Secondary Carpal Tunnel Syndrome Research Articles

Ultrasound and magnetic resonance imaging neurography assessment of diagnostic criteria in patients with carpal tunnel syndrome using electrophysiological tests as gold standard: A prospective study.

Evaluating peripheral neuropathy mainly relies on physical examination, patient history, and electrophysiological studies. High-resolution ultrasound is a fast, noninvasive modality for dynamic nerve assessment that enables the length of the nerve to be examined. Magnetic resonance imaging is preferred for examining deeper nerves with a high contrast resolution; its use shows excellent benefit in patients with atypical presentation, equivocal diagnosis, suspected secondary causes, and postsurgical relapse. We aimed to assess the measurements and criteria for both ultrasound and magnetic resonance neurography for the diagnosis of carpal tunnel syndrome, based mainly on the three measurements assessed by Buchberger et al. This prospective study was conducted to test diagnostic accuracy. Thirty-two patients who presented clinically with, and were diagnosed by electrophysiological tests as having, carpal tunnel syndrome participated. Superficial ultrasound of the wrist joint was performed on all participants, followed by magnetic resonance imaging within 1 week of ultrasonography. The three main parameters of cross-sectional area measurement, distal nerve flattening, and flexor retinaculum bowing indices showed positive occurrences of 93.7%, 59.4%, and 59.4%, respectively; 90.6% of patients had decreased nerve echotexture. The diagnostic ability of magnetic resonance imaging was decreased when cross-sectional area measurements were used: positive results were achieved in 81.2% of patients, but the positive results showing the distal tunnel nerve increased flattening and bowed flexor retinaculum slightly decreased to 56.2% for each. A high T2 signal of the median nerve was observed in 90.6% of patients. In an agreement analysis, we found a statistically significant difference that supported the use of ultrasound as a primary diagnostic modality for carpal tunnel syndrome. However, magnetic resonance imaging improved tissue characterization and was a good diagnostic modality, with a statistically significant difference, for cases of secondary carpal tunnel syndrome, detection of the underlying entrapping cause, and early abnormality detection in the innervated muscle. Our results demonstrate that ultrasound examination can be used as the first imaging modality after physician evaluation, with results comparable to those of electrophysiological studies for evaluating carpal tunnel syndrome and determining its cause. Magnetic resonance neurography examination is the second step in detecting secondary causes in cases with suspected early muscle denervation changes that cannot be elicited by ultrasound or in cases with equivocal results.

Nerve sonography in the diagnostic evaluation of primary and secondary carpal tunnel syndrome in rheumatoid arthritis.

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and extra-articular manifestation of rheumatoid arthritis (RA). However, in patients with RA, it is not always possible to clinically distinguish an actual CTS from other RA-based complaints. We evaluated the diagnostic role of nerve ultrasound (NUS) as supportive tool in the diagnostic process of CTS in patients with RA and tried to provide etiological clarification in cases of secondary CTS. Fifty-eight patients with RA and clinical suspicion of CTS were enrolled. All patients underwent a standardized clinical-neurological, electrophysiological (nerve conduction studies [NCS]), and NUS examination and completed the Boston CTS Questionnaire (BCTQ). In 96 of 116 hands examined, a clinical suspicion of CTS was documented. In 43 of 96 (44.8%) CTS-positive hands, the diagnosis was primarily confirmed by NCS, whereas in another 16 of 96 (30.2%) hands, the diagnosis could only be verified by NUS, leading to a diagnosis of CTS in 59 of 116 (50.8%) hands. In 19 of 59 (32.3%) CTS-positive hands, tenosynovial hypertrophy was observed, and in 7 of 59 (11.8%), a cystic mass was identified as the underlying cause of secondary CTS. A good correlation between NCS and NUS findings was documented, but no significant correlation was found between NCS, NUS, and clinical findings/BCTQ. In people with RA, a diagnosis of CTS purely on a clinical basis is nonspecific and should be supported by NCS and/or NUS. NUS markedly facilitates the diagnosis of CTS in these patients and enables differentiation between primary and secondary causes.

Compression Neuropathies: Revisions and Managing Expectations.

Most compression neuropathies can be reliably treated with surgical decompression; however, in approximately 25% of the cases, this release fails, requiring revision surgery. Defining the correct diagnosis after a failed nerve decompression (ie, persistent, recurrent, or new symptoms) is of the utmost importance and guides toward the optimal treatment. This article describes the clinical categorization of secondary carpal tunnel syndrome and cubital tunnel syndrome, intraoperative principles of revision surgery and treatment options that are currently available.

Comparative study between blind and ultrasound-guided steroid injection for carpal tunnel syndrome

BackgroundCarpal tunnel syndrome is the most common entrapment neuropathy. Local injections of corticosteroids have proven to be an effective treatment option. Injections are either blind (non-guided) or guided by ultrasound. The current study aimed to compare the efficiency of both approaches and determine which one yields better results.MethodThis study involved 30 patients (8 males, 22 females, aged 36–58 years, mean age 48.3 years) with 30 affected hands with mild or moderate carpal tunnel syndrome. Patients were randomly divided into two equal groups. Steroid injections were performed blindly in group 1 and ultrasound-guided in group 2. A mixture of 2 ml of triamcinolone and lidocaine was administered at both groups. Follow-up (using the Boston Carpal Tunnel Questionnaire and ultrasound assessment) was performed 4 weeks after the injection.ResultsThe symptom severity scale, functional status scale, cross-sectional area, and flattening ratio were significantly reduced in both groups at 4 weeks after the procedure. The ultrasound-guided group showed a statistically significant improvement compared to the blindly injected group.ConclusionsLocal steroid injection is an effective method in the management of both idiopathic and secondary carpal tunnel syndrome. Although clinical and sonographic improvement was achieved with blind and guided steroid injections, better results were obtained when ultrasound was used.

Secondary carpal tunnel syndrome caused by space-occupying lesion-lipoma

The etiology of carpal tunnel syndrome is various. One of these etiological factors is space- occupying lesions in the carpal tunnel.

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.

Indicators of Intratissue Pressure in the Carpal Tunnel in Fractures of the Distal Radius

Summary. According to the literature, the pathogenesis of the secondary carpal tunnel syndrome in distal radius fractures remains poorly studied; local post-traumatic compartment syndrome is one of the possible mechanisms of its development.
 Objective: to study the indicators of subfascial pressure in the carpal tunnel in fractures of the distal radius in the acute period of injury and their relationship with the severity of the fracture, skialogic indicators of displacement, the severity of pain syndrome, the patient's age, and time since the injury.
 Materials and Methods. The study included 24 patients with acute fractures aged 48.4±19.0 years, among them 8 males and 16 females. The time from the moment of injury to the measurement of pressure with the “Stryker monitor pressure system” device was 10.5±9.8 hours; the indicators were correlated with pain syndrome according to the VAS scale, skialogic indicators of distal epimetaphysis deformity, and the severity of fractures according to the classification of fractures of the Association of Osteosynthesis (AO). By interviewing patients in a long-term period, the complaints which are a characteristic of lesions of the median nerve at the level of the carpal canal were determined.
 Results. In distal radius fractures in the acute period of injury, the level of subfascial pressure is on average 26.5±12.3 mm Hg; however, more than a third of patients (37.5%) reach critical values, 30 mm Hg and more, which can lead to ischemic damage to the soft tissues of the hand, including the median nerve. A moderate reliable relationship between the subfascial pressure parameters in the carpal canal and the severity of the fracture according to the AO classification, the level of pain syndrome according to the VAS scale, the age of patients, and a weak probable relationship with the period after injury, the degree of relative shortening of the radius, indicators of intra-articular displacement and loss of ulnar inclination of the distal epimetaphysis were determined. No significant and reliable correlation between the indicators of intra-tissue pressure in the carpal tunnel and the angle of the palmar inclination of the articular facet in distal epimetaphysis of the radial bone fractures was found. None of the examined patients developed carpal tunnel syndrome, so there is no direct correlation between increased subfascial carpal tunnel pressure in the acute period after the injury and the incidence of median nerve compression neuropathy.
 Conclusions. A moderate reliable relationship between the subfascial pressure parameters in the carpal canal and the severity of the fracture according to the AO classification, the level of pain syndrome according to the VAS scale, and the age of the patients, as well as a weak reliable correlation with the post-injury period, the degree of post-traumatic deformity of distal epimetaphysis of the radial bone in the form of its relative shortening and loss of inclination, and indicators of intra-articular displacement were determined. In this study, no correlation was found between increased subfascial pressure in the carpal canal in the acute period after trauma and the occurrence of compression neuropathy of the median nerve.

Carpal tunnel syndrome secondary to neoplastic space-occupying lesion

This article presents a previously reported case of a 66-year-old woman with a mass on the volar aspect of her right wrist and a one-month history of right wrist pain. The importance of considering a wide range of causes for carpal tunnel syndrome when assessing a patient with persistent wrist pain and an associated mass is highlighted. The differential diagnosis of space-occupying lesions should include benign and malignant neoplastic etiologies in addition to non-neoplastic etiologies. The clinical features, diagnostic methods, and management options for a patient with carpal tunnel syndrome are presented and key distinctions between conventional and secondary carpal tunnel syndrome are discussed. Lipomas, schwannomas, and synovial sarcomas are discussed to showcase different neoplastic causes that may present as secondary carpal tunnel syndrome with an associated wrist mass as seen in this case.

Lipofibromatous hamartoma of the median nerve and its terminal branches: recurrent branch and ulnar proper palmar digital nerve of the thumb. A case report

Lipofibromatous hamartoma (LFH) is a rare benign tumor affecting the peripheral nerves, particularly the median nerve. It is characterized by fatty tissue infiltrating the nerve. We report the case of a patient with LFH of the median nerve, recurrent branch and ulnar proper palmar digital nerve of the thumb associated with macrodactyly. It was responsible for hypoesthesia of the thumb’s hemi-pulp and secondary carpal tunnel syndrome confirmed by electroneuromyography (ENMG). Diagnosis was suspected based on the MRI findings. The patient underwent surgical treatment consisting of open carpal tunnel release combined with neurolysis of the ulnar proper palmar digital nerve of the thumb. The extraneural LFH tissue was excised also. Forty-five days after surgery, the patient no longer had nocturnal paresthesia. Ninety days after surgery, sensitivity of the thumb pulp was satisfactory. Symptoms of LFH are related to the increased volume of the affected nerve. In the absence of symptoms, abstention seems to be the best option. In case of neurological clinical signs or ENMG abnormality, surgical treatment is indicated to perform neurolysis and excision of extraneural LFH tissue. The diagnosis is based on histological examination of tissue samples.

Diagnostic potential of high resolution ultrasound and nerve conduction study in patients with idiopathic carpal tunnel syndrome

Aim of the workTo evaluate the diagnostic utility of high resolution ultrasound in comparison to nerve conduction study (NCS) in patients with idiopathic carpal tunnel syndrome (CTS). Patients and methods40 patients with CTS (56 hands) and 30 matched controls (30 hands) were included. Patients and controls were assessed by clinical examination, ultrasonographic parameters including cross sectional area (CSA), flattening ratio 1 (FR1) at pisiform and FR2 at hamate and NCS including distal motor latency (DML), motor (MCV) and sensory (SCV) conduction velocity, sensory latency and amplitude. ResultsThe mean age of the patients was 36.02 ± 8.4 years; 39 females and 1 males. This study included 37 right (92.5%) and 3 left-handed (7.5%) patients. Right-hand affection was detected in 17 (42.5%) patients, left-hand in 3 (7.5%) while bilateral hands affection was detected in 20 (50%). CSA and FR2 were significantly associated with CTS severity. CSA significantly correlated with all electrophysiological parameters including DML, sensory amplitude, sensory latency and SCV. FR1 significantly correlated with sensory latency and FR2 with SCV. Regarding sensitivity of ultrasonographic parameters, FR2 was the highest (91.3%) while CSA and FR1 were 80.3% and 50% respectively. Specificity of all ultrasonographic parameters was 100% and the highest sensitivity was for SCV (94.6%). ConclusionsThere was an insignificant difference between nerve conduction study and high resolution ultrasound in diagnosis of idiopathic CTS. However, high resolution ultrasound had a superior diagnostic utility in CTS, and is valuable for exclusion of secondary CTS and anatomical variants of the median nerve.

Carpal Tunnel Syndrome Caused by Bifid Median Nerve in Association with Anomalous Course of the Flexor Digitorum Superficialis Muscle at the Wrist

Secondary carpal tunnel syndrome (CTS) can be caused by vascular anomalies usually involving persistent median artery, variations of the median nerve, and space-occupying lesions in the wrist and palm. High division of the median nerve proximal to the carpal tunnel (known as a bifid median nerve) is a median nerve anomaly with a reported incidence of 2.8% per wrist. The bifid median nerve is often associated with various abnormalities such as persistent median artery and aberrant muscles, causing clinical features of CTS. Most reported cases of bifid median nerves are associated with CTS due to its higher cross-sectional area compared to a non-bifid median nerve. We report a rare case in which an anomalous tendinous course of the flexor digitorum superficialis muscle is associated with bifid median nerve proximal to the flexor retinaculum at the distal wrist. Surgeons should consider the possibility of median nerve variation in patients with unilateral severe CTS and be aware of this anomaly during elective carpal tunnel release. Key words: Carpal tunnel syndrome; Congenital abnormalities; Median nerve; Median neuropathy; Tendons

Disillusioning midterm results after UNI 2 total wrist arthroplasty in RA Patients

Total wrist arthroplasty attempts to produce a stable, pain free joint. Avoidance of arthrodesis is a strong impetus. Early results of the Universal total wrist arthroplasty KMIy in wrist arthritis were at least as encouraging as were reports with other implants. The five to ten year outcomes showed a 45% revision rate with arthrodesis rate below 10%. Our question was wether results withstand over time. Material and method Between 2002 and 2012, 12 rheumatoid patients all but one female had cementless UNI 2 total wrist arthroplasty - the only implant used by a single surgeon - on 14 wrists, average age of 68, 55 years (range 37–84 y.). Indication was panarthritis of the carpus with Simmen Grade I and II without major bone loss intact tendons without active synovitis or infection. No patient was dependent on walking aids. At follow-up average 6.9 years the only question was on the status of the implant whether radiological and mechanical stable or not. Two patients were lost to follow-up due to death for other medical reasons. Results During the follow-up 9 wrists or 75% of the surviving got clinically symptomatic with increasing pain, local swelling and radiovolar drift of the carpus. There was in any instance polyethylene wear accentuated on the radius, synovitis and secondary carpal tunnel syndrome. After an average of 5 years revision rate rose markedly. Radiologic and mechanical loosening of the carpal component was seen 7 times. Surgery - twice there was only the change of the polyethylene component necessary. Three times the carpal component had to be changed in combination with cancellous bone adjunct. Finally, 4 revisions ended in arthrodesis, two of those in first revision. At present, two more patients with three implants are due to reoperation. Thus, arthroplasty showed complication in 75% and mobility was lost in 33% of the surviving. Discussion Early results of the universal total wrist arthroplasty KMIy in rheumatoid arthritis were encouraging. Midterm results show an array of problems focussing on the carpal component. These studies generally sum up degenerative, posttraumatic and rheumatoid arthritis cases. To our knowledge ours is the only focusing on RA patients only. The majority of publications delude oneself to believe in total wrist arthroplasty in this category of patients. The authors own experience is much more deceiving. In our department total wrist arthroplasty in rheumatoid patients is no longer the treatment of choice.

Giant lipoma: an unusual cause of carpal tunnel syndrome

Carpal tunnel syndrome, in its idiopathic form, is an extremely common entrapment neuropathy in the clinical practice however secondary compressive causes are rare. Among secondary causes, tumors are even rarer. Although lipomas are the most common soft tissue tumor in the body, <5% of the benign tumors of the hand are lipomas. A 48-year old manual laborer man presented to us with a two-year history of numbness, tingling and burning pain in the palmar surface of the left hand and fingers along with a progressively increasing swelling in the hand and wrist. His medical history was unremarkable and no trauma episode was reported. According to the clinical examination and the result of median nerve conduction study (NCS) the diagnosis of carpal tunnel syndrome was established. Operative release of the transverse carpal ligament was subsequently performed along with excision of the lipoma using extensile open approach. Intraoperatively, median nerve and its digital branches were found to be stretched over the giant lipoma causing substantial compression to median nerve. Histopathological findings of the resected mass were consistent with lipoma. After two years the patient was pain-free without any sign of tumor recurrence. Lipomas are infrequently seen in hand and wrist, however giant lipoma as a cause of secondary carpal tunnel syndrome is even more rare, which makes this case interesting.

Entrapment Neuropathies II: Carpal Tunnel Syndrome

Diagnostic tests in patients complaining of carpal tunnel syndrome (CTS) are based on physical examination, electrodiagnostic tests (EDTs), and diagnostic imaging. Timely diagnosis helps prevent permanent nerve damage and its sequelae in terms of functional impairment. Imaging provides additional information to that obtained from clinical tests and EDTs. By allowing direct visualization of the compressed median nerve (MN), ultrasound (US) and magnetic resonance imaging can depict the causes for secondary CTS and describe anatomical variants, such as a bifid MN or a persistent median artery of the forearm, as well as space-occupying lesions including tenosynovitis and ganglion cysts. In addition, diagnostic imaging is of value for postoperative patients presenting with persistent symptoms. Finally, US is able to add information for EDT-negative symptomatic patients. Over time, US has increased in its sensitivity and specificity so it can be used as the initial test in patients presenting with clinical symptoms of CTS because it is now equivalent to EDT. The use of US as a screening test may reduce the number of EDT examinations in patients with suspected CTS, providing additional valuable anatomical information.

Lipofibromatous hamartoma of the median nerve

Lipofibromatous hamartoma is a rare tumour of peripheral nerves which is characterised by an excessive infiltration of the epineurium and perineurium by fibroadipose tissue. To the best of our knowledge, only approximately 88 cases are reported in the literature. We report a rare case of lipofibromatous hamartoma of the median nerve causing secondary carpal tunnel syndrome in a 25 year old patient. This patient was treated conservatively with decompression and biopsy and experienced a complete resolution of symptoms post-operatively. Magnetic resonance imaging may be used to diagnose this lesion as it has very distinctive characteristics. Multiple conditions have been associated with this lesion and a greater understanding of these associations may clarify the pathogenesis. The architecture of the tumour makes excision very challenging and the surgical management remains controversial. A review of the literature regarding the etiology, pathogenesis and surgical management of lipofibromatous hamartoma is included.

Lipofibromatous hamartoma of median nerve

Lipofibromatous hamartoma is a rare tumour of peripheral nerves which is characterised by an excessive infiltration of the epineurium and perineurium by fibroadipose tissue. To the best of our knowledge, only approximately 88 cases are reported in the literature. We report a rare case of lipofibromatous hamartoma of the median nerve causing secondary carpal tunnel syndrome in a 25 year old patient. This patient was treated conservatively with decompression and biopsy and experienced a complete resolution of symptoms post-operatively. Magnetic resonance imaging may be used to diagnose this lesion as it has very distinctive characteristics. Multiple conditions have been associated with this lesion and a greater understanding of these associations may clarify the pathogenesis. The architecture of the tumour makes excision very challenging and the surgical management remains controversial. A review of the literature regarding the etiology, pathogenesis and surgical management of lipofibromatous hamartoma is included.

Severity of Carpal tunnel syndrome assessed with high frequency ultrasonography

Although nerve conduction study (NCS) is the method most frequently used in daily clinical practice to confirm clinical diagnosis of Carpal tunnel syndrome (CTS), ultrasonographic (US) measurement of the median nerve cross-sectional area is both sensitive and specific for the diagnosis of CTS. Moreover, an algorithm evaluating CTS severity based on CSA of median nerve was suggested. This study is aimed to investigate the clinical usefulness of this algorithm in assessing CTS severity. The patients underwent a full clinical examination, including Tinel and Phalen test, and questioned about symptoms and the secondary causes of CTS. All of the patients refilled a Turkish version Levine Boston Carpal tunnel syndrome questionnaire (BQ) and the visual analog scale for pain (VAS 0-100 mm) A MyLab 70 US system (Esaote Biomedica, Genoa, Italy) equipped with a broadband 6-18 MHz linear transducer was used for US examination. The cross-sectional area of the median nerve was measured at the proximal inlet of the carpal tunnel (US cut-off points that discriminate between different grades of CTS severity as 10.0-13.0 mm(2) for mild symptoms, 13.0-15.0 mm(2) moderate symptoms and >15.0 mm(2) for severe patients). Nerve conduction studies were carried out, and severity of electrophysiological CTS impairment was reported as normal, mild, moderate, severe and extreme. The agreement between NCS and US in showing CTS severity (normal, mild, moderate and severe) was calculated with Cohen's kappa coefficient. Ninety-nine wrists of 54 patients (male/female: 4/50) were included in the study. Mean ages of patients were (+/-SD) 43.3 +/- 11 years. Forty-nine patients had idiopathic CTS, whereas five had secondary CTS (4 had diabetes mellitus and 1 had hypothyroidism). Symptoms were bilateral in 45 patients (83.3%). There were statistical differences between the groups according to electrophysiologic severity scale in terms of age (P < 0.001), body-mass index (P = 0.034), VAS (P = 0.014), Boston symptom severity (P = 0.013) and CSA of median nerve (P < 0.001). The identification of CTS severity showed substantial agreement (Cohen's kappa coefficient = 0.619) between the US and NCS. Also the four groups based on US CTS severity classification were significantly different in VAS (P = 0.017) and Boston symptom severity (P = 0.021). The median nerve swelling detected by calculation of the CSA reflects in itself the degree of nerve damage as expressed by the clinical picture. In addition to CTS diagnosis, sonographic measurement of CSA could also give additional information about severity of median nerve involvement. Using of US may cost-effectively reduce the number of NCS in patients with suspected CTS.

Accidental Mycobacterium bovis infection in a veterinarian

CASE: A veterinarian developed tenosynovitis and secondary carpal tunnel syndrome following accidental inoculation of Mycobacterium bovis during the necropsy of a tuberculous possum from Westland, New Zealand. CLINICAL RELEVANCE: M. bovis infection is a zoonotic disease, and occupational exposure to tuberculous animals places people at risk of contracting the disease. CONCLUSIONS: Adhering to safe work practices reviewed in this article is important to minimise the risk of infection to people handling tuberculous animals.