Recurrent Carpal Tunnel Syndrome Research Articles

Top 10 Clinical Pearls in Paraproteinemic Neuropathies.

Paraproteinemic neuropathies represent an important subset of peripheral neuropathies. Once identified, further evaluation into the paraproteinemic subtype, clinical exam pattern, and electrodiagnostic phenotype helps clarify if the paraproteinemia is coincidental or causal of the neuropathy, as not all paraproteinemias cause neuropathy. Of all paraproteinemias, immunoglobulin M (IgM)-associated peripheral neuropathy, or IgM neuropathy, is of particular importance as half of IgM neuropathies also harbor anti-myelin-associated glycoprotein antibodies, which produce a characteristic demyelinating pattern on nerve conduction testing. Immunoglobulin G and immunoglobulin A paraproteinemias are less strongly associated with peripheral neuropathy, except in the setting of multiple myeloma or osteosclerotic myeloma (POEMS syndrome), which have characteristic systemic features. In multiple myeloma, chemotherapy is more likely to result in neuropathy than the myeloma itself. Finally, the presence of systemic features (e.g., cardiomyopathy, nephropathy, recurrent carpal tunnel syndrome, and autonomic insufficiency) should raise concern for hereditary or acquired light (AL) chain amyloidosis. AL amyloidosis can occur in the setting of any light or heavy chain paraproteinemia. Central to the proper evaluation of paraproteinemic neuropathy is electrodiagnostic testing, which helps delineate axonal versus demyelinating paraproteinemic neuropathy, the latter often misdiagnosed as chronic inflammatory demyelinating polyradiculoneuropathy.

Revision Endoscopic Carpal Tunnel Release: An Update on Technique and Outcomes.

Carpal tunnel release is among the most frequently conducted upper extremity procedures. While it typically provides patients with improved sensation, decreased pain, and improved function, a small percentage of cases require revision due to failed initial surgery. Consequently, adoption of endoscopic techniques for carpal tunnel revision procedures is beginning to be explored. A retrospective analysis was conducted of postoperative clinical visits and patient-reported outcome measures for four patients who had undergone five endoscopic revision carpal tunnel release procedures (one patient had bilateral disease). All five cases had symptoms consistent with recurrent carpal tunnel syndrome. One hundred percent (5 of 5) of cases resulted in patients reporting symptom improvement. Postoperative clinical visits and improved patient-reported outcome measures (QuickDash, PROMIS Upper Extremity, VAS Pain, PSEQ, PHQ, and Surgery Satisfaction) scores from baseline to 6 weeks demonstrated successful postoperative function and symptom resolution. Five of five cases resulted in patients resuming normal activities without restrictions within 1-5 weeks, with an average of 3.4 weeks. Preliminary findings suggest the endoscopic revision procedure may be safe and effective for patients with recurrent carpal tunnel syndrome, extending the indications to include scars proximal to the wrist crease. Moreover, this minimally invasive procedure facilitates a transition back to normal activities and avoids incisions on weight-bearing surfaces of the palm. Adopting endoscopic revision may reduce the need for prolonged postoperative care and physical therapy. However, due to the limited sample size of five patients, further investigation with larger cohorts is warranted to confirm these observations.

Clinical results of carpal tunnel Re-release revision surgery and synovial wrap for recurrent carpal tunnel syndrome

IntroductionCarpal tunnel syndrome is a challenging condition when conventional carpal tunnel revision surgery fails to alleviate symptoms. This study aims to assess the outcomes of combining carpal tunnel revision surgery with a synovial wrap for cases of recurrent carpal tunnel syndrome in patients who had adhered median nerve, with a minimum 1-year follow-up. Patients and methodsA retrospective analysis was conducted on 10 patients (mean age: 73.7 years, nine females and one male) who underwent treatment for recurrent carpal tunnel syndrome. The approach involved carpal tunnel revision surgery coupled with a median nerve synovial wrap. Patients were followed up for a minimum of 1 year. The procedure involved harvesting a 3.5 cm × 4 cm section of the flexor synovial membrane with a distal ulnar pedicle, which was then wrapped around the adherent site of the median nerve. Physical assessments included the pain visual analogue scale (VAS), Tinel sign in the carpal tunnel, thenar muscle atrophy, the Semmes-Weinstein monofilament test (SW test), manual muscle test (MMT) as assessed on the 5-point British Medical Research Council Scale (5/5, normal; 0/5, absent), and the Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire. The physical variables were compared before surgery and at final follow-up. ResultsAll patients showed some improvement in SW test. The MMT for the abductor pollicis brevis showed significant improvement at final follow-up (3 for four patients, 4 for four patients, and 5 for two patients) compared to pre-surgery assessments (2 for six patients, 3 for two patients, and 4 for two patients). The mean VAS score and DASH score at final follow-up (13.0 ± 10.3, 19.3 ± 12.7, respectively) were significantly lower than those recorded before surgery (76.5 ± 11.1, 52.4 ± 17.1, respectively). The Tinel sign and the thenar muscle atrophy significantly improved from before surgery to final follow-up. ConclusionCarpal tunnel release with a synovial wrap demonstrated significant improvements in muscle strength, pain relief and function. The synovial wrap method is an effective procedure for treating recurrent carpal tunnel syndrome.

Office-Based Carpal Tunnel Release With Ultrasound Guidance: 6-month Outcomes From the Multicenter ROBUST Trial

The purpose of this study was to determine the safety and effectiveness of office-based carpal tunnel release with ultrasound guidance (CTR-US). In this prospective multicenter observational study, patients were treated with CTR-US in an office setting. Outcomes were time to resume normal daily activities, time to return to work, Boston Carpal Tunnel Questionnaire Symptom Severity Scale and Functional Status Scale scores, Michigan Hand Questionnaire, Numeric Pain Scale, EuroQoL-5 Dimension 5-Level score, procedure satisfaction, and adverse events over 6 months. A total of 149 participants (226 hands) from seven centers underwent office-based CTR-US. The mean age was 58 years, 52% were women, and 68% were employed. The mean incision length was 5 mm, 52% had simultaneous bilateral procedures, and wide-awake local anesthesia no tourniquet was used in all cases. All procedures were completed as planned, with no conversions to open repair and mean intraoperative pain severity of 1.6 ± 1.5. The median time to resume normal activities was 2 days (interquartile range: 1-4 days) and return to work was 4 days (interquartile range: 1-5 days). Over 6 months, Boston Carpal Tunnel Questionnaire Symptom Severity Scale decreased by a mean of 1.7 points, Boston Carpal Tunnel Questionnaire Functional Status Scale decreased by 1.1 points, Michigan Hand Questionnaire Global score increased by 35 points, Numeric Pain Scale decreased by 3.7 points, and EuroQoL-5 Dimension 5-Level score increased by 0.11 points. At 6 months, 94% reported procedure satisfaction. Unilateral and simultaneous bilateral procedures were similarly effective. There was one (0.4%) adverse event, a nerve contusion treated with neurolysis and nerve wrap where the patient fully regained normal function within 7 weeks. There were no revisions for persistent or recurrent carpal tunnel syndrome symptoms. Office-based CTR-US, performed either unilaterally or as simultaneous bilateral procedures, is well tolerated with a low complication rate and associated with rapid recovery, sustained improvement in symptoms and function, and high procedure satisfaction. Therapeutic III.

Patient-Reported Outcomes Improve after Hypothenar Fat Flap for the Treatment of Recurrent Carpal Tunnel Syndrome.

Background: Recalcitrant carpal tunnel syndrome (CTS) can present with persistent or recurrent symptoms after carpal tunnel release (CTR). A common aetiology for recurrent CTS is the development of perineural adhesions due to excess scarring. The hypothenar fat pad flap (HFPF) has been described to decrease the amount of scarring formed after revision CTR. Herein, we present a prospective evaluation of these patients. Methods: A prospective series of consecutive patients by a single surgeon with recurrent CTS was conducted. All patients had at least 3 months follow-up. Patients received a revision open CTR with HFPF. The primary outcome was the Boston Carpal Tunnel Questionnaire (BCTQ). Secondary outcomes included pain and satisfaction on visual analogue scale, range of motion, grip strength, patient-reported outcomes and complications. Clinical outcomes were compared between preoperative and postoperative intervals using paired t-tests, with significance defined as p < 0.05. Results: Fifteen wrists (14 patients) were recruited for the study. Patients were predominantly male (n=9; 66%). Revision open CTR with HFPF was performed a median of 42 months (range: 4-300 months) post primary CTR. Patients demonstrated improved patient-reported outcomes with significantly improved BCTQ pain score (p<0.01), Patient-Rated Wrist and Hand Evaluation (p<0.01) and QuickDASH (p<0.001). Two patients in the series reported postoperative complications; however, there was no incidence of donor site morbidity recorded. Conclusions: Revision open CTR with hypothenar fat pad flap is associated with decreased pain, high patient satisfaction and improved functional measures compared to pre-operative status. Level of Evidence: Level IV (Therapeutic).

Persistent Pain as an Early Indicator for Operative Carpal Tunnel Revision after Primary Release: A Retrospective Analysis of Recurrent and Persistent Carpal Tunnel Syndrome.

Prolonged symptoms of carpal tunnel syndrome (CTS) after primary carpal tunnel release (CTR) can reduce the quality of life and lead to multiple referrals across specialties. The following study aimed to identify differences in symptoms, signs, and intraoperative findings between recurrent and persistent CTS cases to avoid undesired outcomes after primary CTR. A retrospective analysis was conducted on revision CTRs performed between 2005 and 2015 using literature-based definitions for recurrent (a relapse of symptoms occurs following a symptom-free period of ≥3 months) and persistent (symptoms persisting longer than three months after surgical release) CTS. The parameters assessed were symptoms, clinical signs, and intraoperative findings. Out of 53 cases, 85% (n = 45) were external referrals, whereby our own revision rate was 0.67% (n = 8/1199). Paresthesia and numbness were frequent in both groups; however, abnormal postoperative pain was reported more often in persistent cases (86%; n = 30/35) in comparison to recurrent cases (50%; n = 9/18; p = 0.009). Scarring around the median nerve was observed in almost all recurrent cases (94%; n = 17/18) and in 40% (n = 14/35) of persistent cases (p < 0.001). Incomplete division of the palmar ligament was the primary cause for revision in the persistent cohort (49%; n = 17/35). For patients experiencing symptoms for more than three months after CTR, primarily presenting as pain, it is advisable to consider referring the patient to a certified hand clinic for additional evaluation.

Recurrent carpal tunnel syndrome: Outcomes after neurolysis and synovial flap

ObjectivesIf symptoms recur after primary neurolysis of the median nerve, surgical revision is required. Soltani et al. (2013) demonstrated that surgical revision with vascularized flap coverage had a higher success rate (86%) than surgical revision without a flap (75%). The aim of this retrospective study was to present clinical outcomes in 36 cases of secondary open neurolysis of the median nerve, with synovial flap in case of recurrent carpal tunnel syndrome. MethodThirty-three patients (36 hands) who had undergone secondary neurolysis of the median nerve combined with synovial flap coverage between 2012 and 2019 were selected for this study. We included only recurrent carpal tunnel syndrome cases presenting with scarring of the transverse carpal ligament or epineural fibrosis of the median nerve and with a symptom-free period of at least 3 months. The results were ranked on a 4-point scale as excellent, good, null or poor, depending on progression at last follow-up. ResultsDescriptive analysis showed that 80% of patients had a positive outcome (excellent 33%, good 47%), 6% null outcome and 14% poor outcome. ConclusionThis is an interesting, relatively non-invasive surgical option, and should be part of the therapeutic armamentarium for recurrent carpal tunnel syndrome in case of adherence of the nerve to the transverse carpal ligament.

Characteristics of Carpal Tunnel Syndrome in Wild-Type Transthyretin Amyloidosis (P11-8.007)

<h3>Objective:</h3> The purpose of our study was to evaluate the prevalence, clinical features, severity, and disease course of carpal tunnel syndrome (CTS) in wild-type transthyretin amyloidosis (wtATTR) patients, as well as the risk of recurrence following carpal tunnel release (CTR). <h3>Background:</h3> Wild-type transthyretin amyloidosis is an important cause of infiltrative cardiomyopathy, particularly in older males. Carpal tunnel syndrome is one of the most common extra-cardiac manifestations of wtATTR and can predate cardiac symptoms by 5–10 years. The association between CTS and wtATTR has been described in several case series; however, the characteristics of CTS in this population remain poorly understood. <h3>Design/Methods:</h3> This retrospective cohort study reports findings from a single-center experience of routine neurological screening of newly diagnosed wtATTR patients including nerve conduction studies. Consecutive wtATTR patients between 2014 and 2021 were included. <h3>Results:</h3> Seventy-nine wtATTR patients were included; 73 (92%) males, mean age of 79 years. Seventy-one (90%) met electrodiagnostic criteria for median neuropathy at the wrist (MNW), 50% had a prior diagnosis and 50% were newly diagnosed at screening. The majority with MNW were symptomatic (53, 67%) with moderate or severe disease (66, 84%) bilaterally (42, 53%) on electrophysiologic testing. Fifty-six percent of our asymptomatic patients had moderate disease at the time of screening. Nineteen (24%) had recurrent CTS despite previous CTR. At the time of screening, 19 (24%) were prescribed wrist splinting and 36 (46%) were referred for CTR. <h3>Conclusions:</h3> Median neuropathy at the wrist affects the vast majority of wtATTR patients. CTS was confirmed in 67% of our patients, most had bilateral disease with moderate to severe MNW on electrophysiology at the time of wtATTR diagnosis. Recurrence after CTR was seen in 27% of our patients at the time of screening, which is higher than the rate of recurrence in the general population, estimated at 3–20%. <b>Disclosure:</b> Dr. Russell has nothing to disclose. Dr. Khayambashi has nothing to disclose. Nowell Fine has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of the American College of Cardiology: Case Reports. The institution of Nowell Fine has received research support from Pfizer, Akcea. The institution of Dr. Chhibber has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Amylyx. Dr. Chhibber has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Amylyx. Dr. Hahn has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Akcea. Dr. Hahn has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Anylim.

The Use of Amniotic membrane in Carpal Tunnel Syndrom, a Cadaver Study

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome worldwide. Even after surgery in 2-25% of patients symptoms persist. Most commonly the carpal tunnel was not completely released. In the other cases perineural scarring is causing recurrent compression of the nerve. The literature states different treatment options including “nerve wraps,” made out of autologous veins or synthetic materials, to protect the nerve from scarring. The human amniotic membrane (HAM) has been proven to express anti-inflammatory and anti-fibrotic properties, without causing a immune reaction. In a rat model it has been shown that nerve gliding could be improved by the application of HAM after introducing a fibrotic scar. The application of HAM in CTS and it´s possible influence on nerve gliding has been examined. Materials and Methods: Fourteen (7 female, 7 male) fresh body donors were dissected. The carpal tunnel was released and a nerve wrap out of HAM was sutured around the median nerve with continuous stitches (7-0). The position of the HAM was measured and the skin was closed (3-0) Next the arm was moved according to a protocol, creating a largest possible movement of the nerve. The position was again evaluated. This was done after 25, 50, 100, 150, 200, 250 movement cycles. Results: The HAM on the median nerve did not change its position significantly between the timepoints. From the beginning to the end of the movements it contracted and reduced its size to about 92% of its starting length. The evaluation of the gliding properties is still in progress. Conclusion: The HAM showed to stay in place and only minor contract on both ends in the carpal tunnel. The application of HAM in the carpal tunnel worked well without any complications and can be seen as feasible treatment method for recurrent carpal tunnel syndrome.

Revision Carpal Tunnel Release With Umbilical Cord Allograft: A Four-Year Retrospective Cohort Study

Background: Refractory symptoms of carpal tunnel syndrome can persist or reoccur after carpal tunnel release (CTR) surgery in 1% to 25% of patients, with up to 12% of patients requiring secondary surgery. If revision surgery is required, the results are much less successful compared to primary surgery. In this study, we investigated whether cryopreserved human umbilical cord allograft placement during CTR revision surgery improved short- and long-term surgical outcomes. Methods: We conducted a single-center cohort analysis of patients between January 2015 and July 2018 who underwent secondary open revision CTR with umbilical cord allograft for recurrent or persistent compression neuropathy of the median nerve. Surgical outcomes of patients in the study group-reduction of pain, paresthesia, and weakness; complications; and Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores-were compared to the outcomes of controls without umbilical cord allograft use who were operated on by the same surgeon between December 2011 and September 2015. Results: A total of 37 patients underwent CTR with (n=26) and without (n=11) umbilical cord allograft (mean follow-up of 4 years). Following surgery, preoperative symptoms of pain (96% vs 73%, P=0.048) and paresthesia (100% vs 73%, P=0.014) were significantly improved in the patients who received umbilical cord allograft. Mean QuickDASH scores (19.0 vs 23.7, P=0.58) and preoperative weakness (90% vs 67%, P=0.14) were improved in the patients who received umbilical cord allograft but were nonsignificant. Short- and long-term complications were similar between groups (P=0.56, P=0.51, respectively). Conclusion: This study suggests that human umbilical cord allograft placement during open revision CTR is safe and effective for improving long-term symptoms of compressive neuropathy in patients with recurrent carpal tunnel syndrome.

Treatment of recurrent carpal tunnel syndrome with fat grafting as an adjunct

Aim: The purpose of this study is to compare the surgical outcomes of treating recurrent carpal tunnel with recurrent carpal tunnel release only compared to recurrent carpal tunnel release with fat grafting as an adjunct. Methods: Retrospective case-control study was performed of the recurrent carpal tunnels treated, excluding explicit nerve injury such as transections, neuromas in continuity, etc. Patients with recurrent carpal tunnel received re-release of carpal tunnel only or fat grafting as an adjunct. The outcomes of both groups were compared utilizing chi-square analysis. Results: A total number of 81 patients were found to meet the inclusion criteria. Of the recurrences, a total of 16 patients did not receive fat grafting and 65 did. The rate of improvement in symptoms for performing a carpal tunnel release was only 50.0% and for performing carpal tunnel release with fat grafting was 92%, with P-value &lt; 0.00. Conclusion: Adipose-derived stem cells as an adjunct to carpal tunnel release increased the rate of improvement in symptoms of carpal tunnel compression after recurrence compared to carpal tunnel release alone. Further studies need to be performed to confirm the validity of these findings.

The Effectiveness of Plasma Rich in Growth Factors (PRGF) in the Treatment of Nerve Compression Syndromes of the Upper Extremity: A Retrospective Observational Clinical Study.

Background: Nerve compression syndromes of the upper extremity are a common cause of neuropathic pain and functional impairment. Recently, platelet-rich plasma (PRP) infiltrations have emerged as an effective biological approach to the treatment of this type of injury. The objectives of this retrospective observational study were to assess clinical improvement in patients with median and ulnar nerve entrapment syndrome after undergoing biologically-assisted nerve release surgery with plasma-rich-in-growth-factors (PRGF) technology. Methods: Participants (n = 39) with moderate-to-severe nerve compression syndrome of the upper limb diagnosed by both electromyography and clinical examination, and who were treated with PRGF, were identified from the center’s medical records. The evaluation was based on patient-reported outcomes. Pre- and post-treatment differences in the Visual analog scale (VAS), the Boston carpal tunnel questionnaire (BCTQ), and the Quick-DASH score were assessed. Results: Three study groups were conducted: patients with carpal tunnel syndrome (n = 16), with recurrent carpal tunnel syndrome (n = 8), and with ulnar nerve entrapment (n = 15). The median follow-up was 12 months (interquartile range (IQR), 9–16). In comparison to pre-treatment values, all three study groups obtained statistically significant improvements for the three analyzed scales at the end of the follow-up, with p < 0.001 for all scales in the carpal tunnel syndrome and ulnar nerve entrapment groups and p < 0.01 for all scales in the recurrent carpal tunnel syndrome group. There were no serious adverse effects in the analyzed patients. Conclusion: PRGF-assisted open surgical nerve release treatment (intraneural and perineural liquid PRGF infiltrations and nerve wrapping with PRGF membrane) exerts long-term beneficial effects on pain reduction and functional improvement in the nerve and nerve–muscle unit in patients with upper extremity compression syndromes.

Treatment of Recurrent Carpal Tunnel Syndrome with the Abductor Digiti Minimi Flap: A Case Series.

Background: Approximately 5% of patients experience recurrent symptoms after carpal tunnel release (CTR) and need revision surgery. Several surgical techniques have been described for recurrent carpal tunnel syndrome (CTS) and the abductor digiti minimi (ADM) flap is one of them. Literature concerning clinical results of the ADM flap for recurrent CTS is lacking. The aim of this study is to evaluate the outcomes of the ADM flap for recurrent CTS. Methods: We treated seven patients with the ADM flap (eight hands) between July 2016 and February 2019. Patient characteristics were assessed, and patients were asked about their symptoms (pain, sensation and paresthesia) before and after surgery. Postoperatively, we administered CTS symptoms, satisfaction with the surgery, patient-reported outcome measurements (BCTQ and QuickDASH) and whether they would undergo the same surgery again. Complications were also recorded Results: The median follow-up was 14 months. The success rate measured by CTS symptoms was 88%. Seven out of eight patients were satisfied with the results and two patients would not elect to undergo the same procedure again. Two patients reported having a weaker grip at the donor site. The median BCTQ symptom and function scores were 2.9 (1.7-3.5) and 2.6 (1.8-3.0) respectively. The median QuickDASH score was 41 (IQR 22-52). Complications reported were wound dehiscence (n = 1) and hypertrophic scar (n = 1). Conclusions: The outcomes of the ADM flap in patients with recurrent CTS were like other commonly used procedures in recurrent CTS. Level of Evidence: Level IV (Therapeutic).

The Effectiveness of Hydrodissection with 5% Dextrose for Persistent and Recurrent Carpal Tunnel Syndrome: A Retrospective Study.

Patients with failure of primary surgery for carpal tunnel syndrome (CTS) present a frustrating clinical problem because there are no relevant treatment guidelines, and the effect of current conservative management or revision surgery is unsatisfactory. Hydrodissection with 5% dextrose is emerging as an effective treatment for primary CTS and may be an effective alternative treatment method for persistent or recurrent post-surgical CTS. We retrospectively investigated the long-term effectiveness of hydrodissection with 5% dextrose for persistent or recurrent CTS. Thirty-six of forty consecutively-treated patients with either persistent or recurrent symptoms of CTS after surgery, who were treated with ultrasound-guided hydrodissection of the median nerve using 10 mL of 5% dextrose, were available to provide outcome data by a structured phone interview at least six months after treatment completion. Symptom relief ≥ 50% represented an effective outcome, while symptom relief < 50% was rated as a poor outcome. Nearly 2/3 (61.1%) of patients reported an effective outcome after a mean of 3.1 injections, with a post-injection follow-up mean of 33 (6–67) months. A non-significant trend toward a more frequently-effective outcome was observed in those with recurrent versus persistent symptoms following CTS (76.9% vs. 52.2%, p = 0.165). However, a significantly higher percentage of those with recurrent symptoms reported an excellent outcome, defined as a greater than 70% improvement (8/13 [61.6%] vs. 3/23 [13%], p = 0.006). The percentage of patients achieving an effective outcome was not significantly different between <2, 2–4, and >4 years of post-treatment follow-up (36.4% vs. 77.8% vs. 57.1%; p = 0.077). Hydrodissection with 5% dextrose may result in a clinically important and durable benefit in those experiencing persistent or recurrent CTS after surgery.

P.041 Characteristics of carpal tunnel syndrome in wild-type transthyretin amyloidosis

Background: Wild-type transthyretin amyloidosis (wtATTR) is an important cause of infiltrative cardiomyopathy in older adults. Carpal tunnel syndrome (CTS) is one of the most common extra-cardiac manifestations of wtATTR; however, the prevalence, severity, and risk of recurrence following carpal tunnel release (CTR) remain poorly understood. Methods: This retrospective cohort study reports findings from a single-centre experience of routine neurological screening of newly diagnosed wtATTR patients including nerve conduction studies. Consecutive wtATTR patients between 2014 and 2021 were included. Results: Seventy-nine wtATTR patients were included, 73 (92%) males, mean age of 79 years. Seventy-four (94%) had median neuropathy at the wrist (MNW), 50% having a prior diagnosis with the remaining 50% being diagnosed at screening. The majority with MNW were symptomatic (53, 67%) with moderate or severe disease (66, 84%) bilaterally (42, 53%) on electrophysiologic testing. Nineteen (24%) had recurrent CTS despite previous CTR. At the time of screening, 19 (24%) were prescribed wrist splinting and 36 (46%) were referred for CTR. Conclusions: Carpal tunnel syndrome is common in wtATTR. Most have bilateral disease with moderate to severe MNW at the time of wtATTR diagnosis. Recurrence of CTS after CTR is more common in wtATTR patients than in the general population.

Exoscope for Upper Extremity Peripheral Nerve Surgery: Revision Carpal Tunnel Release With Epineurolysis and Hypothenar Fat Flap

The exoscope is a high-resolution three-dimensional external microscope that allows the surgeon to perform delicate dissection in multiple regions of the body. The exoscope was originally used for intracranial and spine surgery. In this article, we describe its novel use in upper extremity peripheral nerve decompression surgery after recurrent carpal tunnel syndrome. This surgery is typically performed under the microscope, which allows precise microsurgical dissection to distinguish scar tissue from healthy nerve fascicles. Our case report highlights a 70-year-old man with recurrent carpal tunnel syndrome who underwent revision carpal tunnel surgery with epineurolysis and hypothenar fat flap. The ergonomic benefits of using the exoscope for microsurgery are described, along with intraoperative photos. Adequate symptom resolution was achieved.

A Detailed Comparison of Preoperative Complaints in Severe Carpal Tunnel Syndrome versus Recurrent Carpal Tunnel Syndrome Using the Boston Carpal Tunnel Questionnaire.

Background: The Boston Carpal Tunnel Questionnaire (BCTQ) has a symptom severity scale (SSS) with 11 questions and a functional status scale (FSS) with 8 questions. The final score for each scale is the sum divided by the number of questions and ranges between 1 and 5. A score of 1 indicates they have no complaints and 5 indicates high severity and functional loss. Unfortunately, this single digit score does not permit a detailed analysis of the symptoms and functional status. The aim of this study is to conduct an in-depth comparison of preoperative complaints using the BCTQ between patients with severe carpal tunnel syndrome (SCTS) and recurrent carpal tunnel syndrome (RCTS). Methods: This is a retrospective cohort study on the preoperative status of 37 patients with SCTS and 18 patients with RCTS using the BCTQ. The questions in the SSS and FSS were classified into four groups based on the responses of patients, namely a low complaint (LC) (1-1.99), moderate complaint (MC) (2-2.99), high complaint (HC) (3-3.99), and severe complaint (SC) (4-5) groups. The patients in the SCTS and RCTS groups were compared to find differences in age, gender, hand dominance, and responses to questions in the SSS and FSS. Results: The age of patients in the SCTS group (76.06 years) was significantly higher compared to the RCTS group (51.11 years). There was no significant difference between the two groups with regard to gender or hand dominance. The top question with SC or HC response in the SCTS group was problems in grasping small objects (SSS) and fastening buttons (FSS) and in the RCTS group was tingling in the hand (SSS) and difficulty with opening a jar (FSS). Conclusions: An in-depth analysis of the BCTQ allowed us to compare and understand differences in symptoms and function between patients with SCTS and RCTS. Level of Evidence: Level III (Therapeutic).

Hypothenar fat pad flap to prevent ecurrence of carpal tunnel syndrome: a case report

Background: Carpal tunnel syndrome (CTS) is one of the most prevalent peripheral neuropathies and most commonly affects middle-aged women. The typical symptoms of CTS are nocturnal pain accompanied by tingling and numbness in the hand&amp;apos;s median nerve distribution. The management of CTS ranges from conservative treatment to surgical intervention with good response. However, the recurrence of CTS after the first surgery can reach up to 25%, and up to 95% after the second one. Case Presentation: We report a 41-year-old woman with a Schwannoma of her right median nerve with CTS. She developed a recurrence of the symptoms despite traditional surgical correction three times. The plan is to do an alternative surgical procedure, the hypothenar fat pad flap (HTFPF), particularly due to the neuroma aiming to cover the affected nerve with fat and prevent further recurrence. The surgery was successful, and the patient&amp;apos;s symptoms subsided with no further recurrences. Conclusion: The HTFPF is an excellent surgical choice for recurrent CTS, and the choice of surgery in these cases should be individualized according to the patient clinical condition.

Median Nerve and Carpal Tunnel Morphology Before and After Endoscopic Carpal Tunnel Release: A 6-Year Follow-up Study.

Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR). In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point. All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years. We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.

Flexor Synovectomy as an Adjunct to Carpal Tunnel Release in Primary Carpal Tunnel Syndrome: A Meta-Analysis.

Background: Carpal tunnel release (CTR) aims to achieve surgical decompression of the median nerve for the treatment of carpal tunnel syndrome (CTS). Flexor tenosynovectomy (FS) has been carried out as an adjunct to routine CTR, on the basis that chronic flexor tenosynovitis has been implicated as an etiological factor in idiopathic CTS. However, the benefits of this additional procedure remains unclear. As such, we aimed to compare functional outcomes, nerve function and complication rates from CTR with and without FS. Methods: A systematic review of published literature was performed for original data English language studies comparing outcomes of CTR with and without FS in the treatment of primary CTS. Mean weighted differences and their 95% confidence interval were used for analysis. Results: Three studies comprising 292 wrists were included. Meta-analysis showed no improvement in post-operative grip strength, symptom severity score, functional status score, median nerve motor latency or major complications with FS. Recurrence rate was not reported in the 3 selected articles. Conclusions: The available evidence suggests FS is an unnecessary adjunct which provides no benefit to CTR, and should not be used routinely to treat primary CTS. Larger studies are needed to validate our findings. FS may have a role in recurrent or secondary CTS.