Subsequent bilateral acute carpal tunnel syndrome due to tophaceous infiltration:A case report

BACKGROUND Acute carpal tunnel syndrome(ACTS)is commonly caused by repetitive strain,trauma,or inflammatory conditions.However,ACTS due to tophaceous gout is a clinical event that remains poorly understood and underreported.This rare manifestation necessitates prompt diagnosis and intervention to prevent irreversible complications.CASE SUMMARY A 51-year-old man who had poorly controlled hyperuricemia presented with ACTS secondary to tophaceous gout.Because of rapid symptom progression symptoms and severe median nerve compression within 3 mo,the patient underwent emergency decompression surgery for both wrists at different time points.Postoperatively,he exhibited complete recovery of sensory and motor functions,with no recurrence at long-term follow-up.Favorable outcomes were achieved through immediate decompression surgery,anti-inflammatory medications,postoperative active and passive range-of-motion exercises,and intermittent wrist splinting.Prompt diagnosis and surgical intervention,when necessary,are crucial for preventing long-term complications and obtaining favorable outcomes in patients with ACTS.An optimal gout management strategy involving pharmacologic therapy and lifestyle modifications may help minimize ACTS recurrence and improve clinical outcomes.CONCLUSION Prompt surgical intervention and optimal gout management are crucial for preventing irreversible nerve damage and ACTS recurrence.

Bilateral carpal tunnel syndrome and motor dysfunction caused by gout and type 2 diabetes:A case report

BACKGROUND Carpal tunnel syndrome(CTS)has been associated with gout and type 2 diabetes mellitus(T2DM).However,due to insufficient clinical understanding of goutrelated CTS and reliance on the diagnostic importance of elevated serum uric acid levels,such cases are prone to missed diagnosis,misdiagnosis,and delayed treatment.In addition,the effect of T2DM on gout-induced carpal tunnel syndrome has not been reported.CASE SUMMARY Herein,we present an unusual case of CTS and motor dysfunction caused by miliary tophaceous gout and T2DM.The patient presented to the hand and foot clinic with paresthesia of the fingers of both hands,especially at night.The patient was diagnosed with type 2 diabetes a month ago.Ultrasonography revealed bilateral transverse carpal ligament thickening with median nerve compression during hospitalization.The patient was successfully treated with carpal tunnel decompression and tendon release.The postoperative pathological examination revealed typical gout nodules.This case suggests that the presence of T2DM could accelerate tophi formation and worsen CTS symptoms,although no definitive proof in this regard has been described previously.CONCLUSION Tophi formation may most likely cause the co-occurrence of CTS and flexor dysfunction in gout and incipient diabetes patients.

Effects of the Treatment of Carpal Tunnel Syndrome with Surgery and Injections on the Hospital Anxiety and Depression Scale (HADS)

Background: The prevalence of carpal tunnel syndrome (CTS) and of anxiety and depression in primary care practice are high. Different studies had shown an increased prevalence of anxiety and depression in CTS patients. Nevertheless, few papers had been published studying the anxiety and depression scales in the treatment of CTS, either with corticosteroid injections (I) or with surgical decompression (S). Objective: To assess whether clinical improvement observed after the treatment of CTS either with I or with S correlates with an improvement in the punctuations of the Hospital Anxiety and Depression scales (HADS), at 3, 6 and 12-month follow-up. Methods: Randomized and open-label clinical trial, comparing I and S. Patients with symptoms suggestive of CTS (nocturnal paraesthesias) of at least 3 months duration and neurophysiological confirmation were included. Patients with clinically apparent motor impairment were excluded. The subjective evaluation of symptoms was carried out using the visual-analogue scale of pain (VAS-p). Clinical reviews were performed 3, 6 and 12 months after treatment. Each patient completed the HADS questionnaire and a VAS-p at 0, 3, 6, and 12 months. Statistical significance was established using the Student’s t test and the Mann-Whitney U test when necessary. A linear regression analysis was used to know the effect of the treatment adjusted for the initial score of both scales. Results: 65 patients were included (30 in group I and 35 in group S). There was no statistical difference between both groups in terms of age, gender distribution, disease duration, VAS-p, neurophysiological testing severity of CTS or the 8 subscales of HADS. Both groups improved significantly in relation to the baseline VAS-p values, in the reviews at 3, 6 and 12 months, with no significant differences between I and S. At 6 months, the reduction in the anxiety scale was around 3 points for both treatments (S = 3.6 and I = 3.2), without reaching significant differences. At 12 months, it was somewhat higher for those treated with I, but always around 3 points and without significant differences. The Depression scale score was slightly reduced at 6 months, and in a similar way for both groups (I = 1 and S = 1.19;p = 0.8). After 12 months, group I doubled the previous reduction, with group S experiencing a very slight change (I = 1.96 and S = 1.03;p = 0.3). When analysing the effect of group S on group I, the result was a reduction of 0.25 points for Anxiety (p = 0.7) and of 0.02 points for Depression (p = 0.9). Conclusions: Treatment of CTS with I or S results in a similar and discrete improvement in Anxiety scores on the HADS scale at 6 and 12 months. For both types of treatment, the Depression scores barely changed at 6 months, being somewhat higher in group I after 12-month follow-up. The independent effect of the S on both scales is small and not significant.

Screening for Transthyretin Cardiac Amyloidosis in Patients with Bilateral Carpal Tunnel Syndrome: Identifying Missed Opportunities for Early Detection and Treatment

Purpose: Transthyretin cardiac amyloidosis (ATTR-CA) has been linked to many extra-cardiac manifestations including bilateral carpal tunnel syndrome (CTS). The aim of this study is to analyze patients with bilateral CTS to identify patients with high-risk features or “red flags” for ATTR-CA, identify if systematic screening was done for ATTR-CA and define opportunities for improved detection. Methods: Out of >5000 patients with bilateral CTS evaluated in a single tertiary care center in Southeast Michigan (2010-2016), we retrospectively studied a focused population of patients: men > 50 years and women > 60 years old with bilateral CTS and atrial fibrillation (n = 295). Baseline demographic, comorbidities, and electrocardiographic and echocardiographic findings were analyzed. A high-risk group suspicious for ATTR-CA was identified as patients with bilateral CTS, atrial fibrillation, and concomitant “red flags” including heart failure and left ventricular hypertrophy. Results: Out of 295 patients, 51.2% were female, 75.6% were White, and 22.4% were African American. Upon comparing the high-risk group (n = 67) with the remaining study population (n = 228), both diagnosis of ATTR-CA and mortality were higher among the high-risk group (7.5% vs 0.4% and 43.3% vs 24.6%, respectively, P = 0.003). Conclusions: A substantial number of bilateral CTS patients had additional “red flags” warranting formal evaluation for ATTR-CA;however, systematic evaluation for cardiac amyloidosis was not performed in many patients. This emphasizes that Multidisciplinary collaboration is needed to create a systematic workflow and to raise awareness amongst cardiologists and other physicians for suspecting ATTR-CA in bilateral CTS patients who have additional “red flags”.

Comparison of Histopathology of Transverse Carpal Ligament in Patients with Idiopathic Carpal Tunnel Syndrome and Hemodialysis Patients with Carpal Tunnel Syndrome

The aim of this paper is to point out the growing clinical importance of Carpal tunnel syndrome in patients on hemodialysis especially in aspect of the diagnosis, treatment and possible cause of the syndrome. Sixty patients with clinical diagnosis of Carpal Tunnel Syndrome was defined as the presence of two subjective symptoms (numbness, tingling in the median nerve distribution). The diagnosis was confirmed by electromyography. The patients with rheumatoid arthritis, thalasemia and thyroid dysfunction and the patients having pain due to arthritis or tenosynovitis were excluded. Fifty patients with clinical diagnosis of idiopathic CTS and seven hemodialysis patients having CTS were analyzed. Of 50 patients (47 female, 3 male) with clinical diagnosis of idiopathic CTS, 11 patients (22%) were involved bilaterally, 25 patients (50%) were affected only on the right and 14 patients (28%) were symptomatic only on the left. Of 7 hemodialysis patients (2 female, 5 male) with CTS, 1 patient (14%) was involved bilaterally (having two-sided A-V fistula), 4 patients (57%) were affected only on the right and 2 patients (28%) were symptomatic only on the left. There was significant correlation between the arteriovenous fistula and subsequent development of CTS. The all patients had fistulas in the affected side (5 of them were patent and 2 were occluded). In the relation between the duration of hemodialysis and development of CTS, 4 patients were over 10 years of hemodialysis, 2 patients were between 5 to 9 years and only 1 patient was below 4 years of duration. Amyloid deposit was demonstrated in 4 of 7 operated hands in the hemodialysis group. When we compared the presence of amyloid deposits in these groups, the difference between these two groups were found as statistically significant (p < 0.009). Although hemodialysis has no significant effect on development of fibrosis, the incidence of fibrosis was found as statistically significant in idiopathic carpal tunnel syndrome (p < 0.048). It is likely that there are numerous factors that may act either independently or in concert to potentiate the risk for developing CTS in patients on long-term hemodialysis.

Neural plasticity secondary to carpal tunnel syndrome: a pseudo-continuous arterial spin labeling study

Conventional neuroimaging techniques cannot truly reflect the change of regional cerebral blood flow in patients with carpal tunnel syndrome.Pseudo-continuous arterial spinning labeling(pCASL)as an efficient non-invasive neuroimaging technique can be applied to directly quantify the neuronal activities of individual brain regions that show the persistent symptoms owing to its better spatial resolution and increased signal-to-noise ratio.Therefore,this prospective observational study was conducted in 27 eligible female carpal tunnel syndrome,aged 57.7±6.51 years.Psychometric tests,nerve conduction studies and pCASL neuroimaging assessment were performed.The results showed that the relevant activated brain regions in the cortical,subcrotical,and cerebral regions were correlated with numbness,pain,functionality,median nerve status and motor amplitude of median nerve(K=21–2849,r=–0.77–0.76,P<0.05).There was a tendency of pain processing which shifted from the nociceptive circuitry to the emotional and cognitive one during the process of chronic pain caused by carpal tunnel syndrome.It suggests the necessity of addressing the ignored cognitive or emotional state when managing patients with carpal tunnel syndrome.Approval for this study was obtained from the Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West,China(HKU/HA HKW IRB,approval No.UW17-129)on April 11,2017.This study was registered in Clinical Trial Registry of The University of Hong Kong,China(registration number:HKUCTR-2220)on April 24,2017.

Combined Median Score Increasing Sensitivity of Carpal Tunnel Syndrome Diagnosis

Carpal tunnel syndrome (CTS) is the most common of all focal neuropathies. Electrodiagnostic (EXD) of CTS has advanced to include Combined Sensory Indexes (CSI) improving the specificity and sensitivity of EXD by employing intra-hand comparative data. Ultrasound (US) is a popular tool for the assessment of CTS. Cross Sectional Area (CSA) is the most consistent US parameter, but as a single test, it has a similar false negative profile to EXD. This study describes a dual method of CTS interrogation by EXD and US with the results applied to a single numerical score;the Combined Median Score (CMS). This is the product of CSA of median nerve at Carpal Tunnel inlet and CSI. In a series of 100 suspected cases, standard EDX identified 89 positive cases, CSI identified 92 positives, CMS identified 95 positives. This new method further reduced the false negative rate in CTS.

Exploring the Potential of a Questionnaire in Predicting Results of Nerve Conduction Studies in Patients with Suspected Carpal Tunnel Syndrome: Exploring a Clinician and Patient Complete Version

This evaluation of the Carpal Tunnel Questionnaire (CTQ) was designed to establish the validity and flexibility of its potential use both within a primary and secondary care setting. The questionnaire was originally designed to predict the positive and negative outcome of Nerve Conduction Studies (NCS) in those patients with suspected Carpal Tunnel Syndrome (CTS). Prior to being seen by the hand specialist patients who had been referred with suspected CTS where asked to complete the CTQ. These questionnaires were coded and filed by the clinic nurse. The hand specialist then completed the questionnaire with the patient preceding NCS. Questionnaires were scored subsequent to the appointment. Results for the hand specialist completed questionnaire showed an 80% specificity and 92% sensitivity regarding the ability of the CTQ to predict a positive NCS using a pre-determine cut-off score. The patient completed questionnaire showed a 70.67% specificity and 72% sensitivity. Using receiver operating characteristics a threshold score could be determined to achieve 100% sensitivity/specificity for both questionnaires. This questionnaire provides a useful addition in the assessment of patients with suspected carpal tunnel syndrome and could be used in a range of clinical settings although the scoring cut-off may need to be adapted depending on whether the questionnaire was completed by the clinician or patient. Using the questionnaire in a clinical setting would reduce the requirement for NCS by 60%, this would offer significant time and cost savings.

The Clinical Value of the Self-Administered Kamath and Stothard’s Questionnaire in the Diagnostics of Carpal Tunnel Syndrome

The clinician-administered Kamath and Stothard’s questionnaire is a recommended tool for assessing Carpal Tunnel Syndrome (CTS). The authors investigated whether the self-administered Kamath and Stothard’s questionnaire (KSQ) can categorize the severity of CTS according to the Nerve Conduction Study (NCS) and predict the outcome of Carpal Tunnel Release (CTR). One hundred and forty-two consecutive patients were enrolled in this prospective study, who completed the KSQ and were referred for NCS. Symptom relief after CTR was considered as the reference standard. KSQ’s scores were compared with the severity of CTS confirmed by NCS and the effectiveness of the surgery, Sensitivity and Positive Predictive Value (PPV) of the KSQ was calculated. The sensitivity of KSQ in each NCS severity category (mild, moderate, and severe CTS) was low (11.9% - 50.0%), however, the sensitivity and PPV of KSQ in the moderate + severe CTS category was 88.9% and 95.5%. The KSQ score of 5 or greater was found to be correlated with a successful CTR (sensitivity 92.8%, PPV of 90.2%). The study revealed that the KSQ with a score of 5 or greater is able to distinguish the mild conditions from moderate and severe ones. The KSQ’s score of 5 or greater also can predict the successful outcome of CTR. The authors believe that in addition to reducing the duration and cost of diagnostics, the KSQ can also reduce patient appointments and clinic time. Application of the KSQ may be of paramount importance in the current Covid pandemic era.

Carpel Tunnel Syndrome: A Link with Vitamin D, Body Mass Index and Hyperlipidemia

Introduction: Carbai tunnel syndrome [CTS] is compression of the median nerve at the wrist , this causes tingling in the hands, pain, numbness, tingling in the fingers particularly the thumb, index and middle fingers, loss of sensation in the hands and fingers, also weakness in the hands. The aim of the present study was to study a possible association which could be found between electrophysiological data in CTS, BMI, hyperlipidemia, and vitamin D [Vit D] levels. Methods: We used a sample of 40 females of the same age group, who were divided into Group 1 as a control consists of 18 healthy females and Group II consisted of 22 age matched females with clinical and electrophysiological evidence of CTS. We measured atherogenic index [AI] as a marker of hyperlipidemia, body mass index [BMI], Vit D status and electrophysiological tests of CTS. Results: Subjects with CTS had deficient Vit D status, they had significantly high atherogenic index (AI), and significant high BMI all compared to control Group I. Median sensory conduction velocity was significantly correlated negatively with BMI and atherogenic index, and positively correlated significantly with Vit D status. But median sensory and motor action potential latency were significantly correlated positively with BMI and atherogenic index, and negatively correlated significantly with Vit D status The analysis revealed BMI, atherogenic index and Vit D status as predictors of median nerve sensory and motor action potential latency and sensory nerve conduction velocity in CTS. Conclusion: The results of this study suggest that obesity and hyperlipidemia are potent CTS risk factors and declared the direct association between Vit D status and CTS occurrence. Our study supports the notion of the compensatory neuroprotective role of Vit D which could have a direct impact on the nerves integrity as it has an anti-inflammatory property which acts in relieving nervous insults and stress. .

Liverpool carpal tunnel scoring system to predict nerve conduction study results:A prospective correlation study

BACKGROUND Carpal tunnel syndrome(CTS)is one of the most common peripheral nerve compressive neuropathies.The clinical symptoms and physical examinations of CTS are widely recognised,however,there is still debate around what is the best approach for assessment of CTS.Clinical assessment is still considered the gold standard,however,controversies do exist regarding the need for investigations such nerve conduction studies(NCS)to aid with management decisions.AIM To correlate the severity of NCS results to a scoring system which included symptoms,signs and risk factors.METHODS This was a prospective correlation study.We scored patients’signs and symptoms using our CTS scoring system.This was then correlated with the findings of the NCS.The scoring system included-four symptoms(2 Katz hand diagrams–one for tingling and one for numbness;nocturnal paresthesia and bilateral symptoms)and four clinical signs(weak thumb abduction test;Tinel’s sign;Phalen sign and hypoalgesia in median nerve territory)and two risk factors(age more than 40 years and female sex).We classified the NCS results to normal,mild,moderate and severe.RESULTS There were 61 scores in 59 patients.The mean scores for the categories were as follows:6.75 for normal NCS;5.50 for mild NCS;9.17 for moderate NCS and 9 for severe NCS.All scores of 8 or more matched with NCS results of moderate and severe intensity apart from three scores which were greater than seven that had normal NCS.Eta score was 0.822 for the CTS score being the dependent value and the NCS category being the independent variable showing a strong association between the scoring system and the NCS group.CONCLUSION We feel that this simple scoring system can be used to predict and correlate the severity of NCS in patients with CTS.

Motor versus Sensory Nerve Conduction Monitoring of Median Nerve during Carpal Tunnel Surgery

Background/Aim: Carpal tunnel syndrome (CTS) is one of the most common compressive, canalicular neuropathies of the upper extremities, causing hand pain and impaired function. This clinical study was designed to compare the intraoperative median nerve distal motor latency (DML) versus the distal sensory latency (DSL) and sensory nerve conduction velocity (SNCV) during surgical treatment of CTS. Patients and Methods: A total number of 36 wrists in 30 patients with CTS diagnosed by preoperative median MNCS who underwent surgical intervention for median nerve release. Intraoperative measurements of motor distal latency (DML) and proximal latency, amplitude, and conduction velocity and distal sensory latency (DSL), amplitude, and conduction velocity of both the median and ulnar nerves before and after division of the flexor retinaculum (FR). Results: A significant decrease of the intraoperative median nerve distal motor latency (DML) after release (8.89 ± 0.93) in comparison with the preoperative median nerve DML (6.24 ± 1.06) with (p < 0.001*). But intraoperative distal sensory latency (DSL) and sensory nerve conduction velocity (SNCVM) show non-significant decrease (p = 0.161). Conclusion: Intraoperative monitoring of median nerve show rapidly improve Intraoperative motor nerve conduction than the sensory nerve conduction after release the FR during carpal tunnel surgery.

The Impact of Black Sea Sand Treatment Effectively Reducing Different Type of Pain

Purpose: Low back pain (LBP), Gonarthrosis, knee, and Carpal Tunnel Syndrome have been regarded as affecting more than three-quarters’ of individuals in their lifetime. The aim of this study was conducted to determine and compare the effects of topical patients with sand compared with control related to Gonarthrosis, LBP, knee, and Carpal Tunnel Syndrome pain. Methods: This is a prospective case and control designed study based on 101 pain case with Sand and 101 control subjects. The interventional groups in addition either topical sand or without sand 2 months after the intervention were assessed. We assessed tolerability of an established pain perception scale by the Numeric Rating Scale (NRS). Categorical variables were compared using the chi-square (χ2) test. The paired t-test was used to compare the two groups before and after the intervention. One-way analysis of variance (ANOVA) was employed for comparison of several group means. Results: The study was based on 202 patients, 41 males (20.3%) and 161 females (79.7%). There were statistically significant differences between subjects with and without Sand in term of Gonarthrosis, Rheumatoid Arthritis LBP, knee, and Carpal Tunnel Syndrome pain (p = 0.033). Majority of patients were over age 55 years old (55%) and females 78 (77.2%). The mean score of total pain experience before and after the intervention was 7.41 ± 1.1 for black sand, and 4.24 ± 2.38 for without sand as control group. The mean scores of these 5 groups were highly significant before and after the intervention (p There was statistically highly significant in regarding subjects with Sand as compared with those before Sand after treatment mean score specifically with gonarthrosis before pain 7.23 ± 1.86 vs after treatment 4.54 ± 2.18 p < 0.001;rheumatoid arthritis before 8.28 ± 1.48 vs after treatment 4.80 ± 3.71 p < 0.001;Low Back Pain before 8.42 ± 1.83 vs after treatment 4.37 ± 1.52 p < 0.001;knee pain before 8.93 ± 0.89 vs after treatment 4.24 ± 0.24 p < 0.001;Carpal Tunnel Syndrome before 7.664 ± 1.04 vs after treatment 4.26 ± 1.03 p Conclusion: The current study has revealed that the topical treatments with sand could have a significant effect on the perception of pain compared to those in the control group with respect of gonarthrosis, rheumatoid arthritis, LBP, knee, and Carpal Tunnel Syndrome pain .

Interest of Beta-2-Microglobilin Plasma Assay in Iterative Haemodialysis in the Nephrology and Haemodialysis Department of University Teaching Hospital of Point G, Bamako, Mali

Beta-2-microglobulin (B2M) is a low molecular weight polypeptide (11,800 Da) that exists in a free form and a form bound to cell membranes (light chains of HLA class I molecules). Their dosage is used in the exploration and monitoring of renal function in haemodialysis patients, hence the interest of this study, the objective of which is to study the different players involved in the increase of beta-2-microglobulin. Materials and Methods: This was a prospective and descriptive study from January 1st, 2017 to August 31, 2017 (08 months). All patients with chronic hemodialysis for 3 years or more were included. We analyzed sociodemographic, clinical and paraclinical data. Results: We collected 50 patients. The mean age was 50 ± 4.6 years with extremes of 30 and 82 years. The female sex predominated (52%). Chronic end-stage renal failure was hypertensive (86%), diabetic (4%). All patients benefited from intermittent hemodialysis for 8 hours per week using a low permeability membrane (cuprophane). The average duration of hemodialysis was 68 ± 6.4 months with extremes of 36 and 204 months. Twenty percent (20%) and four percent (4%) of chronic dialysis patients had joint pain and sensory deficit. Phalen’s sign was positive in 2% (1 case), Tinel’s sign in 2% (1 case) and carpal tunnel syndrome in 2% (1 case). The mean serum beta-2-microglobulin level was 58.34 ng/l with extremes of 16.99 and 112.24 ng/l. There was a correlation between hypertensive nephropathies and beta-2-microglobulin levels above 50 ng/l (P < 0.001). The mortality rate was 6%. Conclusion: Our study has objectified factors such as inadequate dialysis (8 hours/week), use of low permeability membrane in the increase of beta-2-microglobulin. The increase in serum beta-2-microglobulin levels in our patients is evidence of poor purification of medium molecules. Its reduction can be established by improving the quality of dialysis, in particular by using a high-permeability membrane.