Severity Of CTS Research Articles

Hand Volume as a Diagnostic Tool in Carpal Tunnel Syndrome

Objectives: To determine whether patients with carpal tunnel syndrome have an objective swelling of their hands. Design: A prospective, cross-sectional study of consecutive patients. Setting: Two independent electromyographic laboratories. Participants: Sixty-three patients referred for electrodiagnostic work-up. Interventions: NCS/EMG testing and volumetric analysis. Limb volume was measured using the water displacement method using a volumeter. Main Outcome Measures: Differences in volume (DHV) and EMG/NCS data. Results: EMG results indicated that 24 subjects (38%) had findings consistent with CTS. Data concerning subjective swelling was available for only six of these 24 subjects. The data, which are limited by low power, indicate that there was no difference 1) between the volume of the affected hand and the unaffected hand among those with CTS; 2) between the DHV of those with CTS and those without;. 3) Patients with lower extremity complaints had significantly less DHV than those with an upper extremity complaint (p<0.0034, excluding patients with both upper and lower extremity complaints). Conclusions: Though a patients’ perception of hand swelling has previously been determined to be an indicator of CTS severity, there was no correlation found in this study between CTS and objective measures of swelling. However patients with an upper extremity complaints had a statistically larger DHV than those with a lower extremity complaint (p<0.0034), suggesting that objective swelling might be present under some unknown circumstances. As this study was limited by a low power, further investigation is warranted in this area.

FRI0242 Value of Ultrasound in Carpal Tunnel Syndrome: Useful Method for Treatment and Therapeutic Response after Steroid Injection

BackgroundCarpal tunnel syndrome (CTS) is the most common compressive neuropathy in rheumatology. Ultrasound guided steroid injection can provide more efficiency compared with blind injection.ObjectivesThe aim of this study was to...

A study of retrograde degeneration of median nerve forearm segment in carpal tunnel syndrome of variable severities

IntroductionCarpal tunnel syndrome (CTS) is a disorder of the hand which results from compression of the median nerve within its fibro-osseous tunnel at the wrist. The slowing in the forearm motor conduction velocity suggests the presence of retrograde degeneration. Existing studies conflict regarding a correlation between the severities of the entrapment neuropathy in CTS and slowing of median motor nerve conduction velocity in the forearm. AimsThe objective of this work was to study retrograde degeneration (RGD) of the median nerve forearm segment in patients with CTS and its relation to variable severity of CTS in Egyptian patients. Patients and methodsTwenty-four patients with CTS were included in this study. The Forearm mixed nerve conduction is presumed to be indicative of the conduction of the median nerve over the forearm and is used widely to assess the causes of slowing forearm conduction velocity in CTS. In addition to conventional nerve conduction studies of the upper limb, forearm median mixed conduction studies were performed. Median motor forearm amplitudes and nerve conduction velocities (NCVs) as well as forearm median mixed amplitudes and NCVs were considered as parameters of RGD. ResultsThere were statistically significant differences as regards forearm mixed nerve action potential (MNAP) amplitude and median motor amplitude in the forearm segment but there were no statistically significant differences as regards forearm median mixed peak latency and NCV. There was no statistically significant relation between grades of severities of CTS in the studied hands and both forearm median motor NCV and forearm MNAP amplitude using Monte Carlo test (MCp=0.323 and 0.464). ConclusionsRetrograde degeneration exists in patients with CTS. Forearm median motor NCV and median mixed conduction study are valid electrophysiologic tools for the assessment of RGD in patients with CTS. Retrograde degeneration is not related to grade of severity of CTS.

Catechol-O-Methyltransferase Val158Met Polymorphism is Associated with Pain and Disability, but not Widespread Pressure Pain Sensitivity, in Women with Carpal Tunnel Syndrome

Background: The genetic influence of Val158Met polymorphisms, one of the potential genetic determinants for nociceptive processing, has not been previously investigated in women with carpal tunnel syndrome (CTS). Objectives: To investigate the association between the Val158Met polymorphism with CTS and to assess the relationship between the Val158Met polymorphism and the clinical outcomes and widespread pressure pain hypersensitivity in women with CTS. Study Design: Case control study. Setting: Neurology department at an urban hospital. Method: One hundred nine (n = 109) women (mean age: 47 ± 9 years) with a clinical and electrodiagnostic diagnosis of CTS and 109 matched healthy women participated. After amplifying the Val158Met polymorphism by polymerase chain reactions, rs4680 genotype frequencies and allele distributions were calculated. We classified individuals according to their Val158Met polymorphism: Val/Val, Val/Met, Met/Met. The intensity of the pain was assessed with a numeric rating scale (0-10) and disability was determined with the Boston Carpal Tunnel Questionnaire. Pressure pain thresholds were bilaterally assessed over median, radial, and ulnar nerve trunks; C5-C6 facet joints; and carpal tunnel and tibialis anterior muscles. Institutional Review Board: The study project was approved by the local human research committee (HUFA-12/14). All participants signed an informed consent prior to their inclusion in the study. Results: The distribution of the 3 Val158Met genotypes (Val/Val, Val/Met, Met/Met) and alleles was not significantly different between women with CTS and healthy women (χ2 = 0.498; P = 0.780). Women with CTS carrying the Met/Met genotype showed higher levels of pain and disability than those with the Val/Met genotype (P &lt; 0.01) and with the Val/Val genotype (P &lt; 0.001). No differences in the years with pain (P = 0.954), age (P = 0.740), depression (P = 0.530), severity of CTS (P = 0.744) or presence of unilateral-bilateral symptoms (P = 0.279) existed depending on the rs4680 Val158Met genotype. No significant differences in widespread pressure pain sensitivity were observed in any of the points depending on the rs4680 Val158Met genotype (P &gt; 0.315). Limitations: We only recruited women from a specialized department. Conclusion: Current results indicated that the Val158Met polymorphism seems not to be a risk factor for the development of CTS; however, it was associated with increased perception of pain and higher disability scores. Key words: Catechol-O-methyltransferase gene, carpal tunnel syndrome, polymorphism pressure pain thresholds, sensitivity.

The value of power and pulsed Doppler in the diagnosis of CTS: Is a solution in sight

ObjectiveTo evaluate the value of power and pulsed Doppler in diagnosis of CTS and compare it with median nerve cross-sectional area (CSA) measured by gray-scale US and nerve conduction studies. Patients and methodsForty patients with definite clinical evidence of CTS and 20 healthy cases were enrolled in the study. All patients and controls underwent nerve conduction studies, gray-scale US (for measurement of CSA) and color Doppler (for assessment of vasomotor activity). ResultsTwenty eight patients (70%) had confirmed diagnosis by NCS while 12 patients (30%) were not detected by the NCS. The CSA ranged from 0.06 to 0.78cm2 with a mean of 0.19+0.12. Comparison between patients and controls as regards CSA showed highly statistically significant difference (P<0.001). There was a significant difference between patients and controls as regards PS, ED & PI. Also there was a significant correlation between median nerve hypervascularization and the parameters of spectral Doppler and the severity of CTS by NCS and also with CSA. ConclusionColor Doppler imaging of the median nerve is a readily accessible and practical method for determining the degree of vasomotor impairment in CTS patients that may be valuable in evaluation and follow up of CTS patients in clinical practice.

A Novel Fuzzy Expert System for the Identification of Severity of Carpal Tunnel Syndrome

The diagnosis of carpal tunnel syndrome, a peripheral nerve disorder, at the earliest possible stage is very crucial because if left untreated it may cause permanent nerve damage reducing the chances of successful treatment. Here a novel Fuzzy Expert System designed using MATLAB is proposed for identification of severity of CTS. The data used were the nerve conduction study data obtained from Kannur Medical College, India. It consists of thirteen input fields, which include the clinical values of the diagnostic test and the clinical symptoms, and the output field gives the disease severity. The results obtained match with the expert's opinion with 98.4% accuracy and high degrees of sensitivity and specificity. Since quantification of the intensity of CTS is a crucial step in the electrodiagnostic procedure and is important for defining prognosis and therapeutic measures, such an expert system can be of immense use in those regions where the service of such specialists may not be readily available. It may also prove useful in combination with other systems in providing diagnostic and predictive medical opinions and can add value if introduced into the routine clinical consultations to arrive at the most accurate medical diagnosis in a timely manner.

Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial

To compare the efficacy of surgical decompression vs local steroid injection in the treatment of idiopathic CTS. This is an open, prospective, randomized clinical trial. We studied the effects of surgical decompression vs local steroid injection in 163 wrists with a clinical diagnosis and neurophysiological confirmation of CTS, with an extended follow-up of 2 years. The primary end point was the percentage of wrists that reached a ≥ 20% improvement in the visual analogue scale score for nocturnal paraesthesias. Statistical analysis was done by Student's t-test for continuous variables and by chi-square test for categorical variables. Analyses were performed on an intent-to-treat basis. P < 0.05 were considered statistically significant. Both treatment groups had comparable severity of CTS at baseline. Eighty wrists were randomly assigned to surgical decompression and 83 wrists to local steroid injection. Fifty-five wrists in the surgery group and 48 wrists in the injection group completed the 2-year follow-up. In the intent-to-treat analysis, at 2-year follow-up, 60% of the wrists in the injection group vs 69% in the surgery group reached a 20% response for nocturnal paraesthesias (P < 0.001). Our findings suggest that both local steroid injection and surgical decompression are effective treatments in alleviating symptoms in primary CTS at 2-year follow-up. Surgery has an additional benefit in the 2-year follow-up, although clinical relevance of those differences remains to be defined. Current Controlled Trials, www.controlled-trials.com, ISRCTN26264638.

Impact of carpal tunnel syndrome on the expectant woman's life

IntroductionCarpal Tunnel Syndrome is known to be a common complication during pregnancy especially during the third trimester.AimThis article focuses on its impact to the third trimester pregnant mothers with CTS.MethodsThird trimester pregnant mothers with no other known risk factors for CTS, were interviewed and examined for a clinical diagnosis of CTS. The severity of CTS was assessed by means of symptoms severity and functionality using the Boston Carpal Tunnel Questionnaire.ResultsOut of 333 third trimester pregnant mothers, 82 (24.6%) were clinically diagnosed with CTS. Malay race was found to have significant correlation with the diagnosis of CTS (p = 0.024) and are two times more likely to get CTS during pregnancy (OR = 2.26) compare to the non-Malays. Bilateral CTS was two times higher (n = 58, 63.4%) than unilateral cases (n = 30, 36.6%), however no significant correlation between the two was found with severity (p = 0.284) or functional (p = 0.906). The commonest complaint was numbness/tingling during day time (n = 63, 76.8%). Majority of the CTS cases were mild (n = 66, 80.5%) and approximately one third (n = 28, 34.1%) had affected hand functions. All symptoms related to pain was found to have significant correlation with severity (p = 0.00, OR = 12.23) and function (p = 0.005, OR = 5.01), whereas numbness and tingling does not (Severity, p = 0.843, function, p = 0.632).ConclusionThis study shows that even though CTS in third trimester pregnancy is prevalent, generally it would be mild. However, function can still be affected especially if patients complain of pain.

Long term effect of local corticosteroid injection for carpal tunnel syndrome: A relation with electrodiagnostic severity

ObjectiveCarpal tunnel syndrome (CTS) is a common entrapment neuropathy. A local corticosteroid injection at the carpal tunnel inlet is often given to reduce the signs and symptoms. The long term effect of a local corticosteroid injection is not known yet. The aims of the study were to assess the long term effect of a local corticosteroid injection and the rognostic factors. MethodsAssessment of 419 consecutive patients, seen between November 2004 and November 2007 at our Neurology out-patient clinic. After confirmation of the diagnosis CTS the treating neurologist decided on the patients eligibility for a local corticosteroid injection, containing 40mg methylprednisolone. ResultsLocal corticosteroid injection was given to 273 of the 419 patients with CTS (65%), 122 (29%) were treated surgically and 24 (6%) were treated by another therapy. Of the 273 patients long term follow-up was available for 211 (77%) patients. A beneficial effect of more than 6months was seen in 132 patients (63%), longer than 12months in 102 patients (48%), and longer than 18months in 71 patients (34%).Only severity of electrodiagnostic testing was a predictor of outcome. The median time until treatment failure was 15months for mild, 5months for moderate and 4.5months for severe CTS (logrank test p=0.02). ConclusionPatients with an electrodiagnostically mild CTS (i.e., abnormal comparative tests or prolonged median DSL>3.5ms but normal median DML) are good candidates for a local steroid injection with 50% having a good long term effect for more than 15months. SignificanceThis study shows that the EMG severity of CTS is an important prognostic factor for the long term effect of a local steroid injection.

Electroneuromyography in the diagnosis of carpal tunnel syndrome

The review is devoted to modern methods of electrophysiological evaluation of median nerve damage in the carpal tunnel (the so-called carpal tunnel syndrome, CTS) which is the most frequently diagnosed form of compression neuropathy of the upper extremities. Specificity and sensitivity of different methods of electromyography (EMG) in diagnostics of the disease, as well as in determining subclinical patterns of nerve involvement and indications for optimal treatment choice are demonstrated. EMG criteria of the CTS severity are provided. A protocol of EMG evaluation of patients suspected for CTS, based on most sensitive methods, is presented. The need of comprehensive electrophysiological evaluation of patients with median nerve lesions is shown, with special attention to exclusion of hereditary neuropathy. Problems of differential and false-positive diagnosis of CTS are considered.

Characteristic of Physical and Functional Variables by CTS Severity

Characteristic of Physical and Functional Variables by CTS Severity

Carpal tunnel syndrome: Ultrasound, neurophysiology, clinical and patient-oriented assessment

Objective The aim of this study is twofold. First, to assess the relationships between the cross-sectional area (CSA) of the median nerve (MN) calculated at ultrasound (US) and: (1) patient’s perception of his/her symptoms and hand function; (2) clinical severity of CTS; (3) neurophysiological classification; (4) hand distribution of symptoms. Second, to assess the sensitivity of ultrasonography (US) and neurophysiology in the diagnosis of CTS using clinical measures as gold standard. Methods We performed a prospective study by using multidimensional assessment: clinical (Historic and Objective scale, Hi–Ob), neurophysiological, patient-oriented measures (Boston Carpal Tunnel Questionnaire, BCTQ) and high-resolution US. The dominant hands of 54 consecutive patients who were referred to our neurophysiologic laboratory with clinical signs of CTS (43 females, mean age 53.3, range 30–80, SD: 13.1) were examined. Results A statistically significant correlation was found between the CSA of the MN at wrist and (1) hand function (according to BCTQ, r = 0.35, p = 0.01), (2) clinical scale (Hi–Ob scale, r = 0.51, p < 0.00007), (3) neurophysiologic classification ( r = 0.80, p < 0.0000001), and (4) hand distribution of symptoms ( p = 0.017). Neurophysiology showed higher sensitivity than US but in one of 3 cases with normal neurophysiological results, US showed data suggestive of CTS. Conclusions A positive correlation exists between US findings and all the conventional measures of CTS severity. The sensitivity of the combination of US and neurophysiology is higher than the sensitivity of neurophysiology or US alone. US is a useful complementary tool for CTS assessment. Significance Information on the contribution of US in CTS and the interpretation of severity measurements in CTS.

Abstracts of the 8th Meeting of the Italian Peripheral Nerve Study Group: 18

Pregnancy in one of the most frequent physiological conditions associated with CTS. During 2000, the Italian CTS study group (participants: T.Carboni‐San Benedetto del Tronto, S.Massi‐San Giovanni Valdarno; M.Mondelli‐Siena, A.Morini‐Trento, D.Murasecco‐Perugia, L.Padua‐Roma, M.Romano‐Palermo) studied the incidence of CTS in pregnancy in women enrolled in 7 Italian centers. CTS was diagnosed clinically in 62% and neurophysiologically in 43% of women. During 2001, 12 and 15 month follow‐up evaluation was performed. The aims were to evaluate: 1) evolution of CTS after delivery and lactation; 2) predictive value of electrodiagnostic assessment and clinical picture at the time of the first diagnosis. An extensive and complete description of the study design was previously reported. Evolution was assessed on the following CTS severity measurements: SYMPT, FUNCT, PAIN, Hi‐Ob and neurophysiologic class. Overall, at follow up, 20 of 37 women (54%) who presented clinical CTS at first evaluation had clinical CTS. All patient‐oriented measurements showed significant improvement of CTS. Conversely, neurophysiologic findings did not differ between baseline and follow‐up. Although CTS severity measurements improved at follow‐up, more than half of women with CTS symptoms during pregnancy complained of CTS symptoms one year after delivery. Moreover, the onset of symptoms during pregnancy was the most predictive factor for untreated CTS evolution. All patient‐oriented and clinical measurements showed that an earlier onset of symptoms was a negative prognostic factor. According to the neurophysiologic evolution, weight gain appeared predictive: an higher gain implied a lower probability of improvement at follow‐up examination.

Wrist and palm indexes in carpal tunnel syndrome.

According to median sensory latency >/= 3.7 ms (wrist-index finger [WIF], 14 cm), median/ulnar sensory latency difference to ring finger >/= 0.5 ms (14 cm) or median midpalm (8 cm) latency >/= 2.3 ms (all peak-measured), 141 Brazilian symptomatic patients (238 hands) have CTS confirmation. Wrist ratio (depth divided by width, WR) and a new wrist/palm ratio (wrist depth divided by the distance between distal wrist crease to the third digit metacarpophalangeal crease, WPR) were measured in all cases. Previous surgery/peripheral neuropathy were excluded; mean age 50.3 years; 90.8% female. Control subjects (486 hands) have mean age 43.0 years; 96.7% female. The mean WR in controls was 0.694 against 0.699, 0.703, 0.707 and 0.721 in CTS groups of progressive WIF severity. The mean WPR in controls was 0.374 against 0.376, 0.382, 0.387 and 0.403 in CTS groups of WIF progressive severity. Both were statistically significant for the last two groups (WIF > 4.4 ms, moderate, and, WIF unrecordable, severe). BMI increases togetherwith CTS severity and WR. It was concluded that both WR/WPR have a progressive correlation with the severity of CTS but with statistically significance only in groups moderate and severe. In these groups both WR and BMI have progressive increase and we believe that the latter could be a risk factor as important as important WR/WPR.