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.     

Carpal Tunnel Syndrome in Patients with Tremor Dominant Parkinson’s Disease

Background

Unilateral hand tremor is one of the cardinal symptoms of Parkinson’s disease. Additionally, mechanical traumatic hand movement is one of the risk factors for carpal tunnel syndrome. Our objective in this study was to examine whether repetitive mechanical movement may be related to the development of carpal tunnel syndrome in Parkinson’s disease with unilateral hand tremor using neurophysiological methods.

Methods

The study participants included 33 de novo Parkinson’s disease patients with unilateral hand tremor, and we compared the tremor hand and non-tremor hand within the same patients.

Results

Seven (21.2%) of the 33 patients had carpal tunnel syndrome. All of carpal tunnel syndrome patients showed neurophysiological abnormalities in both the hand without tremor and the hand with tremor. In addition, in patients without carpal tunnel syndrome, the sensory nerve action potential was lower in the hand without tremor than in the hand with tremor, although there were no significant differences.

Conclusions

We concluded that hand tremor in de novo Parkinson’s disease patients was not directly related to the development of carpal tunnel syndrome. In contrast, more frequent use of hand without tremor may induce mechanical loading and may be associated with CTS in the hand without tremor. Early diagnosis of Parkinson’s disease and proper education in hand use may be essential for preventing carpal tunnel syndrome in Parkinson’s disease tremor patients.     

Adaptation of the Transverse Carpal Ligament Associated with Repetitive Hand Use in Pianists

The transverse carpal ligament (TCL) plays a critical role in carpal tunnel biomechanics through interactions with its surrounding tissues. The purpose of this study was to investigate the in vivo adaptations of the TCL’s mechanical properties in response to repetitive hand use in pianists using acoustic radiation force impulse (ARFI) imaging. It was hypothesized that pianists, in comparison to non-pianists, would have a stiffer TCL as indicated by an increased acoustic shear wave velocity (SWV). ARFI imagining was performed for 10 female pianists and 10 female non-pianists. The median SWV values of the TCL were determined for the entire TCL, as well as for its radial and ulnar portions, rTCL and uTCL, respectively. The TCL SWV was significantly increased in pianists relative to non-pianists (p < 0.05). Additionally, the increased SWV was location dependent for both pianist and non-pianist groups (p < 0.05), with the rTCL having a significantly greater SWV than the uTCL. Between groups, the rTCL SWV of pianists was 22.2% greater than that of the non-pianists (p < 0.001). This localized increase of TCL SWV, i.e. stiffening, may be primarily attributable to focal biomechanical interactions that occur at the radial TCL aspect where the thenar muscles are anchored. Progressive stiffening of the TCL may become constraining to the carpal tunnel, leading to median nerve compression in the tunnel. TCL maladaptation helps explain why populations who repeatedly use their hands are at an increased risk of developing musculoskeletal pathologies, e.g. carpal tunnel syndrome.     

The incidence of recurrence after endoscopic carpal tunnel release

Endoscopic carpal tunnel release has been used to decompress the median nerve in carpal tunnel syndrome for over the past decade, with an advantage (over the traditional "open" release) being decreased pain in the postoperative period. The goals of this study were to attempt to define the recurrence rate after endoscopic carpal tunnel release and to determine if it differs from that of open technique. The charts of 191 consecutive carpal tunnel syndrome patients treated operatively at the University of Missouri were reviewed. For this study, recurrent carpal tunnel syndrome was defined as documented cases in which the symptoms had resolved following surgical release but subsequently recurred, requiring surgical rerelease of the carpal tunnel. All endoscopic releases were performed using the Chow two-portal technique. Statistical analysis was performed using Fisher's exact test. A total of 103 patient hands had open carpal tunnel releases; 88 were endoscopically released. Total follow-up time (from the initial release) averaged 29 months for the open group and 22 months for the endoscopic group. There were no recurrences in the open group and six recurrences in the endoscopic group (7 percent, p = 0.008). All six recurrences were in worker's compensation patients. The median time between endoscopic release and rerelease was 8.5 months. There seems to be a statistically higher incidence of recurrence of carpal tunnel syndrome after endoscopic release compared with the traditional "open" release in our cases. Although the pathogenesis of this increased rate of recurrence is not clear, this should be considered when planning surgical release of the volar carpal ligament for carpal tunnel syndrome.     

Carpal tunnel syndrome and vitamin B6

We reviewed 1075 patients presenting over a 12-year period with symptoms of carpal tunnel syndrome. A total of 994 had a final diagnosis of carpal tunnel syndrome. There were 444 male and 550 female patients with a mean age of 42 years. Three-hundred and ninety-five related symptoms to their job. Surgery was performed in 27 percent of the total diagnosed cases with approximately 97 percent relief of symptoms. Satisfactory alleviation of symptoms was obtained in 14.3 percent of patients treated conservatively prior to 1980, with one or a combination of splinting anti-inflammatory agents, job or activity change, and steroid injections. In 1980, vitamin B6 (pyridoxine) was added as a method of conservative treatment. Satisfactory improvement was obtained in 68 percent of 494 patients treated with a controlled dosage (100 mg b.i.d.). While our findings were not the result of a controlled scientific study, we feel they suggest that regulated use of vitamin B6 may be helpful in treating many cases of carpal tunnel syndrome.     

Median nerve compression and trigger finger in the mucopolysaccharidoses and related diseases.

Patients with Hurler's syndrome (MPS-1H), I-cell disease (ML-II) and pseudo-Hurler's syndrome (ML-III) had median nerve compression and triggering of the fingers which limited finger extension. To our knowledge, this combination has not been reported previously in patients with mucopolysaccharidoses and related disorders. In all of our 3 cases the median nerve was compressed by thickened flexor tenosynovium. Synovectomy and resection of the volar carpal ligament improved the hand function in all, including the mentally retarded patient with Hurler's syndrome. Release of the fibroosseous tunnel in two patients was followed by an increased range of motion (but not full extension). A fourth patient, without a mucopolysaccharide storage disorder, also had the combination of trigger finger and carpal tunnel syndrome.     

A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome

Surgery is the definitive treatment for carpal tunnel syndrome. Conservative treatments, such as wrist splinting and steroid injections, are also effective for the relief of carpal tunnel symptoms, but their use remains controversial because they only offer long-term relief in a minority of patients. A prospective study was performed to assess the role of steroid injections combined with wrist splinting for the management of carpal tunnel syndrome. A total of 73 patients with 99 affected hands were studied. Patients presenting with known medical causes or muscle wasting were excluded. Diagnosis was made clinically and electrodiagnostic studies were performed only when equivocal clinical signs were present. Each patient received up to three betamethasone injections into the carpal tunnel and wore a neutral-position wrist splint continuously for 9 weeks. After that period, symptomatic patients received an open carpal tunnel release, and those who remained asymptomatic were followed up regularly for at least 1 year. Patients who relapsed were scheduled for surgery. At a minimum follow-up of 1 year, seven patients (9.6 percent) with 10 affected hands (10.1 percent) remained asymptomatic. This group had a significantly shorter duration of symptoms (2.9 months versus 8.35 months; p = 0.039, Mann-Whitney test) and significantly less sensory change (40 percent versus 72 percent; p = 0.048, Fisher's exact test) at presentation when compared with the group who had surgery. It is concluded that steroid injections and wrist splinting are effective for relief of carpal tunnel syndrome symptoms but have a long-term effect in only 10 percent of patients. Symptom duration of less than 3 months and absence of sensory impairment at presentation were predictive of a lasting response to conservative treatment. It is suggested that selected patients (i.e., with no thenar wasting or obvious underlying cause) presenting with mild to moderate carpal tunnel syndrome receive either a single steroid injection or wear a wrist splint for 3 weeks. This will allow identification of the 10 percent of patients who respond well to conservative therapy and do not need surgery.     

Comparison of carpal canal pressure in paraplegic and nonparaplegic subjects: clinical implications

The purpose of this study was to evaluate the pressure within the carpal tunnel that was generated with certain tasks in paraplegic versus nonparaplegic subjects. Four groups of subjects were evaluated: 10 wrists in six paraplegic subjects with carpal tunnel syndrome, 11 wrists in six paraplegics without the syndrome, 12 wrists in nine nonparaplegics with the syndrome, and 17 wrists in 11 nonparaplegics without the syndrome. Carpal canal pressures were measured in the wrists in three positions (neutral, 45-degree flexion, 45-degree extension) and during two dynamic tasks [wheelchair propulsion and RAISE (relief of anatomic ischial skin embarrassment) maneuver]. External force resistors were placed over the carpal canal and correlated with internal tunnel pressures. At each wrist position, paraplegics with carpal tunnel syndrome consistently had higher carpal canal pressure than did the other groups at the corresponding wrist position; statistical significance was evident with regard to the neutral wrist position (p < 0.05). Within each group of subjects, wrist extension and wrist flexion produced a statistically significant increase in carpal canal pressure (p < 0.05), compared with the neutral wrist position. Dynamic tasks (wheelchair propulsion and the RAISE maneuver) significantly elevated the carpal canal pressure in paraplegics with carpal tunnel syndrome, compared with the other groups (p < 0.05). Lastly, there is a linear positive correlation between carpal canal pressure and external force resistance.     

神经传导测定技术对腕管综合征病情评估的价值

目的:近年来腕管综合征发病率逐年升高,然而其慢性、隐匿性不易引起人们的重视,发现时往往已造成较大的危害。本文探讨腕管综合征的神经传导测定对病情评估的临床价值,旨在为患者腕管综合征早期发现和后续治疗提供进一步的临床参考依据。方法:选取我院124例确诊的腕管综合征患者。其中无大鱼际肌萎缩者有64例,并选取平均年龄相近的64例正常人作为对照(组A);有大鱼际肌畏缩者60例,并选取平均年龄相近的60例正常人作为对照(组B)。A、B组均经行神经电图检查,握力测定和两点辨别觉测定,分析神经传导速度改变与感觉、运动功能减退程度的关系。结果:A、B两组患者均有不同程度的神经传导改变:在A组患者神经传导改变中,运动和感觉传导速度(MCV和SCV)轻度下降,运动和感觉电位波幅(CMAP和SNAP)轻度下降,潜伏期(ML)轻度延长;在B组患者神经传导中,运动和感觉传导速度(MCV和SCV)明显下降,运动和感觉电位波幅(CMAP和SNAP)明显下降,潜伏期明显延长。结论:腕管综合征患者不同的临床表现有不同程度的神经电图表现,因此神经电图对神经传导的测定结果对腕管综合征患者的病情有良好的评估价值,值得临床推广。     

Carpal tunnel syndrome,humeral epicondylitis,and the cervical spine: a study of clinical and dimensional relations.

Forty-three patients with idiopathic carpal tunnel syndrome, confirmed by nerve conduction studies and treated by surgery, were compared clinically and radiologically with 43 age- and sex-matched control patients. Patients with carpal tunnel syndrome had a significantly greater prevalence of lateral humeral epicondylitis (tennis elbow) (33%) than controls (7%). Randomised reading of the cervical spine radiographs in ignorance of the groups to which they belonged showed no significant difference in the prevalence of either intervertebral disc degeneration or intraforaminal osteophyte protruion using conventional grading methods. Measurement of the minimum anteroposterior diameter of the cervical spinal canal, the anteroposterior diameters of the cervical vertebral bodies, and the ratio of intervertebral disc height to adjacent vertebral body height in the cervical spine, however, showed a consistent trend to smaller measurements in the carpal tunnel group. Differences were significant at several vertebral levels in each of these dimensions. The narrowing of the intervertebral discs relative to the vertebral bodies in patients with carpal tunnel syndrome may indicate connective tissue changes, which might also occur in the common extensor origin at the elbow or in the contents of the carpal tunnel.     

Test of a new technique for the diagnosis of carpal tunnel syndrome.

Several new techniques for carpal tunnel syndrome diagnosis have been developed in the last few years. This work tests a technique that compares the distal motor latency of the median nerve to the second lumbrical muscle (2L) with the distal motor latency of the ulnar nerve to the interossei muscle (INT). Results from 40 normal hands give the superior limit of the normal difference (2L-INT) as 0. 26 ms (&xmacr;+3 SD). In 55 hands with different levels of carpal tunnel syndrome, this new technique was more sensitive and accurate than the conventional test which uses the distal motor latency of the median nerve to the abductor pollicis brevis muscle (APB), especially in the less severe cases. With the absence of the compound muscle action potentials of the APB muscle caused by severe thenar atrophy, it is much easier to obtain the potential from the 2L muscle. We concluded that this is a sensitive, simple, rapid, and non-invasive new technique, and therefore, it should be incorporated as part of the routine ENMG procedures for carpal tunnel syndrome diagnosis.     

Carpal tunnel syndrome in women undergoing reduction mammaplasty

Women with mammary hypertrophy who present for reduction mammaplasty have several well-described musculoskeletal complaints, but a high prevalence of carpal tunnel syndrome has not been reported. We identified 151 patients from a plastic surgery practice who underwent reduction mammaplasty from 1994 to 1996. To this group we added a convenience sample of 64 women volunteers with relatively smaller breasts (brassiere cup size B or smaller). We questioned the entire group about specific symptoms and examined them using standard provocative tests. Carpal tunnel syndrome was defined as the coexistence of symptoms and at least two physical examination findings. We examined its association with breast size, age, race, and body mass index. Stepwise logistic regression was used to determine which physical characteristics were predictive of the condition. Carpal tunnel syndrome was found in 30 patients (19.9 percent) (95 percent confidence interval, 13.8 to 27.1) and in none of the women in the convenience sample. Breast size and, to a lesser degree, body mass index were found to be highly significant predictors of carpal tunnel syndrome. After controlling for breast size, race was also significant. Breast size displayed an independent risk ratio of 6.67 when comparing the upper quartile of size to the lower quartiles. There is a markedly higher prevalence of carpal tunnel syndrome in women who present for reduction mammaplasty than in those with smaller breasts. Breast size was a significant predictor of carpal tunnel syndrome.     

Carpal tunnel syndrome and routine blood chemistries

A total of 110 of the 175 patients examined had symptomatic carpal tunnel syndrome. We were able to isolate 10 patients with carpal tunnel syndrome and electrical evidence of an associated peripheral neuropathy from these 110 patients. We feel that patients with peripheral neuropathies probably warrant an extensive laboratory evaluation for primary and treatable disorders. In contrast, we feel patients with isolated carpal tunnel syndrome, normal ulnar latencies, and normal ankle jerk reflexes do not warrant initial erythrocyte sedimentation rates, thyroid profiles, or blood sugars unless there are other historical or physical factors that suggest a predisposition to diabetes mellitus, thyroid disease, or rheumatic disorders.     

Comparison of two ways of altering carpal tunnel pressure with ultrasound surface wave elastography

Higher carpal tunnel pressure is related to the development of carpal tunnel syndrome. Currently, the measurement of carpal tunnel pressure is invasive and therefore, a noninvasive technique is needed. We previously demonstrated that speed of wave propagation through a tendon in the carpal tunnel measured by ultrasound elastography could be used as an indicator of carpal tunnel pressure in a cadaveric model, in which a balloon had to be inserted into the carpal tunnel to adjust the carpal tunnel pressure. However, the method for adjusting the carpal tunnel pressure in the cadaveric model is not applicable for the in vivo model. The objective of this study was to utilize a different technique to adjust carpal tunnel pressure via pressing the palm and to validate it with ultrasound surface wave elastography in a human cadaveric model. The outcome was also compared with a previous balloon insertion technique. Results showed that wave speed of intra-carpal tunnel tendon and the ratio of wave speed of intra-and outer-carpal tunnel tendons increased linearly with carpal tunnel pressure. Moreover, wave speed of intra carpal tunnel tendon via both ways of altering carpal tunnel pressure showed similar results with high correlation. Therefore, it was concluded that the technique of pressing the palm can be used to adjust carpal tunnel pressure, and pressure changes can be detected via ultrasound surface wave elastography in an ex vivo model. Future studies will utilize this technique in vivo to validate the usefulness of ultrasound surface wave elastography for measuring carpal tunnel pressure.     

Comparison of partial excision with simple section of the transverse carpal ligament in the treatment of carpal tunnel syndrome

In the surgical treatment of carpal tunnel syndrome, debate has commonly focused on whether decompression should be performed by open or blind techniques. Contrarily, the goal of the present study was to determine whether instead of simple section, partial excision of the transverse carpal ligament has contributed to better results. Because complete healing of the transverse carpal ligament observed during reoperations has been reported elsewhere, the charts of 75 carpal tunnel syndrome patients who had been treated with open technique at Dokuz Eylül University were reviewed. Statistical analysis was performed using the Fisher's exact test and Student's t test when appropriate. Thirty-five patients had been treated with simple section of the transverse carpal ligament, whereas 40 had been treated with partial excision. Internal neurolysis was also performed in 19 of the patients, 11 of whom were treated with partial excision. The average follow-up time was 3.8 years. The comparisons regarding the overall operative outcomes did not show any significant difference between the two different techniques of releasing the transverse carpal ligament. In patients treated without neurolysis, results of partial excision of the transverse carpal ligament improved when compared with those of simple section, but this superiority was not statistically significant. There seemed to be statistically higher reoperation rates and worse outcomes after neurolysis (p < 0.05). Reoperation was required in eight patients (11 percent). Five of the patients who underwent reoperation had initially been treated with partial excision and neurolysis, whereas two had been treated with simple section and neurolysis. Another patient who had undergone reoperation had initially undergone only simple section. The mean time to return to work or daily activities did not differ between the types of applied technique for releasing the transverse carpal ligament. However, neurolysis lengthened these periods significantly when performed (p < 0.05). In the present study, partial excision of the transverse carpal ligament without adding neurolysis offered relatively better results than simple section. Verification of this finding endoscopically, if applicable, may improve the success rate of surgical therapy in patients with carpal tunnel syndrome.     

Finite element simulation of the mechanical impact of computer work on the carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a clinical disorder resulting from the compression of the median nerve. The available evidence regarding the association between computer use and CTS is controversial. There is some evidence that computer mouse or keyboard work, or both are associated with the development of CTS. Despite the availability of pressure measurements in the carpal tunnel during computer work (exposure to keyboard or mouse) there are no available data to support a direct effect of the increased intracarpal canal pressure on the median nerve.     

A systematic review of reviews comparing the effectiveness of endoscopic and open carpal tunnel decompression

Controversy persists regarding the benefit of endoscopic carpal tunnel release compared with open carpal tunnel release for pain, numbness, strength, return to work and function, scar tenderness, and complications. For surgeons, a recommended first source of information on treatment effectiveness is a review of high-methodologic-quality articles. This review of reviews was undertaken to answer this clinical question regarding these outcomes. Cochrane, MEDLINE, EMBASE, CINAHL, and HealthSTAR databases were searched using the key words "endoscopic carpal tunnel," with limits "review or overview" and dates from 1989 to present. Five key journals were hand-searched. Any review with a reference to at least one randomized controlled trial that compared endoscopic carpal tunnel release to open carpal tunnel release was to be included. Two reviewers independently scanned titles and abstracts for potential relevance. Selection as relevant was confirmed through a review of full texts. Disagreements were resolved through discussion and consensus. The selected reviews were assessed for methodologic quality on the basis of the scale of Hoving et al. Of 48 articles initially identified, seven pertinent reviews were selected. Of these seven, three reviews of high methodologic quality concurred that there is no difference between the two techniques in symptom relief and that the evidence is conflicting for return to work and function. The risk of permanent median nerve injury does not differ between the techniques. The reviews indicated that the endoscopic carpal tunnel release technique is worse in terms of reversible nerve injury but superior in terms of grip strength and scar tenderness, at least in short-term follow-up. Several trials have not been incorporated in these reviews and statistical pooling has not been conducted. Further systematic review with meta-analysis may permit more definitive conclusions about the relative effectiveness of these two techniques, particularly with regard to return to work and function.     

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.