Carpal tunnel syndrome in children

Severe Carpal Tunnel Syndrome in a Pediatric Patient With a History of Congenital Adrenal Hyperplasia

The patient is a 17-year-old right-hand-dominant girl with a history of virilizing congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase enzyme deficiency. Her CAH had been managed with supplemental exogenous steroids, but unfortunately, she had been noncompliant for many years. She subsequently presented with severe progressive numbness and tingling in the bilateral upper extremities that were refractory to conservative management. Electromyography/nerve conduction studies confirmed bilateral carpal tunnel syndrome (CTS) with the right being more severe than the left, and she underwent uncomplicated carpal tunnel releases that relieved her symptoms immediately and completely. Carpal tunnel syndrome secondary to CAH may be associated with the effects of elevated sex hormones within the CTS, leading to inflammation and median nerve entrapment. Moreover, hyperandrogenism is associated with elevated acute phase reactants and inflammatory cytokines, contributing to progressive median neuropathy. To the author's knowledge, there have been no reported cases of severe pediatric CTS with associated hyperandrogenism from CAH.

10-Year Clinical Follow-Up after Decompression of Lipofibromatous Hamartoma of the Median Nerve in a 3-Year-Old Patient: Case Report and Review of the Literature

Lipofibromatous hamartoma, first reported in 1953, is a rare, slowly progressive soft tissue tumor, the characteristics of which include the enlargement of the affected nerve via the epineurial and perineurial proliferation of adipose and fibrous tissues. Out of 200 previously reported cases of lipofibromatous hamartoma of the median nerve, there have been approximately 25 pediatric cases under the age of 18. Herein, we report a case of lipofibromatous hamatoma of the median nerve in a 3-year-old female patient who was surgically decompressed via carpal tunnel release and epineurolysis. The patient was followed-up on an outpatient clinic basis annually with sonographic evaluations, and the postoperative 10th-year follow-up did not show recurrence or any deficits in motor and sensory functions.

Childhood focal compressive mononeuropathies during the COVID-19 pandemic in Buenos Aires, Argentina

Introduction/Aims

Focal peripheral neuropathies are infrequently seen in pediatric patients. The COVID‐19 pandemic has disrupted normal life for many people, including complete lockdowns and school closing for long periods of time in many countries, which prompted children to stay at home. Our aim is to assess whether there has been an increased incidence of focal compressive peripheral neuropathies in the pediatric population during COVID‐19–associated lockdown.

Methods

Clinical, electrophysiological, and imaging characteristics were reviewed for patients referred to the electrodiagnostic (EDx) laboratory with suspicion of a focal neuropathy. The incidence of focal compressive peripheral neuropathies seen during the period of March to September 2020 was compared with the same time period in 2019.

Results

An increased incidence of focal neuropathies was seen in 2020 (31%) compared with 2019 (6.8%). During 2020, 7 fibular (peroneal) mononeuropathies and 2 ulnar neuropathies were diagnosed. Most patients with focal neuropathies were underweight and acknowledged prolonged screen time periods. Electrophysiological findings consisted of mostly demyelinating lesions with an overall good clinical outcome.

Discussion

In this study we raise awareness about a possible increased incidence of focal compressive peripheral neuropathies in children during COVID‐19–associated lockdown, which may be prevented with changing positions during sedentary activities.

[Median nerve compression in the carpal tunnel in children - a delayed diagnosis. About 20 clinical cases]

OBJECTIVES

The carpal tunnel syndrome is rare in children. We performed a retrospective study of 10 children. The aim is to show that the diagnosis of carpal tunnel syndrome is difficult in children.

PATIENTS AND METHODS

We identified all children with median nerve compression in the carpal tunnel between 2010 at 2020, managed in our service.

RESULTS

Ten children with 20 hands included. There was different etiologies of carpal tunnel syndrome: 5 lysosomal storage diseases, 4 idiopathic carpal tunnel syndrome, 1 genodermatose, 1 Byler syndrome and 1 VACTERL syndrome. Common presenting symptoms were pain (five patients) and under use of fingers (five patients). Two children had opposition deficit of the thumb. We operated 19 hands. Median age at diagnosis was 4 years and 7 months. One children or 2 hands had a reanimation of opposition by tendinous transfer of flexor digitorum superficialis tendon of the ring finger. All children had a complete regression of the painful symptoms, a use improvement of fingers and recovery of the opposition of the thumb.

CONCLUSION

The diagnosis of carpal tunnel syndrome is difficult in children. It is common to be confronted with an advanced clinical symptoms. The atypical symptoms may cause diagnostic delay. Due to the quality of the clinical results obtained, we recommend open carpal tunnel release even when the diagnosis seems delayed.

LEVEL OF EVIDENCE

IV.

Outcomes of Pediatric and Adolescent Carpal Tunnel Release

PURPOSE

To investigate carpal tunnel syndrome (CTS) presentation and long-term outcomes of carpal tunnel release (CTR) in children and adolescents.

METHODS

All pediatric and adolescent patients who underwent CTR between February 2003 and June 2018 were identified. Patients were grouped by etiology: lysosomal storage disease (11 hands), idiopathic (6 hands), acute traumatic (7 hands), delayed traumatic (5 hands) and tumorous (2 hands). Medical records were reviewed for presenting symptoms and preoperative treatments. Final outcomes were assessed via phone interviews, chart review, the Boston Carpal Tunnel Questionnaire (BCTQ), and Patient-Reported Outcomes Measurement Information System (PROMIS) scores.

RESULTS

All 25 patients (31 hands) identified were included in the study; median age at surgery was 12.7 years (range, 2.5-23.3 years). Eighteen patients completed surveys at a median of 4.7 years after surgery (range, 8 months-16 years). Common presenting symptoms in lysosomal storage disease were numbness/tingling (7 hands); pain was only reported in 1 hand. The most frequent indication for acute traumatic CTR (7 hands) was palmar hand swelling at the carpal tunnel (4 hands). Delayed traumatic and idiopathic CTS most often presented with numbness/tingling (4 hands and 6 hands, respectively) and pain (3 hands, 4 hands, respectively). Of the original 4 lysosomal storage disease surgeries included in long-term follow-up, all experienced gradual recurrence of symptoms after years of relief (range, 3-14 years). Two patients underwent revision CTR and were symptom-free at follow-up. All patients with acute traumatic and tumorous etiologies had full resolution of symptoms. Delayed traumatic and idiopathic etiologies frequently experienced recurrent or recalcitrant symptoms (4 of 5 and 3 of 6 surgeries, respectively).

CONCLUSIONS

Carpal tunnel release often alleviates symptoms in children with lysosomal storage disease for years to decades. Carpal tunnel release successfully relieves symptoms in acute traumatic cases, but is not always sufficient to relieve symptoms associated with delayed traumatic etiologies. Approximately half of patients with idiopathic CTS experience recalcitrant or recurrent symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Upper Extremity Compressive Neuropathies in the Pediatric and Adolescent Populations

PURPOSE OF REVIEW

Although somewhat rare, upper extremity compressive neuropathies can occur in the pediatric and adolescent populations due to various etiologies. Some of the most common conditions seen include thoracic outlet syndrome, supracondylar process syndrome, cubital tunnel syndrome with subluxation of the ulnar nerve, and carpal tunnel syndrome. This review will focus on these diagnoses and how to address them in the pediatric and adolescent populations.

RECENT FINDINGS

Due to the rarity of upper extremity compressive neuropathies in the pediatric and adolescent populations, substantial advancement in the literature does not routinely occur. However, recent literature has found a difference in the rate of various subtypes of thoracic outlet syndrome in children versus adults. Additionally, cubital tunnel syndrome associated with ulnar nerve subluxation/instability has recently been found to have better outcomes following surgical decompression of the ulnar nerve and transposition than those with stable ulnar nerves. In summary, this review provides the most recent knowledge surrounding upper extremity compressive and entrapment neuropathies in the pediatric and adolescent populations.

Utility and practice of electrodiagnostic testing in the pediatric population: An AANEM consensus statement

Nerve conduction studies and needle electromyography, collectively known as electrodiagnostic (EDX) studies, have been available for pediatric patients for decades, but the accessibility of this diagnostic modality and the approach to testing vary significantly depending on the physician and institution. The maturation of molecular diagnostic approaches and other diagnostic technologies such as neuromuscular ultrasound indicate that an analysis of current needs and practices for EDX studies in the pediatric population is warranted. The American Association of Neuromuscular & Electrodiagnostic Medicine convened a consensus panel to perform literature searches, share collective experiences, and develop a consensus statement. The panel found that electrodiagnostic studies continue to have high utility for the diagnosis of numerous childhood neuromuscular disorders, and that standardized approaches along with the use of high-quality reference values are important to maximize the diagnostic yield of these tests in infants, children, and adolescents.

Peripheral nerve injuries in the pediatric population: a review of the literature. Part II: entrapment neuropathies

INTRODUCTION

Entrapment neuropathies are infrequent in children, and therefore remain unrecognized. The incidence of radial, median, and cubital mononeuropathies are all similar. Despite the rarity of such cases, extensive, albeit scattered, literature has accumulated concerning entrapment neuropathies in children.

OBJECTIVE

To the literature concerning entrapment neuropathies in children.

METHODS

A systematic review of the existing literature has been made.

RESULTS

The management of chronic pediatric pain is very important in such patients to prevent youths from experiencing prolonged absences from school, sports, or other productive activities, and limit the psychological burden of chronic disease. Nonsurgical treatment of both cubital and carpal tunnel syndromes has been disappointing in pediatric patients, with only limited success; and, to date, there is no clear explanation for the outcome differences generated by nonsurgical management between adults and youths. Simple decompression of the ulnar nerve at the elbow also has much higher rates of failure in children than in adults.

CONCLUSIONS

The presence of an entrapment neuropathy (specially carpal tunnel syndrome) in a pediatric-age patient should alert medical care providers to the potential of some underlying genetic condition or syndrome.

A novel chronic nerve compression model in the rat

Current animal models of chronic peripheral nerve compression are mainly silicone tube models. However, the cross section of the rat sciatic nerve is not a perfect circle, and there are differences in the diameter of the sciatic nerve due to individual differences. The use of a silicone tube with a uniform internal diameter may not provide a reliable and consistent model. We have established a chronic sciatic nerve compression model that can induce demyelination of the sciatic nerve and lead to atrophy of skeletal muscle. In 3-week-old pups and adult rats, the sciatic nerve of the right hind limb was exposed, and a piece of surgical latex glove was gently placed under the nerve. N-butyl-cyanoacrylate was then placed over the nerve, and after it had set, another piece of glove latex was placed on top of the target area and allowed to adhere to the first piece to form a sandwich-like complex. Thus, a chronic sciatic nerve compression model was produced. Control pups with latex or N-butyl-cyanoacrylate were also prepared. Functional changes to nerves were assessed using the hot plate test and electromyography. Immunofluorescence and electron microscopy analyses of the nerves were performed to quantify the degree of neuropathological change. Masson staining was conducted to assess the degree of fibrosis in the gastrocnemius and intrinsic paw muscles. The pup group rats subjected to nerve compression displayed thermal hypoesthesia and a gradual decrease in nerve conduction velocity at 2 weeks after surgery. Neuropathological studies demonstrated that the model caused nerve demyelination and axonal irregularities and triggered collagen deposition in the epineurium and perineurium of the affected nerve at 8 weeks after surgery. The degree of fibrosis in the gastrocnemius and intrinsic paw muscles was significantly increased at 20 weeks after surgery. In conclusion, our novel model can reproduce the functional and histological changes of chronic nerve compression injury that occurs in humans and it will be a useful new tool for investigating the mechanisms underlying chronic nerve compression.

Prevalence of Mucopolysaccharidosis Types I, II, and VI in the Pediatric and Adult Population with Carpal Tunnel Syndrome (CTS). Retrospective and Prospective Analysis of Patients Treated for CTS

BACKGROUND

We wanted to investigate whether the prevalence of mucopolysaccharidoses (MPS) I, II, and VI was higher than expected in a selected cohort of patients with carpal tunnel syndrome (CTS). CTS is a common finding in patients with MPS, and therefore we screened patients who had undergone surgery for CTS for undiagnosed MPS.

PATIENTS AND METHODS

Patients who had been operated for CTS were found in databases from two hospitals. Furthermore, patients who had undergone surgery for CTS when under the age of 18 were retrieved from the National Patient Registry. All included patients had a filter paper blood spot sample taken that was subsequently analyzed enzymatically for MPS I, II, and VI.

RESULTS

425 patients were included. 402 patients tested negative in the first test. 23 had inconclusive result whereof 18 was negative in a second test. The remaining five patients had two inconclusive tests each and were referred for further examination at the Center for Inherited Metabolic Diseases where the diagnosis was excluded. Thus, all included patients were negative for both MPS I, II and VI.

DISCUSSION/CONCLUSION

Though our sample size is relatively small, results indicate that MPS is not prevalent in a cohort of adult patients with monosymptomatic CTS, and that screening is not indicated in this setting.

Idiopathic carpal tunnel syndrome in children and adolescents

PURPOSE

A retrospective review of a single institution's experience with idiopathic carpal tunnel syndrome (CTS) in children and adolescents was performed to evaluate management and outcomes in an effort to establish a treatment protocol.

METHODS

All patients diagnosed with idiopathic CTS from ages 1 to 16 years of age between 1983 and 2013 were reviewed. The results of diagnostic testing and efficacy of therapeutic interventions were analyzed. The Boston Carpal Tunnel Questionnaire was sent to all patients following medical or surgical management.

RESULTS

A total of 20 patients with 31 involved wrists met criteria for entrance into the study. The mean age at diagnosis was 14.4 years. Orthosis fabrication was used as the initial treatment in 30 of 31 wrists and was successful in completely alleviating symptoms in 9 of 30 wrists. A steroid injection was performed in 11 of 31 wrists, completely relieving symptoms in 5 of 11 wrists. Carpal tunnel release was performed in 10 of 31 wrists. Following surgery, patients had complete relief of symptoms in 5 of 10 wrists and partial relief of symptoms in 5 of 10 wrists. Questionnaire response incidence was 55% (11 of 20), with an average long-term follow-up of 17.6 years. Eight questionnaire respondents continued to have mild to moderate symptoms while performing activities of daily living.

CONCLUSIONS

Once metabolic, anatomical, and hereditary causes of pediatric CTS are ruled out, a reasonable treatment course should follow that of adults with orthosis fabrication, followed by injection, and then surgery for those that are refractory to nonsurgical treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Thyroid-related neurological disorders and complications in children

BACKGROUND

Thyroid hormones exert critical roles throughout the body and play an important and permissive role in neuroendocrine, neurological, and neuromuscular function.

METHODS

We performed a PubMed search through June 2014 with search terms including "hypothyroidism," "hyperthyroidism," "neurological complications," "neuropathy," "myopathy," "congenital hypothyroidism," and "encephalopathy." Relevant publications reviewed included case series, individual case reports, systematic reviews, retrospective analyses, and randomized controlled trials. The neurological outcomes of congenital hypothyroidism were reviewed, along with the clinical features of associated neuromuscular syndromes of both hypothyroidism and hyperthyroidism, including other autoimmune conditions. Evidence for, and pathophysiological controversies surrounding, Hashimoto encephalopathy was also reviewed.

RESULTS

The establishment of widespread newborn screening programs has been highly successful in attenuating or preventing early and irreversible neurological harm resulting from congenital thyroid hormone deficiency, but some children continue to display neuromuscular, sensory, and cognitive defects in later life. Acquired disorders of thyroid function such as Hashimoto thyroiditis and Graves' disease are associated with a spectrum of central nervous system and/or neuromuscular dysfunction. However, considerable variation in clinical phenotype is described, and much of our knowledge of the role of thyroid disease in childhood neurological disorders is derived from adult case series.

CONCLUSIONS

Early and aggressive normalization of thyroxine levels in newborn infants with congenital hypothyroidism is important in minimizing neurological sequelae, but maternal thyroid hormone sources are also critically important to the early developing brain. A spectrum of neurological disorders has been reported in older children with acquired thyroid disease, but the frequency with which these occur remains poorly defined in the literature, and much must be extrapolated from adult data. A high index of suspicion for acquired thyroid disease is paramount in the investigation of many neurological disorders of youth, as many reported sequelae of hypothyroidism and hyperthyroidism are reversible with appropriate endocrine management.

Carpal tunnel syndrome following an electrical injury in a child

Carpal tunnel syndrome (CTS) is very rare in children and has been reported very infrequently in the literature. We present an unusual case of CTS in a 14-year-old girl who developed this following an accidental electrical shock. As far as we are aware, this is the first case report of CTS in a child following electrical injury. This rare complication of electrical injury can easily be disregarded or misdiagnosed as neuropraxia, and this can delay appropriate treatment, as evidenced by this case. We propose that CTS should be considered when instigating initial medical care after an electrical injury, and that a referral to a hand surgeon should not be delayed, as these children need urgent surgical intervention to preserve hand function.