Syndromes from segmental vibration and nerve entrapment: observations on case definitions for carpal tunnel syndrome

Abstract

The purpose of this paper is to assess the overlap and stability of two different case definitions of carpal tunnel syndrome CTS. The analysis considers the association between different case definitions and objective tests (sensory nerve conduction velocities, SNCVs and vibrotactile perception thresholds, TTS), and the natural history of CTS, in the context of two vibration-exposed cohorts. Clinical CTS cases were defined in two ways: (1) by the study physician using fixed criteria, and; (2) by questionnaire and hand diagram. SNCV in median and ulnar nerves was measured for digital, transpalmar, and transcarpal segments, and conventionally as from wrist-digit. Skin temperature was assessed as a point measurement by thermistor and regionally by thermal imaging. VTTs were determined at the bilateral fingertips of the third and fifth digits using a tactometer meeting the requirements of ISO 13091-1 (ISO 2001). The subjects were cohorts of shipyard workers in 2001 and 2004, and dental hygienists in 2002 and 2004. Results are reported for 214 shipyard workers in 2001 and 135 in 2004, and for 94 dental hygienists in 2002 and 66 in 2004. In 2001, 50% of shipyard workers were diagnosed as CTS cases by at least one of the diagnostic schemes, but only 20% were positive by both criteria. Among study physician diagnosed cases, 64% were CTS negative in 2001, 76% were negative in 2004, 13% were positive in both years, 22% became negative after being positive, and 11% became positive after being negative. For only study physician diagnosed CTS did VTTs differ between cases differ and non-cases in digit 3; there was no such distinction in digit 5. The dental hygienists had little CTS. Clinical case definitions of CTS based on diagrams and self-assessment, and clinical evaluation have limited overlap. Combining clinical criteria to create a more narrow or specific case definition of CTS does not appear to predict SNCV. The natural history of CTS suggests a protean disorder with considerable flux in case status over time.