Operation For Carpal Tunnel Syndrome Research Articles

Association of carpal tunnel syndrome risk factors with treatment modality selection focusing on corticosteroid injection and surgery: A nationwide population-based study.

Several studies have revealed the risk factors for carpal tunnel syndrome (CTS). However, no studies have evaluated the influence of these risk factors on the selection of treatment modalities for CTS. This study aimed to determine the influence of CTS risk factors on the selection of CTS treatment modalities with a focus on corticosteroid injection (CI) and surgery. We conducted a retrospective cohort study of patients aged ≥20 years with newly diagnosed CTS in the Korean health insurance review and assessment service between 2010 and 2019. We evaluated the demographic information, the existence of CTS risk factors, and the applied treatment modalities for CTS, including CI and operation. The CTS risk factors include age, sex, diabetes mellitus, osteoarthritis of the hand or wrist, rheumatoid arthritis, hypothyroidism, gout, chronic kidney disease (CKD) on dialysis, antiestrogen or aromatase inhibitor medication, and a history of distal radius fracture (DRF). Multivariable logistic regression analyses were conducted. Age over 80 years was the most significantly associated factor for the selection of CI in CTS (odd ratio [OR], 2.149; 95% confidence interval [CI], 2.092 to 2.209; P < .001). Among underlying diseases or medications, CKD on dialysis (OR, 4.001; 95% CI, 3.819-4.193; P < .001) was the most significant associated factor for the selection of operation for CTS, followed by a history of DRF (OR, 1.803; 95% CI, 1.749-1.860; P < .001). Old age was the most significantly related factor for selecting CI. Among underlying diseases or medications, CKD on dialysis and the history of DRF were the most significantly related factors for selecting operative treatment. For these patients, clinicians should proactively consider an operation to reduce the long-term discomfort and economic burdens.

Autonomic nervous system may be affected after carpal tunnel syndrome surgery: A possible mechanism for persistence of symptoms after surgery.

After carpal tunnel surgery, some patients report complaints such as edema, pain, and numbness. Purpose - The aim of this study was to evaluate autonomic nervous system function in patients with a history of carpal tunnel surgery using sympathetic skin response (SSR). Thirty three patients (55 ±10 years old) with a history of unilateral operation for carpal tunnel syndrome were included in the study. The SSR test was performed for both hands. Both upper extremities median and ulnar nerve conduction results were recorded. A reduced amplitude (p=0.006) and delayed latency (p<0.0001) were detected in the SSR test on the operated side compared to contralateral side. There was no correlation between SSR and carpal tunnel syndrome severity. Although complex regional pain syndrome does not develop in patients after carpal tunnel surgery, some of the complaints may be caused by effects on the autonomic nervous system.

Incidence and operations of median, ulnar and radial entrapment neuropathies in Finland: a nationwide register study.

The aim of this study was to investigate the incidence rates and operations for carpal tunnel syndrome and ulnar and radial neuropathies in specialist care in Finland. Patients diagnosed with entrapment neuropathies of the upper extremity were identified from the Care Register for Health Care, 2007-2016. There were 81,911 cases in 54,095,070 person-years. The total crude incidence rates per 100,000 person-years among women and men were 197 and 105 for carpal tunnel syndrome, 26 and 36 for ulnar neuropathies, and 5.7 and 8.5 for radial neuropathies, respectively. Of these, carpal tunnel syndrome was operated on in 63% of women and 61% of men, ulnar neuropathy in 43% of women and 47% of men, and radial neuropathy in 11% of women and 8% of men. Incidence of carpal tunnel syndrome and ulnar neuropathies increased up to late middle age, while radial neuropathies were less common. Level of evidence: III.

Complications arising from a misdiagnosed giant lipoma of the hand and palm: a case report

IntroductionLipomas are benign tumors which may appear in almost any human organ. Their diagnosis rate in the hand region is not known.Case PresentationWe present the case of a 63-year-old Greek Caucasian woman with a giant lipoma of the hand and palm which was not initially diagnosed. After repeated surgical decompression of the carpal tunnel the patient was referred with persisting symptoms of median and ulnar nerve compression and a prominent mass of her left palm and thenar eminence. Clinical examination, magnetic resonance imaging, nerve conduction study and biopsy, revealed a giant lipoma in the deep palmar space (8.0 × 4.0 × 3.75 cm), which was also infiltrating the carpal tunnel. She had already undergone two operations for carpal tunnel syndrome with no relief of her symptoms and she also ended up with a severed flexor pollicis longus tendon. Definitive treatment was performed by marginal resection of the lipoma and restoration of the flexor pollicis longus with an intercalated graft harvested from the palmaris longus. Thirty months after surgery the patient had a fully functional hand without any neurological deficit.ConclusionNot all lipomas of the wrist and hand are diagnosed. Our report tries to emphasize the hidden danger of lipomas in cases with carpal tunnel symptoms. The need for a high index of suspicion in conjunction with good clinical evaluation and the use of appropriate investigative studies is mandatory in order to avoid unnecessary operations and complications. Marginal excision of these tumors is restorative.

Importance of surgical history in diagnosing mucopolysaccharidosis type II (Hunter syndrome): Data from the Hunter Outcome Survey

PurposeTo characterize surgical histories typical of patients with mucopolysaccharidosis type II, thereby broadening understanding of the natural history of these patients and helping physicians recognize the disease. MethodsData on surgical interventions from the Hunter Outcome Survey—a multinational, observational database of patients with mucopolysaccharidosis type II—were analyzed. The study population comprised 527 patients for whom surgical data were reported on/before July 23, 2009. ResultsSurgical interventions were performed in 83.7% of the study population. Patients underwent their first operation at a median age of 2.6 years. Tympanostomies, repairs of inguinal hernias, and operations for carpal tunnel syndrome were performed in a greater proportion of the study population than the general population. A median of 3.0 operations was performed per patient; repeat operations for hernia or carpal tunnel syndrome were common. The majority of patients (221/389) underwent at least one surgical intervention before diagnosis of mucopolysaccharidosis type II. ConclusionPatients with mucopolysaccharidosis type II typically undergo surgical intervention at a young age, often before diagnosis. Repeated early surgical interventions, particularly for hernias or carpal tunnel syndrome, are characteristic of patients with mucopolysaccharidosis type II. We recommend that such patients are carefully examined for manifestations of mucopolysaccharidosis disorders and referred for diagnostic testing.

Récidives de syndrome du tunnel carpien

Recurrence of carpal tunnel syndrome following surgery is not rare. The reported frequency of reoperation varies from 0.3 to 12%. We distinguish between persistent carpal tunnel syndrome, and recurrent carpal tunnel syndrome which we define as reappearance of the condition three months or more following surgery. More proximal nerve lesions or other erroneous diagnoses may cause either persistent or recurrent syndromes. In the cases of persistent syndromes, incomplete division of the flexor retinaculum is a frequent cause, but iatrogenic nerve lesions or active flexor tenosynovitis may also be to blame. In the cases of recurrent carpal tunnel syndrome, the problem is often due to perineural fibrosis. At the time of reoperation, except in those cases where an incomplete division of the flexor retinaculum is found, one must consider whether or not to combine the neurolysis with an additional procedure to prevent or diminish recurrent fibrosis. To achieve this goal, a number of measures have been proposed, including interposition of a biomaterial or raising a local flap to surround and protect the nerve. Others recommend early mobilization to diminish fibrous adhesions between the nerve and surrounding tissues. The results are at best modest, and may be counterproductive after several interventions. It is necessary to distinguish between improvement in symptoms that are due to local irritation, the priority for the patient, and improvement in neurologic function of the motor and sensory components of the nerve. According to the literature, from 43 to 90% of patients who undergo repeat operations continue to have symptoms, and one in five get no relief, while 80% of first operations for carpal tunnel syndrome give excellent results. These findings indicate that the first intervention must be performed with the most rigorous attention to technical detail.

Dialysis-related Amyloidosis on the Buttocks

-microglobulin amyloidosis presenting as a pediculated dermal nodule and large subcutaneous masses on the buttocks.CASE REPORTA 69-year-old man presented with a few years’ history of nodules on the buttocks. Past history included chro-nic renal failure controlled with haemodialysis for 19 years and a decompression operation for carpal tunnel syndrome. Physical examination revealed a red-brown pediculated nodule 50×20 mm in diameter on the sacral region (Fig. 1A). In addition, 120×80 mm elastic, hard subcutaneous masses were palpable beneath the skin of the buttock. Laboratory findings showed increased levels of blood urea nitrogen (38 mg/dl; normal range 7–19 mg/dl), serum creatinine (6.5 mg/dl; normal range 0.5–0.8 mg/dl) and β

Carpal Tunnel Syndrome in Patients with Diabetes

The aim of this study was to evaluate the relation of clinical and neurographic data and their possible influence factors on the course of carpal tunnel syndrome (CTS) in patients with diabetes. From a cohort of 230 patients with diabetes, CTS was found in 1/3 of these patients, 52 patients with 82 affected hands were included in our study. Number of examinations varied from 2 to 11 (mean 5) over 1 to 15 years (mean 5,4 years). Outcome variables were: duration of diabetes, type of diabetes, diabetic neuropathy and grade of CTS affection. Measurement were made of sensible and motor nerve conduction velocity of the Nn. medianus, ulnaris, peronaeus, tibialis and suralis. In 51% of the affected hands we found a latent – and in 49% a symptomatic – CTS at study onset. Women were 3-fold more affected than men, 56% of the patients showed diabetic neuropathy. In regard to the neurographic data, in 61% the results decreased, in 22% they increased the course and in 17% the course remained stable. There was a significant difference (p<0.05) between type 1 and type 2 diabetes, i.e., patients with type 1 (+3.09 pts) decreased in our affection scale (0–21) more than type 2 patients (+0.6 pts). Duration of diabetes as covariate showed a significantly better outcome (p=0.003) for patients with a shorter time of affection. A neuropathy had no severe influence on the course of CTS, in only 1/3 of the patients was there a correlation between the course of CTS and the course of neuropathy. 2/3 of 42 latent courses of CTS turned into a symptomatic one, 1/3 remained clinically latent but with decreasing neurographic values. Due to decreased neurographic and/or clinical results, 26 hands had an operation. Most of these patients suffered from type 2 diabetes with a neuropathy. Post-operatively all patients had an increase in the course of CTS, especially patients without neuropathy. Type 2 patients have a better prognosis in the course of CTS than type 1 and patients with a shorter time of diabetes affection had also a better prognosis. The courses of neuropathy and CTS were not parallel, i.e., neuropathy had no direct influence on the course of CTS. All patients who underwent an operation for CTS improved; especially those without neuropathy. Patients should be neurographically and clinically examined regarding a possible entrapment with a focus on the N. medianus. An operation should not always be the first step in the treatment of CTS.

The position of the tourniquet on the upper limb

Our aim was to determine if a tourniquet placed on the forearm has any advantage in clinical practice over the usual position on the upper arm. We randomised 50 patients who were undergoing an open operation for carpal tunnel syndrome under local anaesthesia into two groups. One had a tourniquet on the upper arm and the other on the forearm. The blood pressure, pulse, and level of pain were recorded at intervals of five minutes during the operation. The surgeons were also asked to evaluate the quality of the anaesthesia, the bloodless field, and the site of the tourniquet. The patients tolerated the tourniquet on the upper arm and forearm equally well. The surgeons had some difficulties when it was placed on the forearm. We therefore recommend placement of a tourniquet on the upper arm for operations on the hand and wrist which are carried out under local anaesthesia.

The position of the tourniquet on the upper limb

Our aim was to determine if a tourniquet placed on the forearm has any advantage in clinical practice over the usual position on the upper arm. We randomised 50 patients who were undergoing an open operation for carpal tunnel syndrome under local anaesthesia into two groups. One had a tourniquet on the upper arm and the other on the forearm. The blood pressure, pulse, and level of pain were recorded at intervals of five minutes during the operation. The surgeons were also asked to evaluate the quality of the anaesthesia, the bloodless field, and the site of the tourniquet. The patients tolerated the tourniquet on the upper arm and forearm equally well. The surgeons had some difficulties when it was placed on the forearm. We therefore recommend placement of a tourniquet on the upper arm for operations on the hand and wrist which are carried out under local anaesthesia.

ACUTE POSTOPERATIVE SWELLING AFTER HAND SURGERY: AN EXPLORATORY, DOUBLE-BLIND, RANDOMISED STUDY WITH PARACETAMOL, NAPROXEN, AND PLACEBO

A model using volumetry to evaluate the effect of drugs on acute postoperative swelling after operations for primary Dupuytren's contracture (DC) and carpal tunnel syndrome (CTS) was established and validated. The temperature of the saline and time of measurement during the day influenced the volumetric readings. The error of measurement after volumetry of unoperated and operated hands after operations for DC was 0.7% and 0.6%, respectively. Naproxen (500 mg twice a day), paracetamol (1000 mg four times a day), or placebo were given postoperatively for three days to 35 patients after DC and 42 patients after CTS in a randomised, placebo-controlled study. Hand volume was measured preoperatively and 72 hours after surgery. There was a difference in swelling (p = 0.009) indicating different degree of development of swelling 72 hours postoperatively between the DC and CTS placebo groups, which invalidated pooling of the data. After operations for DC naproxen was slightly but not significantly superior to paracetamol and placebo, with paracetamol numerically superior to placebo. The power of the study, caused by the limited number of patients included, does not permit this difference to reach significance. Operations for CTS caused so little swelling that comparisons were invalidated. Naproxen treatment, irrespective of type of operation, did not require rescue analgesics, while two patients after CTS treated with paracetamol did. Two and six placebo-treated patients required rescue drugs after operations for DC and CTS, respectively. We conclude that naproxen might have a clinical relevant effect on swelling when used on minor surgery in the hand, unlike paracetamol. Naproxen might be a useful analgesic during the immediate postoperative phase.

Bilateral fast magnetic resonance imaging of the operated carpal tunnel.

Our aim was to quantify the structural changes of the carpal tunnel including area and volume after surgical release. We studied 28 patients who underwent 31 operations for carpal tunnel syndrome (CTS), mean age 54.7 years (range 32-78). All had abnormal nerve conduction studies. Magnetic resonance imaging (MRI) of both wrists was done before and after operation using two fast imaging sequences, turbo spin echo (TSE) and fast field echo (FFE). The same surface coils and parameters were used in both instances. With a computerised analyser we calculated the volume of the whole tunnel from inlet to outlet before and after operation and the wrist volume:carpal tunnel volume ratio. The intensity of the magnetic resonance signal emitted by the median nerve was assessed in all wrists before and after operation. The mean (SD) volume of the tunnel in 31 wrists with CTS was 11511.7 (2857) mm3 before and 13803.4 (3034.9) mm3 after operation (p = 0.0001). The mean (SD) relative signal intensity of the median nerve was 1.7 (1.8) preoperatively and 1.3 (1.1) postoperatively (p = 0.19). Other postoperative changes included persistent nerve enlargement (n = 21), misalignment of the tendons (n = 20), fibrous tissue deposits (n = 20), fat tissue deposits (n = 21), and muscle oedema (n = 6). The modifications of the carpal canal as a consequence of open surgical release (including increased volume and displacement of the flexor tendons) argue for the use of an endoscopic procedure in the treatment of CTS.

An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: Report of 625 cases

This study was undertaken to determine the presence or absence of tenosynovitis in persons with idiopathic carpal tunnel syndrome. Eight hundred thirty-five consecutive operations for carpal tunnel syndrome were retrospectively reviewed, and 625 cases of idiopathic carpal tunnel syndrome were identified. Of these 96% (601) had a synovial tissue histologic diagnosis of benign fibrous tissue without inflammation, 4% (23) showed chronic inflammation, and 0.2% (1) revealed evidence of acute inflammation. We believe that tenosynovitis is not a part of the pathophysiologic process in chronic idiopathic carpal tunnel syndrome. Further histologic analysis of the flexor synovium for pathologic changes other than inflammation is needed.

Simultaneous carpal tunnel release and Dupuytren's fasciectomy

Simultaneous operations for carpal tunnel syndrome and Dupuytren's disease have been reported in only one study which recommended staged treatment because there was an 87% complication rate with simultaneous treatment. The present study reviewed simultaneous treatment of 30 patients during a 20-year period. Complications and unfavourable results were compared to similar groups of patients who underwent either Dupuytren's fasciectomy or carpal tunnel release as sole procedures. Early complications (13%) were far less than in previous studies and were easily corrected. The incidence of recurrence and extension (20%) was lower than in the Dupuytren's fasciectomy group and much lower than in previous reports. Simultaneous carpal tunnel release and Dupuytren's fasciectomy are strongly recommended when these conditions are both present in the same hand.

Crystalline Glomerular Inclusions in Multiple Myeloma

Prominent crystalline inclusions were noted in the glomeruli of a 57-year-old man with a 6-month history of swelling and pain in the hands, slight proteinuria, and elevated serum creatinine and BUN. The crystalline inclusions were most prominent in the visceral epithelium but were also noted in endothelial and mesangial cells, in the parietal epithelium, and in the epithelial cells of the proximal tubules. On electron microscopy the crystalline structures were of various geometric shapes but had no definite substructure. Immunofluorescence was negative. The patient was considered to have a hitherto undescribed metabolic disease. Several months later the patient underwent an operation for carpal tunnel syndrome and amyloid deposits, crystalline inclusions similar to those noted in the kidney were observed in the synovial tissue. Shortly after this the patient was found to have multiple myeloma of IgG, kappa type with Bence Jones proteinuria. Lymphoplasmacytic cells in the bone marrow contained the same crystalline inclusions noted in the kidney and synovium. This case therefore seems to represent a new and very rare form of glomerular involvement in multiple myeloma.