Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies

Reoperation Rates and Short-Term Complications Following Endoscopic vs. Open Carpal Tunnel Release: A Longitudinal Analysis

BACKGROUND

Carpal tunnel syndrome (CTS), affecting approximately 8% of the population, is treated with open (oCTR) or endoscopic (eCTR) carpal tunnel release. Previous literature compares outcomes within 1 to 2 years; this study evaluated >5-year reoperation rates and short-term complications using a large electronic health record database.

METHODS

A retrospective analysis using data from the TriNetX Research Network (2007-2024) identified patients with unilateral CTS who underwent either oCTR or eCTR within 1 year of diagnosis, using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Propensity score matching and multiple logistic regression calculated adjusted risk and odds ratios (ORs) with 95% confidence intervals (95% CIs) to assess reoperation rates at 2, between 2 and 5, >5 years after operation and 90-day postoperative complications (wound dehiscence, surgical site infection [SSI]).

RESULTS

Within 2 years of CTR, reoperation rate was higher for eCTR than that for oCTR (relative risk [RR] = 1.15, 95% CI = 1.09-1.22; OR = 1.36, 95% CI = 1.21-1.53). Beyond 5 years, the revision rate of the two approaches was similar (RR = 0.85, 95% CI = 0.74-1.01; OR = 0.76, 95% CI = 0.58-1.00). The number needed to treat to prevent one reoperation within 2 years was 67, and beyond 5 years, it was 473. Within 90 days of surgery, eCTR was associated with decreased wound dehiscence (RR = 0.67, 95% CI = 0.53-0.85; OR = 0.50, 95% CI = 0.36-0.71) and SSI (RR = 0.77, 95% CI = 0.65-0.91; OR = 0.63, 95% CI = 0.48-0.81).

CONCLUSION

This study demonstrates the clinical insignificance of the difference in early CTR revision rate between approaches and that eCTR necessitates a similar reoperation rate at long term, supporting eCTR to remain an appropriate intervention for CTR.

Carpal tunnel syndrome severity and work: a case-control study

BACKGROUND

Carpal tunnel syndrome (CTS) is a socially relevant condition. Risk factors associated with CTS severity and work have not been explored.

AIMS

This case-control study aims to investigate the association between CTS severity and occupational biomechanical overload considering personal anthropometric risk factors.

METHODS

We consecutively enrolled one CTS case for two controls. CTS cases were grouped into three classes of progressive clinical and electrophysiological severity according to two validated scales. Job titles were coded according to the International Standard Classification of Occupations (ISCO 88) and grouped into two broad socio-occupational categories: blue-collar and white-collar workers.The associations between CTS (or CTS severity) and blue-collar status were assessed using unconditional (or multinomial) logistic regression models adjusted for age, gender, centre and two anthropometric indexes: wrist-palm ratio and waist-stature ratio. Odds ratios (OR) or relative risk ratio and 95% confidence intervals (95% CI) were calculated, as appropriate.

RESULTS

We included 183 cases and 445 controls. Blue-collar status was a risk factor for CTS (OR 2.4; 95% CI 1.5-3.8). Among job titles, vine and/or olive tree growers (OR 6.0; 95% CI 2.0-17.9) and food processing workers (OR 4.8; 95% CI 1.5-15.2) were at higher risk. At multinomial logistic regression analysis, blue-collar status and the two anthropometric indexes were associated with moderate/severe CTS, after mutual adjustment.

CONCLUSIONS

Blue-collar workers showed a higher risk of CTS than white-collar workers, adjusting for anthropometric and body measures as well. Preventive interventions should be addressed to decrease the biomechanical overload of the upper limbs and limit the overweight.

The Effect of Medicaid Expansion on Rates of Carpal Tunnel Release: An Interrupted Time Series Analysis

BACKGROUND

Medicaid expansion through the Affordable Care Act (ACA) has been associated with greater access to and utilization of surgical services in underserved populations. However, its impact on use of hand surgical care is less understood. The purpose of this study was to evaluate the association between New York State adoption of the ACA and carpal tunnel release (CTR) procedural volume in Medicaid beneficiaries.

METHODS

The authors conducted a pooled cross-sectional analysis of patients who underwent CTR using the Healthcare Cost and Utilization Project New York State all-payer database (2010 through 2018). An interrupted time series analysis using an autoregressive integrated moving average model estimated the immediate and long-term impact of Medicaid expansion in January of 2014 on CTR procedural volume in Medicaid beneficiaries and uninsured individuals.

RESULTS

A total of 112,569 patients were included in the sample. After expansion, the authors observed an absolute increase of 6% in the share of CTR procedures provided to Medicaid beneficiaries. Policy implementation was associated with an immediate 1.81% increase (95% CI, 0.0085, 0.0277; P < 0.001) in the probability of Medicaid as the primary payer and an annual increase of 1.68% (95% CI, 0.0134, 0.0202; P < 0.001) after reform. Interrupted time series analysis found that this resulted in 4190 additional CTR procedures in Medicaid beneficiaries than predicted without expansion.

CONCLUSIONS

The study results suggest that New York's adoption of the ACA was associated with an immediate and steady increase in use of outpatient CTR in Medicaid beneficiaries. Most of this increase represented newly treated patients rather than those who were previously uninsured.

Carpal Tunnel Release with Ultrasound Guidance Versus Open and Mini-Open Carpal Tunnel Release: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose

Carpal tunnel release (CTR) can be performed using several techniques, including traditional open CTR, mini-open CTR, endoscopic CTR (ECTR), and CTR with ultrasound guidance (CTR-US). Carpal tunnel release with ultrasound guidance allows the procedure to be performed through a small, nonpalmar incision while maintaining visualization of critical anatomy and may confer benefits in terms of early recovery and incision-related complications. The objective of this study was to compare CTR-US with traditional open or mini-open CTR based on evidence from randomized controlled trials (RCTs).

Methods

The electronic databases Embase and MEDLINE were searched from inception to November 2022. Randomized controlled trials comparing CTR-US with traditional open or mini-open CTR were eligible for inclusion. Studies were assessed for eligibility from title and abstract followed by a full-text review. The main outcomes of interest were return to normal activity or return to work, patient-reported functional scores, and complications.

Results

Three RCTs were eligible for inclusion with a total of 221 patients randomized. Meta-analysis demonstrated that compared with open CTR patients, patients treated with CTR-US had significantly higher functional scores at 3 months (standardized mean difference: -0.91, 95% confidence interval (CI): -1.38 to -0.44, P < .01) and faster return to normal activities (mean difference: -20.8 days, 95% CI: -21.77 to -19.73). There was no significant difference in complication rates between the two groups (odds ratio: 0.80, 95% CI: 0.04-15.10, P = .07). No domains were deemed to be at high risk of bias in any study.

Conclusions

Based on the available evidence, CTR-US is a safe and effective surgical option for treating carpal tunnel syndrome with a similar risk profile to open CTR. Data suggest that patients who receive CTR-US have improved functional outcomes and faster return to work or normal activities. Future RCTs with larger sample sizes are needed to corroborate these benefits and demonstrate long-term outcomes of CTR-US.

Type of study/level of evidence

Therapeutic II.

Incidence and Risk Factors for Revision Within 1 Year of Primary Carpal Tunnel Release

BACKGROUND

The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR.

METHODS

We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year.

RESULTS

Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR.

CONCLUSIONS

The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

In vitro fatigue of human flexor digitorum tendons

Carpal tunnel syndrome and stenosing tenosynovitis (i.e., trigger finger) are common work-related musculoskeletal disorders (WMSDs) that have been linked to overuse of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons of the hand. These injuries occur in response to repetitive loading; as such, they may be characterized using fatigue failure phenomenon. Current WMSD evaluation tools for carpal tunnel syndrome and trigger finger are built upon fatigue data from lower-limb tendons, however this may lead to inaccurate conclusions when assessing overuse injury risk at the wrist. Therefore, the purpose of this study was to characterize the fatigue behaviour of FDP and FDS tendons. We found that similar to other tendons, cyclically loaded FDP and FDS tendons illustrated a logarithmic relationship between applied stress and fatigue life, however the exact parameters of the FDP/FDS stress-fatigue life relationship were unique and may improve the accuracy of current carpal tunnel syndrome and trigger finger WMSD evaluation tools. We also observed that creep and damage rate had the strongest correlations with fatigue life, suggesting that these metrics may represent promising future directions for WMSD risk evaluation.

Kinesio taping can relieve symptoms and enhance functions in patients with mild-to-moderate carpal tunnel syndrome: A systematic review and meta-analysis

BACKGROUND

The effectiveness of Kinesio Taping (KT) for mild-to-moderate Carpal Tunnel Syndrome (CTS) remains controversial.

OBJECTIVE

To evaluate both the short-term and long-term efficacy of KT in the management of CTS.

METHODS

Electronic searches were conducted in PubMed, EMBASE, The Cochrane Library, Web of Science and Scopus databases up to October 2024. Randomized controlled trials comparing KT with control (sham, no intervention, or basic treatment) or other conservative treatment were included. The revised Cochrane Risk of Bias tool (ROB-2) was used to assess the risk of bias across studies. Meta-analysis was performed to pool data from studies, calculating Mean Differences (MD) and 95% confidence intervals (CI) for continuous outcomes.

RESULTS

Fourteen studies with 637 participants were included. Kinesio Taping (KT) significantly improved long-term pain relief compared to control (MD = -1.14, 95% CI: -1.69 to -0.59, p < .001). Additionally, KT led to significant improvements in symptoms and functional status. KT showed similar therapeutic outcomes to orthoses, and combining KT with orthoses provided greater short-term pain relief than orthoses alone (MD = -0.94, 95% CI: -1.76 to -0.11, p = .03).

CONCLUSION

Low to moderate quality evidence indicates that KT may effectively improve long-term pain relief and functional outcomes in patients with CTS. Additionally, low quality evidence suggests that the combination of KT and orthoses may provide greater short-term pain relief.PROSPERO registration number: CRD42024555320.

Quantitative Analysis of the Carpal Tunnel and Its Inner Structures in Primates

To explore the anatomical factors potentially involved in the high incidence of carpal tunnel syndrome in humans, we have quantified the anatomical variations of the carpal tunnel and its inner structures in humans, non-hominoid primates (monkeys), and hominoid primates (apes). In specimens of six humans, eight monkeys, and three apes, we assessed the size of the carpal tunnel, the tendons of the digit flexor muscles, and the median nerve. We compared the size of the carpal tunnel normalized by the wrist size, and the size of the median nerve and the tendons of the digit flexors normalized by the size of the carpal tunnel. Differences between humans and monkeys were calculated using the T test or Mann-Whitney U test, as appropriate. Data on the apes were not included in the statistical analyses due to the small sample size. The normalized size of the carpal tunnel was similar in all specimens. The normalized size of the tendons of the digit flexors was smaller in humans, while that of the median nerve was significantly larger. The median nerve was also larger in apes than in monkeys. The relatively larger median nerve observed in humans could suggest a greater vulnerability of the nerve to compression, which could predispose humans to carpal tunnel syndrome. However, the tendons of the digit flexor muscles were smaller in humans, and moreover, the proportional size of the median nerve was similar in apes, leading us to suggest that the factors predisposing humans to carpal tunnel syndrome must be sought beyond anatomical features and may be more closely related to functional or personal parameters.

Outpatient Point-of-Care Ultrasound

The most commonly used outpatient primary care point-of-care ultrasound (POCUS) applications are similar to those used in the inpatient setting (eg, cardiac, pulmonary, and abdominal ultrasound). However, there are several additional POCUS applications that are highly applicable to the outpatient setting and should be considered for use by primary care practitioners. This article reviews 3 outpatient POCUS applications and their potential role in the primary care setting.

Sex-differences in the risk of carpal tunnel syndrome: results from a large Ontario, Canada worker cohort

BACKGROUND

Carpal tunnel syndrome (CTS) is a prevalent cumulative strain injury associated with occupational risk factors such as vibration, repetitive and forceful wrist movements, and awkward wrist postures. This study aimed to identify Ontario workers at elevated risk for CTS and to explore sex differences in CTS risk among workers.

METHODS

The Occupational Disease Surveillance System (ODSS) links accepted lost time compensation claims to health administrative databases. CTS cases were identified from physician billing (Ontario Health Insurance Plan) records and defined as at least one record for CTS surgery (fee code N290) between 2002 and 2020. A 3-year washout period and restricted follow-up period of 3 years were applied. A total of 792,769 workers were included in the analytical cohort. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for CTS by occupation and industry, adjusted for age and birth year, stratified by sex.

RESULTS

A total of 3,224 CTS cases among females (f) and 2,992 cases among males (m) were identified in the cohort. We observed elevated risks of CTS in many occupations requiring repetitive and forceful manual work: slaughtering and meat cutting, canning, curing and packing (HRf = 2.28, 95%CI = 1.42-3.68; HRm = 1.95, 95%CI = 1.33-2.85); welding and flame cutting (HRf = 1.83, 95%CI = 1.01-3.32; HRm = 1.65, 95%CI = 1.35-2.01); motor vehicle fabricating and assembling (HRf = 2.14, 95%CI = 1.74-2.62; HRm = 2.43, 95%CI = 2.04-2.89); and packaging (HRf = 2.06, 95%CI = 1.43-2.97; HRm = 1.82, 95%CI = 1.12-2.98). Elevated risks were observed among males employed as nursing aides and orderlies (HRm = 1.72, 95%CI = 1.13-2.62), in mining (HRm = 1.57, 95%CI = 1.01-2.45), and in construction (HRm = 1.32, 95%CI = 1.19-1.47). Elevated risks were observed among females in mineral, metal, chemical processing (HRf = 1.58, 95%CI = 1.27-1.97), textile processing (HRf = 1.89, 95%CI = 1.22-2.94), wood machining (HRf = 2.84, 95%CI = 1.47-5.45), and females employed as janitors, charworkers and cleaners (HRf = 1.50, 95%CI = 1.32-1.71). Findings by industry were consistent with occupation results.

CONCLUSION

The risk of CTS varied by occupation, industry, and sex in this large cohort. Workers engaged in highly repetitive and forceful manual work were at elevated CTS risk, highlighting the need to further understand and reduce ergonomic hazards among identified groups. Future studies should also explore CTS risk by sex, with a focus on female workers.

Global and Regional Prevalence of Carpal Tunnel Syndrome: A Meta-Analysis Based on a Systematic Review

BACKGROUND

Carpal tunnel syndrome (CTS) is a considerable concern, impacting individual health and socio-economic factors. A systematic review and meta-analysis of CTS prevalence would offer valuable insights for healthcare planning, improving outcomes and reducing the burden on affected individuals.

METHODS

In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a meta-analysis was conducted to estimate the prevalence of CTS. Medline, CINAHL, AMED, Scopus, and Web of Science databases were searched for studies published from 1 January 2012 to 10 October 2024. The pooled prevalence rates were determined using a random effects model.

RESULTS

The search yielded 548 initial findings, 103 duplicate records were eliminated, and only 31 of these papers were deemed relevant for inclusion in this review. The prevalence estimates were sourced from 15 different countries, including the United States (n = 8), Saudi Arabia (n = 5), Ethiopia (n = 3), Turkey (n = 2), Iran (n = 2) and Brazil (n = 2), among others. Each of the following countries contributed one study: China, France, Germany, India, Kuwait, the United Kingdom, Korea, the Netherlands, and Sweden. In total, the included studies analysed 5,311,785 individuals, revealing a prevalence of CTS ranging from 0.003 to 0.743. The random-effects meta-analysis yielded an overall prevalence estimate of 0.144, with a 95% confidence interval (CI) of 0.067-0.282, based on 30 studies.

CONCLUSION

The prevalence estimates for CTS are notably high, highlighting the need for effective surgical management strategies. Developing and implementing these interventions is crucial to enhancing health outcomes for individuals affected by CTS.

Prevalence and Risk Factors Associated With Carpal Tunnel Syndrome Among Sudanese Females: A Cross-Sectional Study

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy resulting from compression of the median nerve. This condition is more common in females than in males. The earlier the diagnosis, the better the prognosis and treatment outcomes.

MATERIAL AND METHODS

This is a cross-sectional hospital-based study conducted at Soba Teaching Hospital in obstetrics and gynecology outpatient clinic in Khartoum in the period from February 2022 to March 2022. A simple random sampling was applied, and an interview was conducted using a four-part questionnaire. The first part was based on socio-demographic data, the second was lifestyle, and the third and fourth were based on the Boston Carpal Tunnel Questionnaire (BCTQ). The data were analyzed using the statistical package for social sciences (SPSS) software, version 23 (IBM Corp., Armonk, NY) to find the correlation between the various variables.

RESULTS

A total of 113 women participated in the study (response rate=100%). The prevalence of CTS was found to be 5%. No significant association was found between lifestyle and medical history, e.g., obesity and oral contraceptives and CTS were p=0.167, 0.841 respectively. Conversely, there was a significant association between age and residency, with p=0.005 and 0.049, respectively.

CONCLUSIONS

The prevalence of CTS is increasing in Sudan. Therefore, it is essential to thoroughly assess patients for any symptoms related to hand pain by asking detailed questions during consultations. In addition, further studies covering more states are needed to better understand the regional variation in CTS prevalence.

The Correlation Between Electrodiagnostic Severity and Patient-Reported Disability Among Carpal Tunnel Syndrome Patients

BACKGROUND AND OBJECTIVES

The use, easy applicability, and costs of accurate diagnostic tools and their utility for early diagnosis, efficient treatment, and follow-up are important. In this study, we aimed to evaluate how electrophysiologic data were reflected in the clinical data of the patients with carpal tunnel syndrome (CTS).

METHODS

This study included 102 patients with definitive CTS based on electroneuromyography. The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), the 36-item Short Form (SF-36) questionnaire of the general quality of life, the Visual Analog Scale (VAS), and the painDETECT (PD-Q) neuropathic pain questionnaire were administered by a clinical practitioner.

RESULTS

We found a moderate correlation between electrophysiologic measurements and VAS and a weak correlation between PD-Q scores. When we tested the mean scores of the SF-36 quality of life scale subscales for differences across the CTS groups, we found significant differences in the mean scores of the physical functioning, bodily pain, and social functioning subdomains by disease severity ( P < 0.05 for each). While the BCTQ Symptom Severity Scale (BCTQ-SSS) was predictive of the early stages of CTS, we found that both BCTQ-SSS and BCTQ-Functional Status Scale scores increased in correlation with advanced stage CTS.

CONCLUSION

In addition to the electrophysiological data, self-report measures may help to pursue a multidirectional approach in patient management by acting as a reference for the diagnosis, treatment, and monitoring of CTS. The correlation between objective data and time-saving, practical, subjective measurements can serve as markers to facilitate a diagnosis.

External wrist ratio is not a proxy for internal carpal tunnel shape: Implications for evaluating carpal tunnel syndrome risk

Carpal tunnel syndrome (CTS) is highly prevalent, resulting in decreased function and increased need for costly healthcare services. External wrist ratio (depth/width >0.70) is a strong predictor of the development of CTS and has been suggested to be a proxy for internal carpal tunnel (CT) shape. Conversely, sonography can more directly evaluate CT shape. The purpose of our study was to explore the relationship between wrist ratio and sonographic CT measurements to (1) evaluate the reliability of sonographic CT measurements and (2) explore how external wrist measures relate to anthropometric features of the CT. We used sonographic imaging on a sample of healthy participants (n = 226) to measure CT cross-sectional area, depth, width, and depth/width ratio. We conducted exploratory correlation and regression analyses to identify relationships of these measures with external wrist ratio. Reliability for dominant and nondominant sonographic CT measures ranged from good to excellent (0.79-0.95). Despite a moderate correlation between CT width and depth and their external wrist counterparts (0.33-0.41, p < 0.001), wrist ratio and CT ratio demonstrated weak to no correlation (dominant: r = 0.12, p = 0.053; nondominant: r = 0.20, p = 0.002) and the mean CT ratio was far lower than the mean wrist ratio (0.45 vs. 0.71 bilaterally). Supporting this, we observed several key differences in the relationship between external wrist measures compared to corresponding CT measures. Additionally, regression analyses combining participant factors and CT measurements produced models accounting for less than 15% of the variability in external wrist ratio (linear models) or correctly predicting less than 68% of wrist ratio-based risk categorization (logistic models). Overall, among healthy young adults, wrist shape is not an adequate proxy for CT shape.

Anatomical Variation of the Recurrent Motor Branch of the Median Nerve

The recurrent motor branch (RMB) of the median nerve has commonly thought to originate proximal to the terminal digital branches, although its anatomical course and number may vary. We report a rare variation of the RMB that arose from the second common palmar digital nerve. The median nerve bifurcated into the first and second common palmar digital nerves distal to the transverse carpal ligament, with the RMB dividing from the second common palmar digital nerve and traveling retrograde to enter the abductor pollicis brevis muscle. This high origin variation may be at increased risk of injury during procedures of the hand.

Carpal tunnel syndrome and occupational hand exposures: a Danish nationwide cohort study

OBJECTIVES

The aim was to examine exposure-response relations between occupational hand exposures and carpal tunnel syndrome (CTS) and to compare the relation between surgery-treated and non-surgery-treated CTS. The secondary aim was to study sex-specific differences in exposure-response relations.

METHODS

We conducted a nationwide register-based cohort study of all persons born in Denmark (1945-1994). During follow-up (2010-2013), we identified first-time events of CTS. Occupational hand exposure estimates the year before each follow-up year were obtained by linking individual occupational codes with a job exposure matrix. We used multivariable logistic regression equivalent to discrete survival analysis based on sex and surgery. The excess fraction of cases was calculated.

RESULTS

For both sexes, exposure-response relations were found for all occupational hand exposures. Among men, we found ORadj of 3.6 (95% CI 3.2 to 3.8) for hand-related force, 2.9 (95% CI 2.5 to 3.2) for repetitive hand movements, 3.8 (95% CI 2.7 to 5.2) for non-neutral hand posture and 2.5 (95% CI 2.2 to 2.7) for hand-arm vibration in the highest exposure groups. For combined exposure (hand load), ORadj was 3.5 (95% CI 3.1 to 4.0). Slightly higher ORsadj were generally found for surgery-treated CTS compared with non-surgery-treated CTS for both sexes. When comparing sex, somewhat higher ORsadj were found among men. The excess fraction was 42%.

CONCLUSIONS

Occupational hand exposures carried a 3-5-fold increased risk of CTS with slightly higher risks for surgery-treated compared with non-surgery-treated CTS. Even though CTS occurs more frequently among women, somewhat higher exposure-response relations were found for men compared with women. In the general working population, a substantial fraction of first-time CTS could be related to occupational hand exposures.

Registry cost description of carpal tunnel release in Finland in 2011-2015

OBJECTIVES

In this study, we evaluated the amount of public funds spent on the operative treatment of carpal tunnel syndrome (CTS) in Finland in 2011-2015.

DESIGN

A registry-based cost burden study.

SETTING

The data were collected in primary and secondary care in both private and public hospitals, covering the whole population of Finland.

PARTICIPANTS

We collected the total number of patients with new CTS diagnoses and the total number of patients undergoing surgery from the Care Register for Health Care, Finland's national register.

INTERVENTIONS

Open carpal tunnel release (OCTR).

OUTCOME MEASURES

We collected the costs of the OCTR procedure from diagnosis-related group prices. The Social Insurance Institution of Finland provided the total amount of euros reimbursed for sick leaves. We then combined the average amount of reimbursed sick leave with our estimated cost of the treatment chain to approximate the average cost per patient.

RESULTS

The average amount of public funds used for diagnosing and surgically treating new CTS in 2011-2015 in Finland, including reimbursements for sick leaves, was €2759 per patient in 2015 currency. The average direct procedure cost was €1020. We found no clear trend in total cost per patient, but the proportion of surgically treated patients rose from 63.14% to 73.09%. The total annual cost of these treatments was between €18 128 420 and €22 569 973.

CONCLUSIONS

The average amount of public funds used to surgically treat one patient with new CTS in 2011-2015 in Finland was €2759, making the total annual burden €20.7 million.

What have we learned about risk assessment and interventions to prevent work-related musculoskeletal disorders and support work participation?

OBJECTIVE

The Scandinavian Journal of Work, Environment & Health (SJWEH) was established half a century ago. This paper provides an overview of research on musculoskeletal disorders (MSD) published over these 50 years. Three themes are described: risk assessment, interventions to prevent work-related MSD, and interventions to support work participation. Finally, implications for future research are highlighted.

METHODS

A systematic literature search was performed for all papers on MSD published in SJWEH. Each paper was coded on several criteria including research topic, type of MSD, risk factor(s), and number of citations. Findings were tabulated, and discussions within the author team defined the main results and future research directions.

RESULTS

The search resulted in 1056 papers, of which 474 were included. The most reported-on MSD was low-back pain (LBP, 18%) and the most reported-on work-related risk factors were physically demanding work (14%) and psychosocial factors (12%). Research has contributed to improving case definitions, refining work-related exposure criteria, and recognizing the varying importance of physical and psychosocial factors across different MSD. Research on the association between work-related risk factors and LBP continues to emerge. Effective interventions for prevention of MSD are characterised by sufficient exposure reduction, while supporting work participation requires integrating health care, with multidisciplinary actions directed at factors involving the worker, employer, and workplace.

CONCLUSION

Research has provided valuable insights into risk assessment, interventions for preventing work-related MSD, and supporting work participation. Intervention studies remain warranted and new areas include adopting whole-system approaches to prevent work-related MSD and promoting the concept of musculoskeletal health.

Diabetes Increases Median Nerve Cross-Sectional Area but Not Disease Severity in Patients with Carpal Tunnel Syndrome

Background

Ultrasonography (US) is a useful diagnostic modality for diagnosis of carpal tunnel syndrome (CTS). Diabetes mellitus is increasingly prevalent and is a risk factor for CTS. Given the increasing use of US in the diagnosis of CTS, our goal was to evaluate the influence of diabetes on CTS severity and the cross-sectional area (CSA) of the median nerve in patients with CTS.

Methods

Patients with clinically diagnosed CTS were seen in the outpatient setting from October 2014 to February 2021. Median nerve CSA and patient reported severity measures were obtained: Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) and CTS-6. For patients with diabetes, additional parameters were collected including most recent A1c, insulin pharmacotherapy, and polypharmacy.

Results

Ninety-nine patients (122 nerves) without diabetes and 55 patients (82 nerves) with diabetes were recruited for the study. Patients in the diabetes group were more obese and older and had a significantly increased median nerve CSA compared with patients without diabetes. Obesity was associated with higher median nerve CSA in all patients but not in patients with diabetes. There was no difference in disease severity in patients with and without diabetes as reported by BCTSQ or CTS-6 scores. In patients with diabetes, there was significantly decreased median nerve CSA with A1c of 6.5 or higher and a trend to decreased CSA with polypharmacy. There was no influence of insulin therapy on median nerve CSA.

Conclusion

Diabetes is associated with higher median nerve CSA in patients with CTS of similar disease severity. The increased median nerve CSA in patients with diabetes may be reflective of diabetes-related microvascular changes. Interestingly, the trend to decreased median nerve CSA in patients with suboptimal diabetic control (A1c ≥ 6.5) may suggest eventual degenerative changes to the median nerve. In summary, clinicians should be cautious with interpreting a larger median nerve CSA as more severe CTS in patients with diabetes.

Level of Evidence

Level 3 Diagnostic.

Physical and psychosocial work-related exposures and the incidence of carpal tunnel syndrome: A systematic review of prospective studies

This systematic review summarizes the evidence on associations between physical and psychosocial work-related exposures and the development of carpal tunnel syndrome (CTS). Relevant databases were searched up to January 2020 for cohort studies reporting associations between work-related physical or psychosocial risk factors and the incidence of CTS. Two independent reviewers selected eligible studies, extracted relevant data, and assessed risk of bias (RoB). We identified fourteen articles for inclusion which reported data from nine cohort studies. Eight reported associations between physical exposure and the incidence of CTS and five reported associations between psychosocial exposures and the incidence of CTS. Quality items were generally rated as unclear or low RoB. Work-related physical exposure factors including high levels of repetition, velocity, and a combination of multiple physical exposures were associated with an increased risk of developing CTS. No other consistent associations were observed for physical or psychosocial exposures at work and CTS incidence.

Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance in Over 100 Patients at Two to Six Years

Purpose

The purpose of this study was to determine the clinical results of carpal tunnel release using ultrasound guidance (CTR-US) at a minimum of 2 years postprocedure.

Methods

The study consisted of 102 patients (162 hands) treated with CTR-US by the same physician between June 2017 and October 2020 for whom minimum 2-year follow-up data were available. Questionnaires were sent to gather long-term information, with additional phone calls for clarification if needed. Outcomes included Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores; global satisfaction scores; and subsequent surgeries.

Results

The 102 patients included 68 females and 34 males with a mean age of 56.9 years at the time of surgery. Fifty-five (53.9%) patients had simultaneous bilateral procedures, 42 (41.2%) had unilateral procedures, and 5 (4.9%) had staged bilateral procedures. Significant improvements in BCTQ-SSS, BCTQ-FSS, and QuickDASH scores persisted at a mean final follow-up of 46 months (range 2-6 years). At final follow-up, 91.2% of patients reported satisfaction with the procedure. No outcomes were significantly different between those treated with simultaneous bilateral versus unilateral procedures. No revision surgeries were reported.

Conclusions

CTR-US is a safe and effective procedure that results in significant improvements that persist up to 6 years postprocedure. Long-term results of simultaneous bilateral and unilateral procedures are similar.

Type of study/level of evidence

Therapeutic IV.

Relationship of obesity indices with clinical severity and nerve conduction studies in females presenting with median nerve compression neuropathy at the wrist

Background

Carpal tunnel syndrome (CTS) is considered to be one of the most common peripheral nerve disorders with female preponderance which significantly reduces work efficacy and needs further research on its preventable factors, especially obesity. We studied the effects of obesity indices on Phalen's test duration and median nerve conduction study (NCS) parameters in patients presenting with CTS.

Methods

We examined 229 female patients presenting with clinical features of CTS. Clinical examinations including Phalen's test, median NCSs, and body composition were evaluated. Obesity indices and electrophysiological parameters were compared.

Results

There were significant associations of both body mass index (BMI) degrees and body fat percent (BF%) with clinical and NCS parameters with a linear relationship. BF% and BMI were strongly negatively correlated with Phalen's test duration (BF%; r = -0.334, BMI; r = -0.270 P = 0.001). On the other hand, BF% and BMI were positively correlated with median distal latency (BF%; r = 0.338, BMI; r = 0.372, P value = 0.001), M-latency (BF%; r = 0.264, BMI; r = 0.285, P = 0.001), median motor conduction velocity (MMCV) (BF%; r = 0.119, P = 0.072, BMI; r = 0.173, P = 0.009), median sensory conduction velocity (MSCV) (BF%; r = -0.195, P = 0.003, BMI; r = 0.327, P = 0.001), and sensory nerve action potential (SNAP amplitude) (BF%; r = -.239, BMI; r = -0.350, P = 0.001).

Conclusions

Nerve conduction parameters are significantly affected by obesity degree defined by BMI and BF%. Therefore, combining BMI and BF% assessments gives more clinical information regarding CTS severity and management. The true predictive value of these indices needs to be elucidated further.

The Effect of Proprioceptive Training on Hand Function and Activity Limitation After Open Carpal Tunnel Release Surgery: A Randomized Controlled Study

OBJECTIVE

To investigate the effect of proprioceptive training on hand function and activity limitation in patients undergoing open carpal tunnel release surgery.

DESIGN

Randomized controlled study.

SETTING

A university hospital.

PARTICIPANTS

Thirty patients were included in the study and randomized to proprioceptive training (PT) and conventional rehabilitation (CR) groups.

INTERVENTION

One week after surgery, both groups received CR for 6 weeks. All participants were asked to perform home-based exercises daily in 3 sets with 10 repetitions. For the PT group, a 6-step PT program was conducted starting from Week 6. Both groups received face-to-face interventions twice a week for 12 weeks.

MAIN OUTCOME MEASURES

The outcome measures included the Purdue Pegboard Test (PPT), the joint position sense test (JPST), the Boston Carpal Tunnel Questionnaire, and the Patient-Specific Functional Scale. In total, 3 assessments were performed (at 1, 6 and 12 weeks postoperatively).

RESULTS

In the PT group, the results for PPT were statistically significant (P<.05). Although there was a greater decrease in the absolute angular error value (JPST) of the PT group compared to the CR group, the difference was nonsignificant (P>.05). Similar reductions in activity limitation were seen in both groups (PT: 176%, CR: 175%). Symptom severity decreased by 40% in the PT group vs 32% in the CR group. The effect sizes were larger for the changes between the second and third assessments in the PT group compared to the CR group in all parameters tested.

CONCLUSION

When applied after carpal tunnel release surgery, PT may potentially to improve hand functions, reduce activity limitation, increase participation in activities of daily living, and thus improve quality of life.

Demographics of Common Compressive Neuropathies in the Upper Extremity

BACKGROUND

The purpose of this study was to compare the demographic differences of the most common peripheral nerve compressions in the upper extremity-carpal tunnel syndrome (CTS), ulnar nerve compression (UNC) at the elbow, combined CTS and UNC, radial tunnel syndrome (RTS), and posterior interosseous nerve syndrome (PINS)-as a means to better understand the etiologies of each.

METHODS

A retrospective chart review was performed of all patients over the age of 18 years seen at our institution in the 2018 calendar year. International Classification of Diseases, Tenth Revision codes were used to identify patients with diagnoses of upper extremity peripheral nerve compressions. Demographic details and relevant comorbidities were recorded for each patient and compared with controls, who were seen the same calendar year with no neuropathies. χ2 analyses, independent-samples t tests, and multivariate logistic regressions were performed (P < .05).

RESULTS

A total of 7448 patients were identified. Those with CTS were mainly women, former smokers, and diabetic (all P < .001) and with a greater average body mass index (BMI) (P = .006) than controls. Patients with UNC were more often men and younger when compared with controls (both P < .001). A history of smoking, diabetes, and average BMI were similar between patients with UNC and controls (all P > .05). Those patients with combined CTS/UNC were mainly men, former smokers, and diabetic (all P < .001) when compared with controls. Patients with RTS/PINS were also mostly men (P = .007), diabetic (P = .042), and were more often current smokers (P < .001).

CONCLUSIONS

The demographics of patients with various compressive neuropathies were not homogeneous, suggesting different etiologies.

Interspecialty Variation in Perioperative Health Care Resource Usage for Carpal Tunnel Release

BACKGROUND

We investigated whether any interspecialty variation exists, regarding perioperative health care resource usage, in carpal tunnel releases (CTRs).

METHODS

The 2010 to 2021 PearlDiver Mariner Database, an all-payer claims database, was queried to identify patients undergoing primary CTRs. Physician specialty IDs were used to identify the specialty of the surgeon-orthopedic versus plastic versus general surgery versus neurosurgery. Multivariate logistic regression analysis was used to identify whether there was any interspecialty variation between the use of health care resources.

RESULTS

A total of 908 671 patients undergoing CTRs were included, of which 556 339 (61.2%) were by orthopedic surgeons, 297 047 (32.7%) by plastic surgeons, 44 118 (4.9%) by neurosurgeons, and 11 257 (1.2%) by general surgeons. In comparison with orthopedic surgeons, patients treated by plastic surgeons were less likely to have received opioids, nonsteroidal anti-inflammatory drugs, oral steroids, and preoperative antibiotic prophylaxis but were more likely to have received steroid injections and electrodiagnostic studies (EDSs) preoperatively. Patients treated by neurosurgeons were more likely to have received preoperative opioids, gabapentin, oral steroids, preoperative antibiotic prophylaxis, EDSs, and formal preoperative physical/occupational therapy and less likely to have received steroid injections. Patients treated by general surgeons were less likely to receive oral steroids, steroid injections, EDSs, preoperative formal physical therapy, and preoperative antibiotic prophylaxis, but were more likely to be prescribed gabapentin.

CONCLUSIONS

There exists significant variation in perioperative health care resource usage for CTRs between specialties. Understanding reasons behind such variation would be paramount in minimizing differences in how care is practiced for elective hand procedures.

Early Return to Work after Carpal Tunnel Release with Ultrasound Guidance

Background

The duration of postoperative leave varies by the carpal tunnel release (CTR) technique. This study aimed to determine the time to return to work (RTW) after CTR with ultrasound (CTR-US) guidance and identify factors contributing to this duration.

Methods

This was a multicenter postmarket registry of patients treated with CTR-US. Time to RTW was analyzed with Kaplan-Meier methods. Logistic regression identified the association of patient, work, and procedural factors with the probability of RTW within 5 days (a standard work week) after CTR-US.

Results

A total of 544 employed patients (655 hands) from 24 centers were treated with CTR-US between November 2019 and August 2022. The mean patient age was 50 years, 62% were women, and most (76%) were full-time employees, where work activities were desk-based (49%), light manual (28%), or heavy manual (23%). The complication rate was 0.8%. After CTR-US, the median RTW was 3 days (interquartile range: 1-6 days), with 74.6% returning by 5 days, 87.8% by 10 days, and 97.1% by 30 days. Work activity (desk-based versus heavy manual: odds ratio = 2.93, 95% confidence interval: 1.70-5.04, P < 0.001) and sex (man versus woman: odds ratio = 1.85, 95% confidence interval: 1.15-2.98, P = 0.01) were associated with higher probability of RTW within 5 days. The median RTW ranged from 2 to 4 days in all patient subgroups, including heavy manual laborers (median 4 days) and women (median 3 days).

Conclusions

CTR-US offers an efficient approach to treating CTS, enabling most patients to RTW with minimal delay. The short recovery periods observed across diverse patient and work characteristic subgroups compare favorably to other CTR techniques.

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.

Low-Income, Poor Physical Health, Poor Mental Health, and Other Social Risk Factors Are Associated With Decreased Access to Care in Patients With Carpal Tunnel Syndrome

BACKGROUND

Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS.

METHODS

This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care.

RESULTS

In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care.

CONCLUSION

Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Local corticosteroid injection versus physical therapy for the treatment of carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials

The comparative effect of commonly used conservative treatments for carpal tunnel syndrome remained controversial. The purpose of this study was to compare the clinical effect of local corticosteroid injection and physical therapy for the treatment of carpal tunnel syndrome. A systematic literature search of PubMed, EMBASE, and Cochrane library was conducted to identify relevant randomized clinical trials published before 21st Mar 2023. Two independent reviewers assayed quality of included studies using the Cochrane collaboration risk of bias tool. Relevant data were extracted and pooled analyses were conducted. Outcome measurements included Boston Carpal Tunnel Syndrome Questionnaire, visual analogue scale and some electrophysiology tests, while the former two were set as the primary outcomes. Subgroup analysis and sensitive analysis were performed and publication bias was evaluated. Heterogeneity among the included studies was examined using the I2 statistic. After selection, 12 studies were identified eligibility for inclusion. Only one study was found to have a high risk of bias. Pooled data of primary outcomes did not show any differences between treatments, and subgroup analysis supported the results. However, patients treated with local corticosteroid injection showed better improvement in distal motor latency (p = 0.002) and compound muscle action potential (p = 0.04). Some studies failed to pass the sensitive analysis, indicating the related analysis might be not so stable. A slight publication bias was observed in subgroup analysis of function scales, among three publication bias test. In conclusion, compared to physical therapy, local corticosteroid injection might have better treatment effects on carpal tunnel syndrome.

Long-Term Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance: A Multicenter Pragmatic Study

Purpose

The purpose of this study was to report the 1-year clinical outcomes of carpal tunnel release using ultrasound guidance (CTR-US) performed in a large, real-world population of patients enrolled in a multicenter registry.

Methods

All patients who participated in a postmarket registry study of CTR-US outcomes and provided both preoperative and 1-year postoperative data were included. Main outcomes were the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QDASH), Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS), and Boston Carpal Tunnel Functional Status Scale (BCTQ-FSS) scores at 1 year. Subgroup analysis was performed to assess the effect of patient and procedural factors on 1-year outcomes.

Results

A total of 300 patients (341 hands) were treated by 25 different physicians, including 41 (13.7%) treated with simultaneous bilateral procedures. Mean patient age was 54.2 years, 63% were women, 24% had ≥2 comorbidities, and 54% had symptoms for >2 years. Mean QDASH scores decreased from 40.6 ± 20.6 to 12.2 ± 18.3 at 1 year, BCTQ-SSS scores decreased from 3.0 ± 0.7 to 1.5 ± 0.7 at 1 year, and BCTQ-FSS scores decreased from 2.4 ± 0.8 to 1.4 ± 0.6 at 1 year. Women improved more than men at 1 year for QDASH, BCTQ-SSS, and BCTQ-FSS. Patients treated with simultaneous bilateral procedures had similar 1-year outcomes to those treated with unilateral procedures. Multiple other factors including high body mass index, diabetes status, current tobacco use, rheumatoid/inflammatory arthritis, operation in the dominant hand, higher comorbidity burden, and concurrent ipsilateral procedures did not significantly affect 1-year outcomes. Two patients had revision surgeries in addition to one patient with an infection, and one with a suspected small finger tendon injury.

Conclusions

Patients treated with CTR-US in real-world conditions report significant and clinically meaningful improvements in symptoms and function that are maintained at 1 year. The results are consistent across broad patient demographics and are not affected by performing simultaneous bilateral procedures.

Type of study/level of evidence

Therapeutic IV.

Carpal tunnel syndrome

Median neuropathy at the wrist, commonly referred to as carpal tunnel syndrome (CTS), is the most common entrapment neuropathy. It is caused by chronic compression of the median nerve at the wrist within the space-limited carpal tunnel. Risk factors that contribute to the etiology of compression include female gender, obesity, work-related factors, and underlying medical conditions, such as hypothyroidism, pregnancy, and amyloidosis. The diagnosis is made on clinical grounds, although these can be confounded by anatomical variations. Electrodiagnostic studies, which are specific and sensitive in diagnosing CTS, support the diagnosis; however, a subgroup may present with normal results. The advent of imaging techniques, including ultrasound and MRI, further assists the diagnostic process. The management of CTS is divided into the nonsurgical approaches that include hand therapy, splinting and corticosteroid injection, and surgical decompression of the carpal tunnel. Although several surgical techniques have been developed, no one method is more effective than the other. Each of these management approaches are effective at providing symptom relief and are utilized at different severities of the condition. There is, however, a lack of consensus on standardized diagnostic criteria, as well as when and to whom to refer patients for surgery.

Assessment of the carpal tunnel and associated neural structures with superb microvascular imaging: a scoping review

INTRODUCTION

Superb microvascular imaging (SMI) is an advanced ultrasound technique that portrays microcirculation. Its clinical applications have been studied in various diseases, including carpal tunnel syndrome (CTS) i.e. the most common entrapment neuropathy. This scoping review explores the role of SMI in diagnosing CTS or the assessment of relevant neural structures.

METHODS

We conducted a comprehensive search of electronic databases (PubMed, Embase and Web of Science) up to 26 September 2023. Two independent authors conducted the literature search, quality assessment, and data extraction.

RESULTS

This review includes seven studies comprising 385 wrists. SMI consistently revealed increased intraneural vascularity in the median nerves of patients with CTS compared to healthy individuals. While SMI demonstrated higher sensitivity than traditional Doppler methods for detecting CTS, its specificity was somewhat lower. Combining SMI with B-mode ultrasound appears to enhance the diagnostic accuracy for CTS. However, the relationship between SMI findings and CTS severity remains unclear.

CONCLUSIONS

This review highlighted the ability of SMI to provide detailed vascular structures in both healthy wrists and those with CTS. Additional research is crucial to determine the typical SMI findings of the carpal tunnel and within that context, tailor more precise diagnostic/therapeutic applications for the CTS population.

Ultrasound measurement of subsynovial connective tissue thickness in the carpal tunnel: An intrarater/interrater reliability and agreement study

OBJECTIVES

Non-inflammatory thickening of the subsynovial connective tissue (SSCT) in the carpal tunnel is commonly found in subjects with carpal tunnel syndrome (CTS), and quantification may shed light on CTS pathogenesis. To date, information on the reliability of ultrasound quantification of SSCT is scarce. Therefore, we investigated intrarater and interrater reliability/agreement for ultrasound quantification of SSCT thickness in subjects with and without CTS, and predictors for tissue thickness.

MATERIAL AND METHODS

Two investigators quantified SSCT thickness and thickness ratio on ultrasound in 16 healthy subjects (age, 24-65 years; 16 left/14 right wrists) and 17 subjects with CTS (age, 37-83 years; 14 left/14 right wrists). Intra- and inter-rater reliability/agreement were assessed on intraclass correlation coefficients, standard error of measurement and minimal detectable change. A mixed-effects model was used to evaluate potential predictors for SSCT thickness.

RESULTS

Intra- and inter-rater reliability analysis showed good to excellent intraclass correlation coefficients in both groups, ranging from 0.772 to 0.965. The maximum percentage standard error of measurement was 8%. The maximum minimal detectable change was 14% within raters, and 20% between raters. Both intra- and inter-rater reliability values for thickness ratio were poor. Presence of CTS (ß = 0.180; p = 0.015) correlated positively with SSCT thickness.

CONCLUSIONS

Ultrasound is a reliable method for quantification of SSCT thickness, but not for thickness ratio. Presence of CTS correlates positively with SSCT thickness.

Best-Evidence Systematic Review and Meta-Analysis of Endoscopic Carpal Tunnel Release Outcomes

Purpose

The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of endoscopic carpal tunnel release (ECTR) using best-evidence synthesis methods.

Methods

A systematic search of multiple databases was conducted for prospective contemporary studies published between January 2013 and January 2023 with at least 50 ECTR cases. Outcomes included the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH) measured on a 0-100 scale, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS) on a 1-5 scale, pain visual analog scale on a 0-10 scale, conversion to open carpal tunnel release (CTR), complications, and reoperations. Outcomes were analyzed using a random-effects meta-analysis model. Metaregression was used to determine the association of patient- and study-level factors with ECTR outcomes.

Results

A total of 17 studies with 1,632 patients treated with ECTR were included. Median follow-up durations ranged from 4 to 7 months depending on the outcome. Statistically significant and clinically important improvements were noted after ECTR for Q-DASH, BCTQ-SSS, BCTQ-FSS, and pain visual analog scale scores, with mean differences from baseline of -28.8, -1.8, -1.5, and -5.1, respectively (P < .001 for all). In metaregression, the strongest predictor of improvement in Q-DASH, BCTQ-SSS, and BCTQ-FSS was a greater preoperative score for that variable (all P ≤ .005), indicating that patients with worse symptoms improved the most. The risks of conversion to open CTR, complications, and revision CTR were 0.7%, 0.7%, and 0.5%, respectively.

Conclusions

In a best-evidence synthesis of contemporary studies, ECTR resulted in significant improvements in function and pain, with a low risk of conversion to open surgery, complications, and reoperations over short-term follow-up.

Clinical relevance

Patients treated with ECTR can expect generally favorable clinical outcomes over the short term. However, long-term outcomes after ECTR are not well characterized.

Awareness of Carpal Tunnel Syndrome Among the Middle-Aged Population in Riyadh, Saudi Arabia

Background Carpal tunnel syndrome (CTS), a common and often underdiagnosed condition, imposes a significant burden on individuals, particularly in middle-aged populations. This study aims to assess the awareness and prevalence of CTS among middle-aged residents in Riyadh, highlighting the crucial need for targeted educational initiatives to address knowledge gaps. Methodology A cross-sectional study design was employed to capture a snapshot of CTS awareness and prevalence among the middle-aged population in Riyadh, Saudi Arabia. Participants aged 40-60 residing in Riyadh were included. A self-reported questionnaire gathered data on demographics, CTS diagnosis, and awareness levels regarding symptoms, risk factors, treatment, and the impact of CTS. Statistical analysis included descriptive statistics and Chi-squared tests. Results We collected 415 valid responses to the questionnaire. The demographic profile revealed a balanced gender distribution, with 48.4% (n=201) males and 51.6% (n=214) females, and a majority (66.5%; n=276) within the 40-50 age range. A substantial 87.2% (n=362) reported no prior CTS diagnosis. Neuroimaging studies were infrequently conducted at 15.9% (n=66). Participants exhibited significant knowledge gaps, notably in the awareness of CTS diagnosis 66.3% (n=275) uncertainty, symptoms 55.4% (n=230) lack of knowledge, and risk factors 54.7% (n=227) lack of awareness. The results indicated uncertainty regarding the relationship between CTS and diabetes 63.9% (n=265) and knowledge gaps on anesthesia methods for CTS operations 64.1% (n=294). The association between age and CTS diagnosis was significant (p-value 0.004), while awareness did not significantly vary with gender or age. Conclusion This study unveils a substantial lack of awareness about CTS among the middle-aged population in Riyadh, emphasizing the need for targeted educational interventions. The prevalence of CTS remains underreported, with a notable gap in understanding symptoms, risk factors, and available treatments; the findings underscore the vital importance of targeted educational programs designed to raise public awareness, bridge information gaps, and empower individuals to make informed decisions about their hand health.

Association between carpal tunnel syndrome and the five-year incidence of anxiety disorder and depression in adults followed in general practices in Germany

OBJECTIVE

Little is known about the longitudinal relationship between carpal tunnel syndrome (CTS) and mental health. Therefore, this retrospective cohort study investigated the association between CTS and the five-year incidence of anxiety disorder and depression in adults from Germany.

METHODS

Data from the Disease Analyzer database (IQVIA) were used for the present study. Patients aged ≥18 years diagnosed for the first time with CTS in one of 1284 general practices in Germany in 2005-2020 were included (index date). Individuals without CTS were matched to those with CTS using a propensity score based on age, sex, the mean number of consultations per year during the follow-up, and the index year. In people without CTS, the index date was a randomly selected consultation in 2005-2020.

RESULTS

There were 75,135 patients with and 75,135 patients without CTS included in the study (mean [SD] age 57.2 [16.5] years; 59.7% women). Within five years of the index date, the incidence of anxiety disorder was 3.9% and 3.6% in the group with and the group without CTS, respectively (log-rank p-value<0.001), while figures for depression were 14.8% and 11.5% (log-rank p-value<0.001). These findings were corroborated in the Cox regression analyses adjusted for multiple physical conditions, as CTS was associated with anxiety disorder (HR = 1.14, 95% CI = 1.08-1.21) and depression (HR = 1.29, 95% CI = 1.25-1.33) in the overall sample.

CONCLUSION

CTS was associated with an increased incidence of anxiety disorder and depression in Germany. Further research should identify the mediators involved in these relationships.

Cardiovascular Disease Risk Factors Predict the Development and Numbers of Common Musculoskeletal Disorders in a Prospective Cohort

OBJECTIVE

The aim of the study is to assess risk of common musculoskeletal disorders (MSDs) based on cardiovascular disease (CVD) risk scores.

METHODS

Data from a 9-year prospective cohort of 1224 workers in three states were analyzed. Baseline data included questionnaires, structured interviews, physical examinations, anthropometric measurements, nerve conduction studies, and individualized measurement of job physical factors. Monthly follow-ups were conducted. Framingham risk scores were calculated. A priori case definitions were constructed for carpal tunnel syndrome, lateral epicondylopathy, medial epicondylopathy, and rotator cuff tendinopathy.

RESULTS

Adjusted RRs for one or more MSDs increased to 3.90 (95% confidence interval, 2.20-6.90) among those with 10-year cardiovascular disease risk scores greater than 15% and 17.4 (95% confidence interval, 3.85-78.62) among those with more than 4 disorders.

CONCLUSIONS

Cardiovascular disease factors are strongly associated with the subsequent development of common MSDs. Risks among those with multiple MSDs are considerably stronger.

Relative motion between the flexor digitorum superficialis tendon and subsynovial connective tissue is time dependent

The subsynovial connective tissue is an integral component of flexor tendon gliding in the carpal tunnel, which is strained during longitudinal tendon displacement. We tested the effects of repetition frequency and finger load on flexor tendon function throughout active finger movement. Eleven participants performed metacarpophalangeal joint flexion/extension of the long finger cyclically at three repetition frequencies (0.75, 1.00, 1.25 Hz) and two finger loads (3.5, 7 N). Relative displacement between the flexor digitorum superficialis tendon and subsynovial connective tissue was assessed as the shear-strain index with color ultrasound throughout the entire time history of finger flexion and extension. In addition, long finger joint angles were measured with electrogoniometry while flexor digitorum superficialis and extensor digitorum muscle activities were measured with fine-wire electromyography to characterize the finger movements. The shear-strain index increased with greater finger flexion (p = 0.001), representing higher relative displacement between tendon and subsynovial connective tissue; however, no changes were observed throughout finger extension. The shear-strain index also increased with higher repetition frequencies (p = 0.013) and finger loads (p = 0.029), further modulating time-dependent effects during finger flexion versus extension. Using ultrasound, we characterized the time-dependent response of the shear-strain index, in vivo, providing valuable data on flexor tendon function during active finger movement. Our results infer greater subsynovial connective tissue strain and shear during repetitive and forceful finger movements. Future research characterizing time-dependent effects in carpal tunnel syndrome patients may further elucidate the relations between subsynovial connective tissue function, damage, and carpal tunnel syndrome.

Carpal tunnel tendon and sub-synovial connective tissue mechanics are affected by reduced venous return

BACKGROUND

The effects of blood flow occlusion and sex-specific differences in tendon-subsynovial connective tissue relative strain are not well understood. Thus, the purpose of this study was to investigate the influence of blood flow, biological sex, and finger movement speed on carpal tunnel tendon mechanics to further develop our understanding of carpal tunnel syndrome.

METHODS

Colour Doppler ultrasound imaging quantified relative motion between flexor digitorum superficialis tendon and subsynovial connective tissue in 20 healthy male and female participants during repetitive finger flexion-extension under brachial occlusion of blood flow and two movement speeds (0.75 & 1.25 Hz).

FINDINGS

Flexor digitorum superficialis and subsynovial connective tissue displacement decreased with occlusion (small effect) and fast speed (large effect). Speed × Condition interactions were found for mean FDS displacement and peak FDS velocity, where slow speed with occlusion reduced both outcomes. Movement speed had a small but significant effect on tendon-subsynovial connective tissue shear outcomes, where MVR decreased with fast finger motion.

INTERPRETATION

These results suggest the influence of localized edema through venous occlusion on tendon-subsynovial connective tissue gliding within the carpal tunnel. This insight further develops our understanding of carpal tunnel syndrome pathophysiology and suggests ramifications on carpal tunnel tissue motion when the local fluid environment of the carpal tunnel is disturbed.

Ultrasound Measurements of the Median Nerve at the Distal Wrist Crease Correlate With Electrodiagnostic Studies

Background: Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy and is commonly evaluated using electrodiagnostic studies (EDSs). Ultrasound (US) has emerged as a potentially easier and more comfortable alternative to EDSs. The purpose of this study is to evaluate whether measurements of the cross-sectional area (CSA) of the median nerve via US correlate with the severity rating of CTS based on EDSs. Methods: A retrospective review of patients aged 18 years or older who underwent US and EDSs of the median nerve for CTS was performed. Sensory nerve action potential, distal motor latency, and compound muscle action potential were measured, and severity was graded on American Association of Neuromuscular and Electrodiagnostic Medicine guidelines. Cross-sectional area of the median nerve was measured via US at the wrist crease. Results: There was a significant association between increasing CSA and increasing EDS severity (P < .0001). The mean CSA for normal, mild, moderate, and severe CTS was 7.48 ± 2.00, 10.36 ± 2.53, 12.01 ± 3.64, and 14.34 ± 4.77 mm2, respectively. The area under the curve demonstrated the ability of median nerve CSA to discriminate between normal and abnormal EDSs with an optimal cutoff CSA of ≥10 mm2, as well as, the ability to discriminate between mild CTS and moderate to severe CTS at a cutoff CSA of greater than or equal to 12 mm2. Conclusions: The results of this study show that US measurements of the median nerve at the distal wrist crease discriminate between normal and abnormal EDSs, and between mild CTS and moderate to severe CTS.

A literature review of carpal tunnel syndrome and its association with body mass index, wrist ratio, wrist to palm ratio, and shape index

STUDY DESIGN

Systematic literature review of case-controlled studies.

INTRODUCTION

Carpal tunnel syndrome (CTS) is one of the most common tubular neuropathies where certain anatomical variations may be accounted for as risk factors for CTS, including body mass index (BMI), wrist ratio (WR), wrist to palm ratio (WPR), shape index (SI), and digit length.

PURPOSE OF THE STUDY

To assess case-control studies examining the association between specific anatomical variations of the wrist as risk factors for developing CTS and whether this effect is the same for both genders.

METHODS

The literature search was conducted between February-June 2020 through PubMed, Cochrane Library, CINAHL Plus and PEDro. The literature search yielded 149 potential publications, fifteen of which were filtered in accordance with eligibility criteria. The methodological quality was assessed by using the Newcastle-Ottawa Quality Assessment Form for Case-Control Studies (NOS).

RESULTS

The total number of subjects included in this review was n=4299. The largest sample was n=1117 participants and the smallest n=54. All studies included patients who had a clinical diagnosis of CTS confirmed with nerve conduction studies and or ultrasonography. CTS was significantly higher in patients with higher BMI, WR, WPR compared to control groups. BMI and WR were the only indicators that can be considered as strong risk factors.

CONCLUSIONS

Discussion: Despite the general patterns on the association of BMI, WPR, WR and SI as risk factors for the development of CTS, there were exceptions to the accepted results and conclusions.

CONCLUSION

Clinicians are recommended to conduct more research to confirm anthropometric measurements as risk factors for the development of CTS, mainly SI and WPR. When determining the cut-off values for BMI and WR, it is recommended to take into account additional risk factors such as occupation.

Outcomes Following Distal Nerve Blocks for Open Carpal Tunnel Release: A Single-Institution Retrospective Study

Background Severe cases of carpal tunnel syndrome (CTS) are treated with surgical decompression, for which regional nerve blocks are often administered. There is little data about complications associated with these regional techniques for this surgery. The primary objective was to assess the association of ultrasound-guided regional anesthesia nerve blocks in patients undergoing carpal tunnel release with symptom resolution. Methods This single-institution, retrospective study analyzed all patients undergoing open carpal tunnel release from March 2018 to November 2020. Primary exposure was either regional anesthesia (median and ulnar nerve blocks) or non-regional anesthesia (general anesthesia or local infiltration by surgeon). The primary outcome measurement was symptom resolution at postoperative follow-up at 30-60 days. Secondary outcomes were postoperative surgical site infection, time in operating room (minutes), and post-anesthesia care unit (PACU) length of stay (min). The primary outcome was analyzed using multivariable logistic regression. Results A total of 417 patients were included in this study. Of these, 269 (64.5%) subjects received regional anesthesia as their primary anesthetic. When adjusting for confounders, the use of regional anesthesia was not associated with symptoms not improving at postoperative visit (OR 0.52, 95% CI 0.22 - 1.26, P = 0.15), postoperative surgical site infection (OR 1.47, 95% CI 0.44 - 4.85, p = 0.53), or operating room time duration (p = 0.09). However, the use of regional anesthesia was associated with an approximately 15-minute decrease in PACU length of stay (p < 0.001). Conclusions Regional anesthesia is a safe, effective, and time-efficient method for anesthesia in patients undergoing open carpal tunnel release.

Hormone replacement therapy in women and risk of carpal tunnel syndrome: a systematic review and metaanalysis

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common entrapment mononeuropathy. Menopausal status and/or estrogen level may play a role in CTS. The evidence regarding the association between hormone replacement therapy (HRT) in postmenopausal women and CTS is still conflicting. This meta-analysis aimed to investigate the association between carpal tunnel syndrome (CTS) and women using hormone replacement therapy (HRT).

METHODS

A search was conducted in the PubMed/Medline, Scopus, Embase, and Cochrane databases, from their inception through July 2022. Studies which reported on the association between any type of HRT use and the risk of developing CTS in postmenopausal women compared to a control group were included. Studies which did not include a control group were excluded. Of the 1573 articles extracted from database searches, seven studies involving 270,764 women were included of which 10,746 had CTS. The association between CTS and HRT use was evaluated using the pooled odds ratio (OR) with a 95% confidence interval (CI) under random-effects modelling. Risk of bias in each study was assessed using the Newcastle-Ottawa Scale (NOS) and version 2 of the Cochrane tool for assessing risk of bias in randomized trials (RoB 2).

RESULTS

HRT use showed no statistically significant association with a higher risk of CTS with pooled odds ratio (OR) 1.49, 95% confidence interval (CI) 0.99-2.23, and p = 0.06, although high heterogeneity among the studies was observed (I² 97.0%, Q-test p-value < 0.001). Subgroup analysis of groups in non-randomized controlled studies showed a significantly increased risk of CTS, while groups in randomized controlled studies showed a decreased risk of CTS (pooled OR 1.87, 95% CI 1.24-2.83 versus pooled OR 0.79, 95% CI 0.69-0.92, respectively) with the p-value of group difference < 0.001. The risk of bias in most of the included studies was estimated to be low.

CONCLUSIONS

This meta-analysis supports the safety of using HRT in postmenopausal women with potential risk factors for CTS.

LEVEL OF EVIDENCE

I, Prognosis.

REGISTRATION

INPLASY (202280018).

Diagnostic Test Accuracy of Provocative Maneuvers for the Diagnosis of Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to summarize and evaluate the research on the accuracy of provocative maneuvers to diagnose carpal tunnel syndrome (CTS).

METHODS

The MEDLINE, CINAHL, Cochrane, and Embase databases were searched, and studies that assessed the diagnostic accuracy of at least 1 provocative test for CTS were selected. Study characteristics and data about the diagnostic accuracy of the provocative tests for CTS were extracted. A random-effects meta-analysis of the sensitivity (Sn) and specificity (Sp) of the Phalen test and Tinel sign was conducted. The risk of bias (ROB) was rated using the QUADAS-2 tool.

RESULTS

Thirty-one studies that assessed 12 provocative maneuvers were included. The Phalen test and the Tinel sign were the 2 most assessed tests (in 22 and 20 studies, respectively). The ROB was unclear or low in 20 studies, and at least 1 item was rated as having high ROB in 11 studies. Based on a meta-analysis of 7 studies (604 patients), the Phalen test had a pooled Sn of 0.57 (95% CI = 0.44-0.68; range = 0.12-0.92) and a pooled Sp of 0.67 (95% CI = 0.52-0.79; range = 0.30-0.95). For the Tinel sign (7 studies, 748 patients), the pooled Sn was 0.45 (95% CI = 0.34-0.57; range = 0.17-0.97) and the pooled Sp was 0.78 (95% CI = 0.60-0.89; range = 0.40-0.92). Other provocative maneuvers were less frequently studied and had conflicting diagnostic accuracies.

CONCLUSION

Meta-analyses are imprecise but suggest that the Phalen test has moderate Sn and Sp, whereas the Tinel test has low Sn and high Sp. Clinicians should combine provocative maneuvers with sensorimotor tests, hand diagrams, and diagnostic questionnaires to achieve better overall diagnostic accuracy rather than relying on individual clinical tests.

IMPACT

Evidence of unclear and high ROB do not support the use of any single provocative maneuver for the diagnosis of CTS. Clinicians should consider a combination of noninvasive clinical diagnostic tests as the first choice for the diagnosis of CTS.

An Integrated Review of Carpal Tunnel Syndrome: New Insights to an Old Problem

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy characterized by pain, numbness, and impaired function of the hand due to compression of the median nerve at the level of the wrist. Although CTS can develop from repetitive strain, injury, or medical conditions, there are also congenital and genetic risk factors that can predispose individuals to the condition. With respect to anatomical factors, some individuals are born with a smaller carpal tunnel, which increases their susceptibility to median nerve compression. Variations in specific genes, such as those encoding proteins involved in extracellular matrix remodeling, inflammation, and nerve function, have also been linked to an increased risk for CTS. CTS is associated with a high cost of health care maintenance and loss of work productivity. Therefore, it is vital that primary care physicians fully understand the anatomy, epidemiology, pathophysiology, etiology, and risk factors of CTS, so they can be proactive in prevention, diagnosing, and guiding proper treatment. This integrated review also provides insights into how biological, genetic, environmental, and occupational factors interact with structural elements to determine who is most likely to acquire and suffer from CTS. Keeping health practitioners abreast of all the factors that could impact CTS should go a long way in decreasing the health care and socioeconomic burden of CTS.

Pilot Cadaveric Study of Anatomical Variations of the Median Nerve at the Wrist in the Lithuanian Population

INTRODUCTION

 Carpal tunnel syndrome (CTS) is known as one of the most common neurological disorders in the human body. Nowadays, the prevalence in the general population ranges between 1% and 5%. Due to its high prevalence and increasing incidence of carpal tunnel surgery, the anatomical variations of the median nerve at the wrist are important to know to avoid iatrogenic injury of the nerve.

PURPOSE

The objective of this study was to evaluate the anatomical variation of the median nerve at the level of the wrist in the Lithuanian population with a focus on its thenar motor branch based on the classifications of Lanz.

MATERIAL AND METHODS

A cadaveric study was performed, and 30 wrists of 15 adult Lithuanian cadavers ranging from 70 to 89 years of age were dissected and examined. Eight female and seven male cadavers were included in the study. Any anatomical finding was documented, and the results were compared with the classification of Lanz as well as with the data found in the literature.

RESULTS

All hands showed different patterns in comparison to the standard anatomical variation Lanz type 0. The most common result was dedicated to Lanz group 4A. Nineteen out of 30 hands (63%, p<0.01) had an accessory branch proximal to the carpal tunnel, while one of these hands showed a third thenar motor branch. Five hands (16%) were dedicated to Lanz group 2 with an accessory branch distal to the carpal tunnel. One hand (3%) showed a variation close to Lanz group 2, but in this case, the thenar motor branch had its origin under the flexor retinaculum instead of proximal to it. Two hands each (6%) were classified by Lanz groups 1B and 3A. Additionally, one variation showed a pattern of a combination of Lanz types 3A and 3B. The bifid median nerve had a connecting branch in between which started distal to the flexor retinaculum. Two anatomical variations (6%) were not described by the classification of Lanz.

Risk factors for carpal tunnel syndrome in patients attending the primary care center of a tertiary hospital in Riyadh, Saudi Arabia: A case-control study

BACKGROUND

Carpal tunnel syndrome (CTS), the most common entrapment neuropathy in the upper extremity, is known to be a multi-factorial disease that raises medical and nonmedical risk factors. The aim of the current study was to determine the risk factors of CTS in patients attending the primary care center at a tertiary hospital.

MATERIALS AND METHODS

A case-control study was conducted by reviewing all medical records of patients above the age of 18 years old diagnosed with CTS from 2015 to 2021. The selected cases were evaluated by physical examination and confirmed by a nerve conduction study. Cases and controls were matched by age, gender, and nationality, with a case-to-control ratio of 1:2. Odds ratios were calculated for association between carpel tunnel syndrome and various factors and Chi-sqauare test determined statistical significance. Multiple logistic regression was performed to adjust for confounding.

RESULTS

The study recruited 144 cases with a mean age of 53.38 ± 12.20 years and 288 controls with a mean age of 53.80 ± 12.27 years. The majority of subjects were female (84.7%) and of Saudi nationality (68.3%). There was a significant difference in body mass index, employment status, number of years of employment, occupation, mean systolic blood pressure, mean low-density lipoprotein cholesterol level, and mean blood urea level between cases and controls (P < 0.05). Laboratory tests that were found to be significantly associated with CTS in univariate analysis were thyroid-stimulating hormone (crude odds ratio [COR] = 0.828) and urea level (COR = 0.802). In fully adjusted analyses, obesity (adjusted odds ratio [AOR] =3.080), chronic kidney disease (AOR = 3.629), and the use of corticosteroid (AOR = 0.470) were also significantly associated with CTS.

CONCLUSION

Similar to the findings of other studies, this study identified several potential risk factors for CTS. More large-scale longitudinal studies are required to establish a precise causal association.

Vasculitis presenting as carpal tunnel syndrome: a case report

BACKGROUND

Carpal tunnel syndrome is the most common focal mononeuropathy which presents with pain in the wrist and hand, paresthesia, loss of sensation in the distribution of the median nerve, and in more severe cases, weakness and atrophy of the thenar muscles. Meanwhile, carpal tunnel syndrome can present as an initial manifestation of underlying systemic vasculitis disorder and result in severe physical disabilities.

CASE PRESENTATION

A 27-year-old Iranian man was referred to our electrodiagnosis center with a clinical diagnosis of carpal tunnel syndrome in April 2020. Surgical intervention had been taken into account for him because of unsuccessful conservative therapies. On admission, thenar eminence was reduced. Electrodiagnostic findings were not compatible with median nerve entrapment at the wrist. All sensory modalities in the distribution of the right median nerve were decreased. Additionally, a mild increase in erythrocyte sedimentation rate was noted in laboratory tests. Because of the high vasculitis suspicion, we recommended the nerve biopsy and/or starting a high-dose corticosteroid. However, the surgery release was performed. After 6 months, the patient was referred for progressive weakness and numbness in the upper and lower limbs. After documentation of vasculitis neuropathy by biopsy, a diagnosis of non-systemic vasculitic neuropathy was confirmed. A rehabilitation program started immediately. Rehabilitation led to gradual improvement and recovery of function and muscle strength, and no complications remained, except mild leg paralysis.

CONCLUSIONS

Physicians should be suspicious of the median nerve vasculitis mononeuropathy in a patient with carpal tunnel syndrome-like symptoms. Median nerve vasculitis mononeuropathy as an initial presenting feature of vasculitis neuropathy can further result in severe physical impairments and disabilities.

The Association of Insurance Status and Complications After Carpal Tunnel Release

BACKGROUND

Carpal tunnel release (CTR) is one of the most commonly performed procedures in hand surgery. Complications from surgery are a rare but significant patient dissatisfier. The purpose of this study was to determine whether insurance status is independently associated with complications after CTR.

METHODS

We retrospectively identified all patients undergoing CTR between 2008 and 2018 using the Indiana Network for Patient Care, a state-wide health information exchange, and built a database that included patient demographics and comorbidities. Patients were followed for 90 days to determine whether a postoperative complication occurred. To minimize dropout, only patients with 1 year of encounters after surgery were included.

RESULTS

Of the 26 151 patients who met inclusion criteria, 2662 (10.2%) had Medicare, 7027 (26.9%) had Medicaid, and 16 462 (62.9%) had commercial insurance. Compared with Medicare, Medicaid status (P < .001) and commercial insurance status (P < .001) were independently associated with postoperative CTR complications. The overall complication rate was 2.23%, with infection, wound breakdown, and complex regional pain syndrome being the most common complications. Younger age, alcohol use, diabetes mellitus, hypertension, and depression were also independently associated with complications.

CONCLUSIONS

The incidence of complications after CTR is low. Insurance status, patient demographics, and medical comorbidities, however, should be evaluated preoperatively to appropriately risk stratify patients. Furthermore, surgeons can use these data to initiate preventive measures such as working to manage current comorbidities and lifestyle choices, and to optimize insurance coverage.

Diagnostic value of diffusion-weighted MRI using apparent diffusion coefficient (ADC) in evaluation of median nerve in carpal tunnel syndrome

Background

The diagnosis of carpal tunnel syndrome is based on a combination of clinical history, clinical examination and frequent use of electrodiagnostics as nerve conduction study and electromyography which often do not provide the spatial and anatomical localizing information, especially with small nerves of the extremities. Conventional magnetic resonance imaging can reveal morphological changes in carpal tunnel syndrome patients.

Aim

The purpose of our study was to assess the efficacy of diffusion magnetic resonance imaging as a functional imaging in evaluation of median nerve in carpal tunnel syndrome.

Patients and methods

This prospective study included a group of 33 patients with carpal tunnel syndrome diagnosed by both clinical examination and electromyography; 40 writs were examined. A control group of 20 subjects of matched age group were also included. All the participants were subjected to conventional and diffusion magnetic resonance imaging studies.

Results

Median nerve apparent diffusion coefficient values of patients are lower than those of controls. The sensitivity and diagnostic accuracy of diffusion conventional magnetic resonance imaging were 95% and 97.5%, respectively, versus 25% and 62.5% of conventional magnetic resonance imaging. A cut-off apparent diffusion coefficient value ≤ 0.99 obtained at distal radio-ulnar joint level and > 1.07 at pisiform level as well as apparent diffusion coefficient ratio at a cut-off ≤ 0.2 was significantly valid for diagnosing carpal tunnel syndrome.

Conclusions

Diffusion magnetic resonance imaging provides functional evaluation of median nerve in patients with carpal tunnel syndrome.