Secondary carpal tunnel surgery

A small but significant group of patients with carpal tunnel syndrome "fail" primary carpal tunnel release and require secondary surgery. The persistence or recurrence of previous symptoms or the development of new symptoms is often indicative of the nature of the patient's problem. Postoperative complications may be classified into the general areas of neurological, vascular, tendon, and wrist complaints. A thorough clinical evaluation, including a complete neurological examination of the hand and upper extremity, provides an accurate assessment of the status of the median nerve. Important surgical techniques that may be used during secondary carpal tunnel surgery include internal neurolysis, neuroma-in-continuity assessment, neuroma management, nerve grafting, and tissue interposition flaps.     

A regression model for carpal tunnel syndrome

The purpose of this study was to determine whether a logistic regression model for the diagnosis of carpal tunnel syndrome (CTS) could be developed. Forty-eight variables were initially identified, for the 28 CTS and 34 non-CTS subjects, including 28 measures of nerve function, 6 anatomical measurements, 8 variables relating to disease symptoms, and 6 variables relating to physical attributes. An a priori clustering procedure was used to establish groups for the principal components analyses. The first principal component of each cluster was then used in a backward, stepwise logistic regression analysis. The best combination of candidate variables, as identified by the regression equation, was Raynaud's symptoms and median nerve motor function. The results of this study indicate that a model for CTS can be generated from a set of variables and that a linear combination of variables representing nerve function is closely associated with conduction decrements resulting from CTS.     

Topography of carpal bone - An experimental model for carpal tunnel syndrome

By preparing a new experimental model for the carpal tunnel syndrome, the authors evaluated the differences of the human and rabbit carpal tunnels using a comparative anatomical study. A nearly identical situation-regarding the osseous and connective tissue formations in the carpal channel--was found. Therefore, the carpal tunnel of the rabbit is recommended for a model of chronic nerve compression, which is now planned by the authors.     

Idiopathic carpal tunnel syndrome caused by carpal stenosis.

Computed tomography was used to measure the cross-sectional area of the carpal canals in normal controls of both sexes and in women with idiopathic carpal tunnel syndrome. The women controls had significantly smaller carpal canals than the men controls both proximally and distally. In the patients both the proximal and distal cross-sectional areas were significantly reduced compared with the women controls. The measurements showed that carpal canal stenosis is associated with idiopathic carpal tunnel syndrome, narrowing of the canal is bilateral in patients who have unilateral symptoms, and narrowing is greater in the proximal carpal canal. There was no correlation between age and the size of the canal. The difference in the size of the carpal canal between normal men and women might explain the tendency of women to develop carpal tunnel syndrome. The lack of correlation between age and the size of the canal suggests that stenosis of the carpal canal is inherited rather than acquired. Symptoms arise only later in life, when degenerated changes in the content or the walls of the carpal canal compete with the median nerve for space and its function becomes impaired by compression.     

A comparison of flexor tenosynovectomy, open carpal tunnel release, and open carpal tunnel release with flexor tenosynovectomy in the treatment of carpal tunnel syndrome

The purpose of this study was to identify the advantages and disadvantages of performing a flexor tenosynovectomy without dividing the transverse carpal ligament, an open carpal tunnel release, and an open carpal tunnel release with flexor tenosynovectomy in the treatment of carpal tunnel syndrome. From 1990 to 1998, a retrospective study was done in which a flexor tenosynovectomy was performed in 133 patients without division of the transverse carpal ligament and compared with 68 patients who had an open carpal tunnel release and 75 patients who had an open carpal tunnel release and flexor tenosynovectomy. Patients were followed up for an average period of 30 weeks with history and physical findings and nerve conduction velocities and for an average period of 2.6 years with telephone interviews. There was a 2.3 percent incidence of pillar pain in the flexor tenosynovectomy group, which may explain the earlier return to their regular jobs at an average time of 9.9 weeks, compared with 10.7 weeks for the carpal tunnel release group and 12.0 weeks for the carpal tunnel release/flexor tenosynovectomy group. The latter two groups had an incidence of pillar pain of 12.1 percent and 25.3 percent, respectively. Postoperative grip strength was statistically significantly improved in the flexor tenosynovectomy group compared with the other two groups, where adjustments were made for sex and preoperative grip strengths with standard error of adjusted means. In the flexor tenosynovectomy group, 20.6 percent of patients had a previous open or endoscopic carpal tunnel release with recurrent carpal tunnel syndrome, compared with 5.2 percent in the open carpal tunnel release group and 21.6 percent in the open carpal tunnel release with flexor tenosynovectomy group. Excisional biopsies of flexor tenosynovium in the flexor tenosynovectomy, open carpal tunnel release, and open carpal tunnel release with flexor tenosynovectomy groups revealed an incidence of fibrosis in 89.2 percent, 88.9 percent, and 87.7 percent of specimens, respectively. Edema was a frequent finding, but an active inflammatory response was seldom seen. The findings in this study indicate that because of a significant decrease in pillar pain, a flexor tenosynovectomy in the treatment of carpal tunnel syndrome would likely benefit workers who use the palm of the hand in heavy manual or highly repetitive work by allowing them to return to regular duty sooner.     

Estrogen and progesterone receptors in carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a compression median nerve neuropathy common in women at menopausal age. The aim of this work was to study immunohistochemically the expression of estrogen (ER) and progesterone (PR) receptors in CTS and control specimens. Biopsies of transverse carpal ligament (TCL) and flexor tendon synovitis were collected from 23 women and from 7 men undergoing surgery for median nerve decompression at the wrist for CTS. In TCL and synovial tissue, cells expressed ER and PR with statistically significant differences related to the age and sex of patients. Immunoreactivity was observed in fibroblasts of TCL, and in lining cells and fibroblasts of synovial tissue. In women, the number of ER-positive cells in the TCL and synovial tissue increased with the age, peaking at 55-70 years, and then decreasing. PR-immunoreactivity was observed only in fibroblasts of TCL and its expression decreased with age, while no immunolabeling was found in the synovial tissue. In TCL samples, the number of ER- and PR-positive cells in non-CTS patients was significantly lower than in CTS patients. These results demonstrate that ER and PR are present in TCL and flexor tendon synovitis, suggesting a role for sex steroid hormones in the pathogenesis of CTS disease.     

Concomitant presentation of carpal tunnel syndrome and trigger finger

Background

Carpal tunnel syndrome (CTS) and trigger finger (TF) are common conditions that may occur in the same patient. The etiology of most cases is unknown. The purpose of this study was to evaluate the rate of concomitant occurrence of these two conditions at presentation and to compare the concomitant occurrence in normal and diabetic patients.

Methods

One-hundred and eight consecutive subjects presenting to our hand clinic with CTS and/or TF were evaluated. The existence of both of these conditions was documented through a standard history and physical examination. The definition of trigger finger was determined by tenderness over the A1 pulley, catching, clicking or locking. CTS was defined in the presence of at least two of the following: numbness and tingling in a median nerve distribution, motor and sensory nerve loss (median nerve), a positive Tinel's or Phalen's test and positive electrophysiologic studies.

Results

The average age of the participants was 62.2 ± 13.6 years. Sixty-seven patients presented with symptoms and signs of CTS (62%), 41 (38%) subjects with signs and symptoms of TF. Following further evaluation, 66 patients (61%) had evidence of concomitant CTS and TF. Fifty-seven patients (53% of all study patients) had diabetes. The rate of subjects with diabetes was similar among the groups (p = 0.8, Chi-square test).

Conclusion

CTS and TF commonly occur together at presentation though the symptoms of one condition will be more prominent. Our results support a common local mechanism that may be unrelated to the presence of diabetes. We recommend evaluation for both conditions at the time of presentation.     

Poor outcome for neural surgery (epineurotomy or neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone: a meta-analysis of global outcomes

A meta-analysis was performed on the results of eight studies that compared the global outcomes of patients who received carpal tunnel release with the global outcomes of patients who received carpal tunnel release and neurolysis or epineurotomy. The meta-analysis suggests that patients who received such neural surgery tended to have poorer global outcomes than those who did not (odds ratio, 0.54; 95 percent confidence interval, 0.32 to 0.90). The data are homogenous, and linear-regression analysis indicates that patient attrition did not influence the outcome of the meta-analysis. The results of this meta-analysis indicate that neural surgery is potentially harmful for most patients with carpal tunnel syndrome. The possibility remains that neural surgery may be helpful in special cases, such as in the presence of marked scarring or neural adhesion, but no available evidence specifically documents the benefits and harms of surgery among such patients.     

Genetic linkage analysis of the carpal tunnel syndrome

Two generations of a family with autosomal dominant carpal tunnel syndrome were studied for genetic linkage to 20 informative polymorphic blood markers. No linkage was demonstrated between the syndrome and the markers tested; exclusion of close linkage (lod score less than -2.0) was found for MNSs, ACP, GALT, GPT, GLO, Hp, Gc, and Pi.