sensory nerve conduction velocity (SMD = -0.89; p = 0.27) or latency (SMD = -0.04; p = 0.81), motor nerve conduction velocity (SMD = -0.04; p = 0.88) or latency (SMD = -0.01; p = 0.78), pain intensity (MD = 0.34; p = 0.59), handgrip strength (MD = -0.97; p = 0.09), or pinch strength (SMD = -2.05; p = 0.06). Iontophoresis only seemed to be superior in sensory amplitude (SMD = 0.53; p = 0.01).

CONCLUSIONS

Iontophoresis did not obtain an enhanced improvement compared to other interventions, but no clear recommendations could be made due to the limited number of included studies and the heterogeneity found in the assessment and intervention protocols. Further research is needed to draw sound conclusions.