Thenar Muscle Atrophy Research Articles

CARPAL TUNNEL SYNDROME (DIAGNOSIS AND MANAGEMENT)

Carpal Tunnel Syndrome (CTS) is a neuropathy disease that affects the median nerve with an incidence of around 90%. Carpal Tunnel Syndrome appears in 3.8% of the general population, with the highest prevalence occurring in women. There are several risk factors associated with CTS, namely medical and non-medical factors. The mechanism of carpal tunnel syndrome until now is still very complex and is not known with certainty, but compression and traction factors in the median nerve are thought to be the most common cause of CTS. Carpal Tunnel Syndrome can manifest clinically with subjective signs such as paresthesia, proprioceptive changes, and paresis, as well as objective signs, such as changes in motor sensitivity and function, positive Tinel and Phallen tests, and thenar muscle atrophy. The diagnosis of Carpal Tunnel Syndrome is based on the classic symptoms of pain, numbness, tingling, and/or burning sensation in the distribution of the median nerve in the hand, as well as the abnormal function of the median nerve based on nerve conduction studies. Conservative therapy is an option. Especially in Carpal Tunnel Syndrome patients with mild to moderate symptoms. Conservative therapy can be given in the form of corticosteroid and physical therapy. Patients with severe CTS or whose symptoms have not improved after four to six months of conservative therapy should be considered for surgical treatment.

Differences in characteristics of carpal tunnel syndrome between male and female patients

BackgroundSex difference is known to be a risk factor of carpal tunnel syndrome. However, sex differences with regard to the clinical presentation of carpal tunnel syndrome have not received much attention. Thus, this study aimed to detect any difference in the characteristics of carpal tunnel syndrome between male and female and thereby add new insights into disease prevention. MethodsA total of 647 patients (male 193 hands and female 454 hands) with carpal tunnel syndrome who underwent endoscopic or open carpal tunnel release were retrospectively reviewed. The average age at time of surgery was 66 years. Clinical and electrophysiological data of all patients were collected. Six medical conditions, including trigger finger, diabetes mellitus, hemodialysis, hyperlipidemia, hypertension, and obesity were also investigated. ResultsA significant difference was found in the distribution of comorbidities between the male and female groups. Particularly, the prevalence of diabetes mellitus, hemodialysis, and hypertension were significantly higher in the male group than in the female group. Meanwhile, the presence of thenar muscle atrophy was significantly higher in the female group than in the male group. ConclusionsWomen are more likely to experience carpal tunnel syndrome even though they have no comorbidities. We suggest that carpal tunnel syndrome especially in male patients may be reduced by early intervention for diabetes mellitus. Prospective studies are needed to validate the causal relationship between diabetes mellitus and carpal tunnel syndrome.

A Tablet-Based App for Carpal Tunnel Syndrome Screening: Diagnostic Case-Control Study.

BackgroundCarpal tunnel syndrome (CTS), the most common neuropathy, is caused by a compression of the median nerve in the carpal tunnel and is related to aging. The initial symptom is numbness and pain of the median nerve distributed in the hand area, while thenar muscle atrophy occurs in advanced stages. This atrophy causes failure of thumb motion and results in clumsiness; even after surgery, thenar atrophy does not recover for an extended period. Medical examination and electrophysiological testing are useful to diagnose CTS; however, visits to the doctor tend to be delayed because patients neglect the symptom of numbness in the hand. To avoid thenar atrophy-related clumsiness, early detection of CTS is important.ObjectiveTo establish a CTS screening system without medical examination, we have developed a tablet-based CTS detection system, focusing on movement of the thumb in CTS patients; we examined the accuracy of this screening system.MethodsA total of 22 female CTS patients, involving 29 hands, and 11 female non-CTS participants were recruited. The diagnosis of CTS was made by hand surgeons based on electrophysiological testing. We developed an iPad-based app that recorded the speed and timing of thumb movements while playing a short game. A support vector machine (SVM) learning algorithm was then used by comparing the thumb movements in each direction among CTS and non-CTS groups with leave-one-out cross-validation; with this, we conducted screening for CTS in real time.ResultsThe maximum speed of thumb movements between CTS and non-CTS groups in each direction did not show any statistically significant difference. The CTS group showed significantly slower average thumb movement speed in the 3 and 6 o’clock directions (P=.03 and P=.005, respectively). The CTS group also took a significantly longer time to reach the points in the 2, 3, 4, 5, 6, 8, 9, and 11 o’clock directions (P<.05). Cross-validation revealed that 27 of 29 CTS hands (93%) were classified as having CTS, while 2 of 29 CTS hands (7%) did not have CTS. CTS and non-CTS were classified with 93% sensitivity and 73% specificity.ConclusionsOur newly developed app could classify disturbance of thumb opposition movement and could be useful as a screening test for CTS patients. Outside of the clinic, this app might be able to detect middle-to-severe-stage CTS and prompt these patients to visit a hand surgery specialist; this may also lead to medical cost-savings.

Carpal tunnel syndrome: issues of diagnosis and treatment

Objective: to analyze the typical medical practice management of patients with carpal tunnel syndrome (CTS), to evaluate the efficiency of surgical treatment, and to identify factors influencing the successful outcomes of surgical treatment.Patients and methods. The investigation enrolled 85 patients (14 men and 71 women; mean age, 62±10.8 years). Previous diagnosis and treatment of patients were assessed in other healthcare facilities. All patients underwent median nerve decompression. The efficiency of surgical treatment was assessed according to the Boston Carpal Tunnel Questionnaire (BCTQ) and a visual analogue scale for pain before and 1, 3, 6, and 12 months after surgery.Results and discussion. Informative diagnostic tests are rarely performed in patients with CTS, but cervical spine neurovisualization is often unreasonably prescribed. Erroneous diagnoses (predominantly those of cervical spine osteochondrosis (46%), and diabetic neuropathy (6%)) are made frequently (60%) in patients with CTS; the latter receive ineffective treatment for a long time. Surgical treatment in reducing pain and improving hand functionality is noted to be highly effective. The mean BCTQ score decreased from 2.81±0.68 to 1.62±0.55 and 1.24±0.41 at 1 and 12 months, respectively (p&lt;0.05), the mean functional state score dropped from 2.92±0.78 to 2.4±0.72 and 1.46±0.57, respectively (p&lt;0.05). Permanent numbness, subjective weakness, thenar muscle atrophy, Stage III CTS, and diabetes mellitus are predictors for less pronounced improvement in BCTQ scores after surgery (p&lt;0.05).Conclusion. Physicians are noted to be unaware of the manifestations of CTS and effective methods for its diagnosis and treatment. Decompression surgery is shown to be a highly effective procedure in patients with CTS following 1 and 12 months.

Median nerve decompression in carpal tunnel syndrome: short- and long-term results

Objective: to investigate the short- and long-term results of surgical median nerve decompression via classical and minimally invasive approaches in patients with carpal tunnel syndrome (CTS), as well as factors that influence surgical outcomes. Patients and methods. The investigation enrolled 70 patients (13 men and 57 women) aged 36 to 84 years (mean age, 62±10.8 years) who had undergone median nerve decompression. Surgery was performed in the classical way in 35 patients (Group 1) and via a minimally invasive access in the remaining 35 patients (Group 2). The efficiency of treatment was evaluated using the Boston Carpal Tunnel Questionnaire (BCTQ) and a visual analog scale for pain before and 1, 3, 6, and 12 months after surgery, as well as from patient satisfaction with surgical outcomes. Results. No complications of surgical treatment were detected. There was a marked reduction in pain and other neuropathic disorders just 1 month after surgery and a substantial hand functional improvement following 6 months. After 12 months, in Group 1, the mean BCTQ Symptom Severity Scale and Functional Deficit Scale scores decreased from 2.76 to 1.15 (p≤0.01) and from 2.72 to 1.24 (p≤0.01), respectively; in Group 2, these dropped from 2.86 to 1.14 (p≤0.01) and from 2.95 to 1.24 (p≤0.01), respectively. Complete recovery from sensory problems occurred in 24 (69%) patients in Group 1 and in 25 (71%) patients in Group 2; their partial recovery was observed in 11 (31%) and 10 (29%) patients in these groups, respectively. One 1 month following decompression, the patients in Group 1 had more severe pain syndrome than those in Group 2; these differences became statistically insignificant after 6 months. The patients were found to be highly satisfied with surgical treatment. Permanent numbness, subjective weakness, thenar muscle atrophy, stage III CTS, and diabetes mellitus (DM) were predictors for less pronounced improvement in BCTQ scores after surgical treatment (p&lt;0.05). The paper describes a clinical case that achieved full postoperative occupational and home rehabilitation. Conclusion. The patients with CTS were observed to have a marked reduction in pain and other neuropathic disorders just one month after surgical decompression and a substantial hand functional improvement following 6 months. The benefit from a minimally invasive access is less severe pain syndrome at 1 month after surgery. The predictors of less successful results of surgery are age (the older the patient is, the greater likelihood of having a worse result), permanent numbness, subjective hand weakness, thenar muscle atrophy, DM, and stage III CTS.

F163. Role of ultrasonography in severe distal median nerve neuropathy

Patients with severe carpal tunnel syndrome may present with atrophy of thenar muscles and loss of sensations in the median nerve distribution. Nerve conduction studies do not provide precise localization especially when compound muscle action potential (CMAP) is absent over the abductor pollicis brevis (APB) and the 2nd lumbrical and no senssory action potential is recordable. In such patients, presumptive diagnosis of entrapment at the carpal tunnel is made based upon topography of denervation observed on needle EMG; however, denervation limited to the APB points to median nerve involvement distal to the branching of anterior interoseous nerve and not necessarily to the carpal tunnel. This study was aimed at determining how often a localization other than carpal tunnel results when ultrasound imaging is used as a complementary test. Patients with a clinical diagnosis of severe carpal tunnel syndrome seen in 2 years with the following criteria were included in the study: 1. Absent CMAP over APB and 2nd lumbrical on stimulation of the median nerve at the wrist and the elbow; 2. Absent sensory potentials over digits on median nerve stimulation at the wrist; 3. Needle EMG showing denervation of APB with normal findings in flexor pollicis longus, pronator teres, first dorsal interosseous and extensor indicis. Patients with diabetes mellitus and other causes of neuropathy or those with prior history of carpal tunnel release were excluded. Ultrasonic studies were done with 8–18 MgHz probe. CSA of median nerve was measured at the level of distal wrist crease and mid forearm (short axis view). The nerve was also studied in the long axis view across the carpal tunnel measuring the diameter at the carpal tunnel inlet and at the narrowest part of the nerve within the carpal tunnel. Measurements included cross sectional area (CSA) at wrist and forearm as well as diameter at the carpal tunnel inlet and within carpal tunnel. Wrist/forearm CSA ratio was calculated. Ratio between diameter at the carpal tunnel inlet and the smallest diameter within the tunnel was also calculated. A total of 18 patients were included consisting of 10 males and 8 females; age range was 30–91 with a mean of 70. 12 involved the right and 6 the left hand. CSA at wrist was 22.5 ± 7.4 mm2. Wrist forearm ratio was 2.8 ± 0.9. Ratio between diameter at inlet and within carpal tunnel was 0.49 ± 0.1. In 16 patients ultrasonic imaging confirmed entrapment at carpal tunnel. In 2 patients abnormality was found proximal to the carpal tunnel, one instance of neuroma and one of dislocated lunate. In 16 out of 18 patients presenting with no CMAP over APB and 2nd lumbrical and with absent SNAPs, presumptive diagnosis of CTS was further supported by ultrasonic imaging. In 2 patients additional diagnostic features were detected by ultrasonic imaging.

Minimally invasive modified Camitz opponensplasty for severe carpal tunnel syndrome.

We aimed to compare the clinical results and the complications between the minimally invasive modified Camitz opponensplasty and the conventional Camitz opponensplasty for severe carpal tunnel syndrome (CTS), and to evaluate the efficacy of the modified technique for CTS. Twenty-eight hands in 24 patients with severe CTS who had disorder of the thumb opposition with thenar muscle atrophy (group 1) were treated by minimally invasive modified Camitz opponensplasty, passing the transferred palmaris longus (PL) tendon under the abductor pollicis brevis (APB) fascia using only palm and thumb incision, and no incision to either wrist crease or forearm. Ten hands in 10 patients (group 2) were treated by the conventional Camitz opponensplasty. Clinical evaluation was made by comparing the results before and after surgery for the angle of the thumb palmar abduction, pinch power, and grip strength. All clinical findings significantly improved after surgery compared with before surgery in all patients. In group 1, there were no complications including transferred tendon bowstring, painful wrist scar, or injury to the palmar cutaneous branch of the median nerve in all hands. Conversely, patients in group 2 had four painful wrist scars and nine bowstrings of the transferred tendon. Several complications have been considered to attribute to the long incision and an extensive dissection crossing the wrist crease from the palm to the wrist in the conventional Camitz procedure. The current modified Camitz opponensplasty by minimally invasive incision without straddling the wrist crease is a simple and effective procedure that can decrease the risk of painful scar around the wrist crease in severe CTS patients with disorder of thumb opposition. Additionally, this technique, by passing the transferred PL tendon under the APB fascia, is useful in restoring the thumb opposition immediately, and in preventing the bowstringing of the transferred tendon.

Ulnar Neuropathy due to Intraneural Ganglion Cyst of the Ulnar Nerve at the Elbow

AbstractIntraneural ganglion cysts are rare mucinous cyst originating within the epineurium of peripheral nerves. They occur most commonly in the peroneal nerve. However, they have also been described in many nerves in the vicinity of synovial joints. Intraneural ganglion cysts in the upper extremity are rare. Those at the elbow joint comprise only 9% of intraneural ganglion ever reported.A 66-year-old and right-handed male patient presented with a sudden onset of right-hand weakness. He initially noticed paresthesia with decreased sensation in the lateral two digits and radial palm in his right hand. Physical examination showed thenar muscle atrophy and muscle weakness of the abductor pollicis brevis in the right hand. Preoperative diagnosis of intraneural ganglion cyst was made on the basis of characteristic magnetic resonance imaging (MRI) findings. On exploration, the ulnar nerve was identified proximal to the elbow joint. Its articular branch was addressed and divided from the elbow joint.To the best of our knowledge, addressing the articular branch connecting the glenohumeral joint for the treatment of intraneural ganglion at the elbow has only been reported twice. We experienced a rare occurrence of intraneural ganglion cyst at the elbow manifesting an ulnar neuropathy. Here, we report intraoperative findings for the articular branch-connected to intraneural ganglion of the ulnar nerve at the elbow. Early diagnosis of intraneural ganglion with precise identification of the pathology and addressing the articular branch with atraumatic dissection of ganglion cyst are essential to achieve successful treatment for this rare lesion.

Effectiveness of wrist tube inside and outside releasing for treating median nerve double entrapment at wrist

To investigate the effectiveness of wrist tube inside and outside releasing for treating median nerve double entrapment at wrist. Thirty-one patients of median nerve double entrapment at wrist were treated between April 2011 and May 2014. There were 8 males and 23 females with an age of 33-69 years (mean, 56.4 years). In palm lateral three and a half finger, the two-point discrimination was 7-14 mm (mean, 9.5 mm), in which 24 cases were 4-10 mm and 7 cases were more than 10 mm. Carpal tunnel median nerve Tinel sign was positive; there was weak and acid swollen felling when press big thenar muscle on median nerve return branch palm surface projection points. Electromyography examination showed that median nerve endings movement incubation period was 4.5-10 ms in 22 cases, more than 10 ms in 9 cases; fibrillation potentials and positive phase voltage happened in 6 cases; the median nerve sensory conduction velocity of all patients was slow, and the motor conduction velocity also slowed down; the motor amplitude was 5-10 mV in 19 cases, less than 5 mV in 12 cases. The disease duration was 3-8 months (mean, 5.5 months). Surgical exploration of wrist median nerve in carpal tunnel and median nerve return branch outside carpal tunnel were performed in patients, especially completely released the variety entrapment factors such as thickening bow at starting point of short hallux flexor tendon, fiber bundles at ulnar side of short hallux flexor tendon, deep layer fiber of the palmar aponeurosis, and variant shallow head of short hallux flexor. All the wounds healed by first intention without wound scar pain. The patients were followed up 24-59 months (mean, 33 months). Night numbness and pain disappeared, and weak and acid swollen feeling in big thenar muscle on median nerve return branch points also disappeared. The sensation recovered to S 4 in 28 patients in palm lateral three and a half finger, the index and middle fingertip sensation recovered to S3+ in 3 cases. In the median nerve innervation area, the two points discrimination was 4-6 mm (mean, 4.8 mm). The thumb opposition function returned to normal in 29 cases and mild confinement in 2 cases. The grip strength of all the 31 cases recovered, and 1 of them increased significantly. In preoperative big thenar muscle atrophy cases, muscle strength recovered to S 5 in 4 cases, S 4 in 2 cases. At 2 years after operation, according to the functional assessment of carpal tunnel syndrome recommend by GU Yudong, the results were excellent in 29 cases and good in 2 cases, with an excellent and good rate of 100%. When treating the nerve double entrapment in wrist using wrist tube inside and outside releasing method, the variety entrapment factors of return branch of median nerve should be completely released, so the effectiveness can be improved.

A study the various clinical and electrophysiological parameters of severity of carpal tunnel syndrome, their correlation with post-operative recovery.

Objective:We aimed to study the various clinical and electrophysiological parameters of severity of carpal tunnel syndrome (CTS) and to see if the severity of CTS affects recovery after surgery.Patients and Methods:A prospective study of 35 patients suffering from CTS. Clinical severity was assessed using visual analogue scale and standard questionnaires such as Levine and Disabilities of Arm, Shoulder and Hand questionnaires. All the patients underwent electrophysiological evaluation to assess electrophysiological severity of CTS. According to modified Padua classification, they were classified into three groups, namely, minimal to mild, moderate and severe to extreme. All patients underwent Carpal tunnel release in our unit. The clinical assessment was repeated 3 months post-operatively.Results:Out of 33 patients, majority (65.7%) of the patients were suffering from moderately severe CTS. The clinical provocative tests were positive in majority of patients. Clinically and statistically significant (P < 0.001) improvement was seen in all clinical severity scores. However, it did not show any statistical correlation with electrophysiological severity of the disease when compared among the groups. There was no association of age, gender of the patient, body mass index, hand dominance, affected side of the patient, results of provocative tests and the presence or absence of thenar muscle atrophy when compared among the three severity groups (P > 0.05).Conclusions:Although pre-operative clinical scores of severity and electrophysiology have a diagnostic role in CTS, they do not correlate with post-operative recovery and in turn fail to predict the extent of post-operative recovery before surgery.

Work-related carpal tunnel syndrome treatment: a cross-sectional study among 106 patients.

The objective is to assess the influence of sociodemographic, professional and clinical variables on the choice of treatment of work-related carpal tunnel syndrome (CTS). An exhaustive and trans-sectional study was conducted over a period of eight years, from 1st January 2006 to 31 December 2013 in the Department of Occupational Medicine at University Hospital of Mahdia, Tunisia. The study population was represented by patients with work-related carpal tunnel syndrome. Data collection was based on a questionnaire sheet, describing social, occupational and medical characteristics of patients. The study population was characterized by a large female dominance, representing 95.3% with an average age of 42±7.8 years. Patients medically treated represented 38.7% and 61.3% had had surgical treatment. After binary logistic regression, surgical indication of CTS was significantly correlated to diabetes (p=0.017), other musculoskeletal disorders (p=0.02), functional signs of CTS (acrocyanosis p=0.05; muscle weakness p=0.015; radiating pain p=0.01; painful discomfort of the hand, the forearm or arm p=0.027) and to the atrophy of thenar muscles (p=0.018). According to this study, the choice of therapy for occupational CTS depends only on clinical data. More detailed studies will be needed to refine these results.

Evaluation of thenar muscles by MRI in carpal tunnel syndrome

In the present study, the thenar muscles were evaluated using magnetic resonance imaging (MRI), in addition, the correlations between thenar muscle changes, clinical findings and electrodiagnostic results from patients with carpal tunnel syndrome were investigated. The subjects were 13 patients (17 wrists) who were clinically diagnosed with carpal tunnel syndrome. In all patients, a medical history was obtained and physical examination was performed, in addition to assessment using the Kapandji scoring system, visual analogue scale (VAS), quick-disabilities of the arm, shoulder and hand (Q-DASH) score, electrodiagnostic results of the median nerve, and MRI of the thenar muscles. Thenar muscle volume was not significantly correlated with clinical data or the electrodiagnostic results. The thenar muscle major axis was significantly correlated with grasp power (P<0.05) and the Kapandji score (P<0.05), while the thenar muscle minor axis was significantly correlated with abductor pollicis brevis distal motor latency (APB DML) (P<0.01). In addition, the thenar muscle minor axis/thenar muscle major axis ratio was significantly correlated with APB DML and Kanatani's stage. Notably, thenar muscle thinness was significantly correlated with the severity of electrodiagnostic changes, while the grasp power and Kapandji score were correlated with thenar muscle thickness. Furthermore, it was demonstrated that thenar muscle thinness was significantly correlated with the severity of electrodiagnostic changes; in addition, there was a significant correlation between the thenar muscle major axis and the grasp power or Kapandji score. Taken together, these results revealed that thenar muscle atrophy did not affect patient-based assessments, including VAS and Q-DASH, but reflected electrodiagnostic results, particularly DML and severity. The results of the present study suggest that thenar muscle atrophy can be used to estimate the severity of carpal tunnel syndrome.

Strickland's hypothenar fat pad flap for revision surgery in carpal tunnel syndrome: Prospective study of 34 cases

Several techniques are available for revision surgery of carpal tunnel syndrome (CTS) to preserve a gliding layer and protect the median nerve, including Strickland's pedicled hypothenar fat pad flap. The objective of this single-center, prospective study was to report the results of this flap after a minimum follow-up of two years. Between March 2006 and April 2014, 34 patients were enrolled (mean age 67 years) who had postoperative complications after the primary surgical release of CTS with nighttime paresthesia and/or neuropathic pain and abnormal electromyography findings. All patients were operated on using the same technique: neurolysis of the median nerve in the carpal tunnel with the nerve protected by a Strickland flap. The preoperative and postoperative evaluations consisted of questionnaires (paresthesia, neuropathic pain using the VAS and DN4 score, QuickDASH) and a clinical examination (grip strength, Weber two-point discrimination, atrophy of thenar muscles). Eighteen patients were reviewed in person and sixteen over the telephone. The outcomes were analyzed after at least 24 months’ follow-up for all patients and 60 months for 13 patients. At 24 months postoperative, nighttime paresthesia was present in 3 of 34 patients and neuropathic pain in 2 of 24 patients. There was a significant reduction in pain on the VAS in all 34 patients (1.4 versus 6.4), the DN4 score (1.3 versus 5.7) and QuickDASH (60.7 versus 19.8). Of the 18 patients examined, grip strength improved from 72% to 86% of the opposite side (P<0.05), the mean static Weber was 6.4mm (versus 7.1mm preoperatively); nine patients had atrophy of the thenar muscles (versus eight preoperatively). The results observed at two years were maintained at five years’ follow-up. This flap appears to improve the subjective neurological signs of CTS.

Coexistence du syndrome du canal carpien et du syndrome du rond pronateur : étude rétrospective de 21 cas

PurposeConcurrent carpal tunnel syndrome and pronator syndrome are rarely considered and the proximal compression sites are easily overlooked. We retrospectively studied 21 concurrent cases in our series from 2009 to 2015 and report the results. Patients and methodsThe typical symptoms were pain, tingling, and numbness of the radial 3½ digits. If paresthesia involved the thenar eminence and proximal forearm pain was noted in cases of carpal tunnel syndrome, carpal tunnel syndrome combined with pronator syndrome was considered. Additionally, nocturnal paresthesia symptoms are absent in pronator syndrome. Therefore, if nocturnal symptoms occurred in pronator syndrome, carpal tunnel syndrome was considered. We included concurrent carpal tunnel syndrome and pronator syndrome. We used arthroscopic release of the transverse carpal ligament and open decompression for the pronator teres in cases that underwent surgery for the first time. Howerver, recurrent carpal tunnel cases were treated with the open carpal tunnel release and open pronator decompression procedure in our hospital. The two-point discrimination was used for evaluation of sensory deficit. The grip and pinch (thumb tip to index) strength were measured by dynamometry and pinch gauge, respectively. ResultsWe retrospectively reviewed 344 cases of sustained carpal tunnel syndrome or pronator syndrome from the medical records of our institution. Of the 344 cases, 322 involved carpal tunnel syndrome alone, 1 involved pronator syndrome alone, and 21 involved carpal tunnel syndrome combined with pronator syndrome. The 21 cases of carpal tunnel syndrome combined with pronator syndrome were included in our study. Among the total cases of carpal tunnel syndrome, 6% (21/343) had pronator syndrome. The patients included 3 men and 18 women with a mean age of 52 years (range: 42–69 years). Electromyography (EMG) and nerve conduction studies were routinely performed. Postoperative evaluation showed that 15 out of 21 patients (71%) were completely relieved of pain and paresthesia and had no sensory deficit, satisfied strength improved (>85% of the opposite hand). Six patients (29%) had occasional paresthesia and pain, but no sensory deficit; grip and pinch strength deficit were recorded (<50% of the opposite hand). Six cases of these partially relieved patients had recurrent carpal tunnel syndrome but no one needed to perform tendon transfer for thenar muscle atrophy. ConclusionIt is important to consider the diagnosis of double crush syndrome of the median nerve, as carpal tunnel syndrome combined with pronator syndrome may impede treatment of the carpal tunnel syndrome.

Effects of Modified Camitz Opponensplasty to Restore Thumb Opposition for Severe Carpal Tunnel Syndrome

Objective: Hand function damaged by Carpal tunnel syndrome (CTS) is usually recoverable after the surgery of carpal tunnel release, but treatment for severe CTS does not always result in functional recovery. The purpose of the present study was to assess the effectiveness of modified Camitz opponensplasty for severe CTS. Specifically, we employed a combined operation of open carpal tunnel release (OCTR) and modified Camitz opponensplasty for severe CTS patients who needed early recovery of thumb opposition. Methods: The subjects were 26 hands in 22 patients with severe CTS. Before surgery, all hands had marked thenar muscle atrophy and loss of thumb opposition. All patients underwent surgery through OCTR and modified Camitz opponensplasty using a pulley at the radial side of the released flexor retinaculum. Compound muscle action potential (CMAP) from the abductor pollicis brevis (APB) muscle and the second lumbrical (SL) muscle were recorded and analyzed. Static 2 points discrimination test data, grip strength, pulp pinch strength and active palmar abduction of the thumb were assessed. Outcomes were evaluated according to Kelly’s grading and patient-reported outcome measures were assessed using the Carpal Tunnel Syndrome instrument (CTSI). Results: Before surgery, APB-CMAP was not recordable and SL-CMAP was recordable in all 26 hands. After surgery, according to Kelly’s grading of outcome, results were excellent in 11 hands, good in 12, and fair in three. In all patients, both the symptom severity score and function score in CTSI markedly improved at final follow-up. At 3 months, postoperative pulp pinch strength and active palmar abduction of the thumb increased significantly. There was no significant difference in postoperative thumb palmar abduction and pulp pinch strength between the hands showing and not showing the recovery of APB-CMAP. Conclusion: Modified Camitz opponensplasty was effective to restore thumb palmar abduction and pulp pinch strength from the early postoperative phase in severe CTS.

Concurrent carpal tunnel syndrome and pronator syndrome: A retrospective study of 21 cases

PurposeConcurrent carpal tunnel syndrome and pronator syndrome are rarely considered and the proximal compression sites are easily overlooked. We retrospectively studied 21 concurrent cases in our series from 2009 to 2015 and report the results. Patients and methodsThe typical symptoms were pain, tingling, and numbness of the radial 3½ digits. If paresthesia involved the thenar eminence and proximal forearm pain was noted in cases of carpal tunnel syndrome, carpal tunnel syndrome combined with pronator syndrome was considered. Additionally, nocturnal paresthesia symptoms are absent in pronator syndrome. Therefore, if nocturnal symptoms occurred in pronator syndrome, carpal tunnel syndrome was considered. We included concurrent carpal tunnel syndrome and pronator syndrome. We used arthroscopic release of the transverse carpal ligament and open decompression for the pronator teres in cases that underwent surgery for the first time. However, recurrent carpal tunnel cases were treated with the open carpal tunnel release and open pronator decompression procedure in our hospital. The two-point discrimination was used for evaluation of sensory deficit. The grip and pinch (thumb tip to index) strength were measured by dynamometry and pinch gauge respectively. ResultsWe retrospectively reviewed 344 cases of sustained carpal tunnel syndrome or pronator syndrome from the medical records of our institution. Of the 344 cases, 322 involved carpal tunnel syndrome alone, 1 involved pronator syndrome alone, and 21 involved carpal tunnel syndrome combined with pronator syndrome. The 21 cases of carpal tunnel syndrome combined with pronator syndrome were included in our study. Among the total cases of carpal tunnel syndrome, 6% (21/343) had pronator syndrome. The patients included 3 men and 18 women with a mean age of 52 years (range: 42–69 years). Electromyography (EMG) and nerve conduction studies were routinely performed. Postoperative evaluation showed that 15 out of 21 patients (71%) were completely relieved of pain and paresthesia and had no sensory deficit, satisfied strength improved (>85% of the opposite hand). Six patients (29%) had occasional paresthesia and pain, but no sensory deficit; grip and pinch strength deficit were recorded (<50% of the opposite hand). Six cases of these partially relieved patients had recurrent carpal tunnel syndrome but no one needed to perform tendon transfer for thenar muscle atrophy. ConclusionIt is important to consider the diagnosis of double crush syndrome of the median nerve, as carpal tunnel syndrome combined with pronator syndrome may impede treatment of the carpal tunnel syndrome.

Extensor Digiti Minimi Transfer for the Treatment of an Unstable Metacarpophalangeal Joint in Thumb Polydactyly Without Thenar Atrophy.

Dear Sir, As treatments for the laxity of metacarpophalangeal (MCP) joint in hypoplastic thumb, joint capsular plication, free tendon graft or MCP arthrodesis have been performed [1]. In addition, transfer of abductor digiti minimi [2] or ring finger flexor digitorum superficialis [3] have been used to provide thumb opposition and restore MCP joint stability. In the present case, we used extensor digiti minimi (EDM) transfer to treat MCP joint instability due to ulnar collateral ligament laxity in a patient with thumb polydactyly without thenar muscle atrophy. An 11-year-old girl who was naturally right thumb polydactyly with floating ulnar thumb had a thumb plasty at the age of five. But she was bothered by an unstable MCP joint due to ulnar collateral hypoplasia (Fig. 1a). Six years later from primary operation, she underwent a second surgery to improve joint instability and outer appearance of the thumb. The MCP joint instability was corrected by an EDM transfer, which involved fasting the end of the transferred tendon to the ulnar side of the MCP joint at the bottom of proximal phalanx and at the metacarpal head (Fig. 2). At 10 months postoperatively, the appearance of the thumb was improved and the MCP joint was stable (Fig. 1b). The EDM transfer procedure was initially reported for restoration of thumb adduction in ulnar nerve paralysis [4], but MCP joint stability could be achieved by changing the distal tendon insertion as this case. We consider there are some advantages to this procedure: 1) the MCP joint achieves maximum stability in the opposite position, because the tension of the transferred EDM tendon increases with the increase in the angle of opposition, 2) the mobility of the MCP joint is not impaired, 3) the strength of side pinch could be increased by increasing the thumb adduction force. On the other hand, the disadvantages of this procedure include that this transfer would position thumb in extension and adduction, and a decrease in the extension force of the little finger. The former demerit barely mattered in actuality, because we think the tension of transferred EDM is not strong in the rest position.

A retrospective follow-up study of the postoperative outcomes of late stage carpal tunnel syndrome

Objective To assess the postoperative outcomes of 56 cases of late stage carpal tunnel syndrome through retrospective follow-up studies and provide treatment guidelines. Methods A retrospective study of 56 cases of late stage carpal tunnel syndrome (thenar muscle atrophy + + + or more) that were surgically treated from February 2010 to December 2011 was conducted. The recovery of thenar muscle atrophy, thenar muscle strength and sensation of the radial three digits was assessed. Results Postoperative follow-up period of these 56 cases ranged from 50 to 71 months, with an average of 64 months. Atrophy of the thenar muscles was entirely reversed in 28 cases (50%) and reversed to (+ + ) in 8 cases (14.3%). No change of thenar muscle atrophy was seen in 20 cases (35.7%). Complete sensory recovery was observed in 51 cases, while the rest 5 cases had near normal sensation. The overall excellent and good rate of postoperative hand function recovery was 85.7%. Conclusion Carpal tunnel release is effective in 85.7% of late stage carpal tunnel syndrome patients. The decision to perform thumb opponensplasty at the same time should be made based on the requirements of individual patients. Key words: Carpal tunnel syndrome; Follow-up studies; Treatment outcome

13. Comparison of digits 2 and 3 sensory studies in patients with carpal tunnel syndrome

Introduction According to AANEM guidelines, an initial step in the electrodiagnostic study for carpal tunnel syndrome (CTS) is the recording of median sensory response across the wrist. Although any median nerve innervated digit can be studied, digit 2 is most common. Objective The current prospective study was undertaken to determine differences between median nerve sensory parameters following stimulation of digit 2 and 3 in patients presenting with clinical CTS. Methods We prospectively studied 211 wrists in 158 patients with clinically definite CTS defined as nocturnal and/or activity-related sensory symptoms, sensory deficits in the median nerve distribution, or weakness and/or atrophy of median-innervated thenar muscles. Electrophysiological studies were conducted using standard techniques based on the AANEM practice parameters. Specifically, orthodromic sensory studies were performed following stimulation of both digit 2 and 3. Comparison sensory studies with the radial nerve were performed with stimulation at digit 1. Median motor studies were also performed. A cohort of normal patients were also recruited and studied. Results Sensory conduction velocity (SCV) following digit 3 stimulation (32.3 ± 14.5m/s) was significantly slower ( P 0.001) when compared to digit 2 (35.1 ± 14.1m/s) in all severity groups, although the difference was most pronounced in patients with mild compared to those with severe CTS ( p =0.005). 5% of the total cohort had normal digit 2 SCV, but abnormal digit 3 SCV. In our cohort of normal wrists, there was no significant difference between digits 2 and 3 SCV and sensory amplitude. Conclusion Orthodromic median nerve sensory studies following digit 3 stimulation are significantly more abnormal compared to digit 2 stimulation in patients with CTS, and may be more sensitive for the diagnosis of CTS, particularly in mild cases.

Intraoperative dynamic pressure measurements in carpal tunnel syndrome: Correlations with clinical signs

ObjectiveThis study was designed to evaluate the correlations between dynamic carpal tunnel pressure and clinical signs. MethodsFrom December 2008 to May 2010, open carpal tunnel release (OCTR) was performed on a total of 90 hands (83 patients). All patients completed neurological and provocation tests (two-point discrimination, Tinel test, Phalen test, reverse-Phalen test and assessment of thenar muscle atrophy). Carpal tunnel pressure (CTP) was measured in two parts of carpal tunnel (proximal and distal carpal tunnel) and in three different postures (neutral, wrist flexion and wrist extension). ResultsThere were 74 females and nine males aged 36 to 86 years (mean age 54). CTP values were more elevated in the wrist extension than wrist flexion in the proximal carpal tunnel but not at the distal carpal tunnel. There was no statistically significant correlation among CTP, provocation testing, and clinical signs. However, two-point discrimination (2-PD) showed a statistically significant correlation with CTP, especially in the proximal area in the wrist extension posture (P<0.01). Duration of symptoms (SD) statistically correlated with CTP in the distal carpal tunnel in the neutral posture (P<0.01). Conclusions2-PD and duration of symptoms are correlated with the CTP value in specific areas and with hand postures. This emphasizes the importance of releasing the entire carpal tunnel lesion since CTP values appear to vary within the carpal tunnel space and according to hand posture.