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.

Carpal Tunnel Syndrome: A Marker for Amyloidosis

Introduction: Amyloidosis are systemic conditions and carpal tunnel syndrome (CTS) precedes the principal systemic complications and can be used as an early marker. Our objective was to determine the frequency of amyloid deposition in idiopathic CTS and its systemic impact. Methods: We retrospectively evaluated patients with CTS between September 2019 to January 2020. Samples from the anterior carpal ligament were pathologically evaluated and amyloid deposition was confirmed by apple-green birefringence on polarized light using Congo red stain. When amyloid was detected we performed genetic testing for transthyretin variants (ATTRv), immunofixation electrophoresis in serum and urine for light chains and multidisciplinary evaluation. Results: Thirty consecutive patients were included, 19 women, 11 men, mean age 70 years old (range 42 - 89 years). We identified 3 patients (10%) with amyloid deposits (mean age: 78.6 years, 2 men, 1 woman). Genetic testing for ATTRv and light chains studies were negative. During follow-up: The first patient required aortic valve replacement. The second patient developed progressive cardiac failure with syncopal episodes, atrioventricular block and atrial fibrillation and required a pacemaker and anticoagulation. The third patient had unexplained chronic edemas. The cardiac evaluation in all 3 patients revealed left ventricular hypertrophy and myocardial uptake (Perugini Score > 2) in their nuclear bone scintigraphies with technetium pyrophosphate. Two patients were treated with tafamidis and one patient died due to refractory cardiac insufficiency. Discussion: Our findings underline the importance of investigating amyloidosis in idiopathic CTS. The identification of deposits allows early diagnosis of cardiac amyloidosis leading to timely intervention and treatment.

Update on surgical procedures for carpal tunnel syndrome:What is the current evidence and practice?What are the future research directions?

Carpal tunnel syndrome(CTS)is a multifactorial compression neuropathy.It is reported to be very common and rising globally.CTS’s treatment varies from conservative measures to surgical treatments.Surgery has shown to be an effective method for more severe cases.However few unclear aspects and room for further research and improvements still remains.We performed a narrative literature review on the most up to date progress and innovation in terms of surgical treatments for CTS.The simple algorithm of leaving the choice of the surgical method to surgeons’preference and experience(together with consideration of patients’related factors)seem to be the best available option,which is supported by the most recent metanalysis and systematic reviews.We suggest that surgeons(unless in presence of precise indications towards endoscopic release)should tend to perform a minimally invasive open approach release,favoring the advantage of a better neurovascular structures visualization(and a consequent higher chance to perform a complete release with long term relief of symptoms)instead of favoring an early reduction(in the first postoperative days)of immobilization and pain.Research towards a universally accepted standardization should be aimed for by the researchers,who have failed to date to sufficiently limit bias and limitations.

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”.

Evaluation of Intraoperative Iatrogenic Lesions and Postoperative Complications in 1140 Patients Treated for Carpal Tunnel Syndrome in the Orthopedic Surgery and Traumatology Department of the Moulins-Yzeure Hospital Center in France

Introduction: Carpal tunnel syndrome is a more common form of upper limb canal syndrome, resulting from compression of the median nerve in the carpal tunnel, but is particularly troublesome. Medical treatment is often unsuccessful, and surgical treatment usually involves transection of the annular ligament. The aim of this study was to assess iatrogenic intraoperative and postoperative complications, as well as patient outcomes following the use of conventional and endoscopic surgery in the surgical management of carpal tunnel syndrome. Hypothesis: Are nerve, vascular and tendon injuries of iatrogenic origin always present in the surgical management of carpal tunnel syndrome, even though this surgery is performed on an outpatient basis? Patients and methods: This retrospective series is composed of 1140 patients, 230 men and 910 women, mean age 58.6 ± 16.4 years, operated on between 2010 and 2020 for carpal tunnel syndrome by conventional surgery and under endoscopy. Medical records, operative reports and consultation letters were consulted. All patients were reviewed regularly at one month post-op until recovery. Results: No nerve, vascular or tendon damage was noted, and at a maximum follow-up of 2 years, 20 patients had recurred, i.e. a 2.51% failure rate. Scar disunion was observed in 0.9%, wound infection in 0.9% and scar fibrosis in 0.9%. 92.98% of patients underwent outpatient surgery, irrespective of the type of anesthesia or surgical technique used. Patients who stayed in hospital for a short time were suffering from carpal tunnel syndrome associated with compression of the ulnar nerve in Guyon’s canal, for which both the median and ulnar nerves were freed during the same operation, under general anaesthetic. All patients were able to return to their previous activity within 30 days of surgery. Conclusion: Intraoperative iatrogenic complications, notably nerve, vascular and tendon lesions, were not identified despite the large sample size. On the other hand, postoperative skin complications related to scarring, such as wound disunion, fibrosis and recurrence, were present despite low rates.

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.

A handy review of carpal tunnel syndrome:From anatomy to diagnosis and treatment

Carpal tunnel syndrome(CTS) is the most commonly diagnosed disabling condition of the upper extremities. It is the most commonly known and prevalent type of peripheral entrapment neuropathy that accounts for about 90% of all entrapment neuropathies. This review aims to provide an outline of CTS by considering anat-omy, pathophysiology, clinical manifestation, diagnostic modalities and management of this common condition, with an emphasis on the diagnostic imaging evaluation.

Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome

Both in vitro and in vivo experiments have confirmed that platelet-rich plasma has therapeutic effects on many neuropathies, but its effects on carpal tunnel syndrome remain poorly understood. We aimed to investigate whether single injection of platelet-rich plasma can improve the clinical symptoms of carpal tunnel syndrome. Fourteen patients presenting with median nerve injury who had suffered from mild carpal tunnel syndrome for over 3 months were included in this study. Under ultrasound guidance, 1-2 m L of platelet-rich plasma was injected into the region around the median nerve at the proximal edge of the carpal tunnel. At 1 month after single injection of platelet-rich plasma, Visual Analogue Scale results showed that pain almost disappeared in eight patients and it was obviously alleviated in three patients. Simultaneously, the disabilities of the arm, shoulder and hand questionnaire showed that upper limb function was obviously improved. In addition, no ultrasonographic manifestation of the carpal tunnel syndrome was found in five patients during ultrasonographic measurement of the width of the median nerve. During 3-month follow-up, the pain was not greatly alleviated in three patients. These findings show very encouraging mid-term outcomes regarding use of platelet-rich plasma for the treatment of carpal tunnel syndrome.

Does the ratio of the carpal tunnel inlet and outlet cross-sectional areas in the median nerve reflect carpal tunnel syndrome severity?

Although ultrasound measurements have been used in previous studies on carpal tunnel syndrome to visualize injury to the median nerve, whether such ultrasound data can indicate the severity of carpal tunnel syndrome remains controversial. The cross-sectional areas of the median nerve at the tunnel inlet and outlet can show swelling and compression of the nerve at the carpal. We hypothesized that the ratio of the cross-sectional areas of the median nerve at the carpal tunnel inlet to outlet accurately reflects the severity of carpal tunnel syndrome. To test this, high-resolution ultrasound with a linear array transducer at 5–17 MHz was used to assess 77 patients with carpal tunnel syndrome. The results showed that the cut-off point for the inlet-to-outlet ratio was 1.14. Significant differences in the inlet-to-outlet ratio were found among patients with mild, moderate, and severe carpal tunnel syndrome. The cut-off point in the ratio of cross-sectional areas of the median nerve was 1.29 between mild and more severe（moderate and severe） carpal tunnel syndrome patients with 64.7% sensitivity and 72.7% specificity. The cut-off point in the ratio of cross-sectional areas of the median nerve was 1.52 between the moderate and severe carpal tunnel syndrome patients with 80.0% sensitivity and 64.7% specificity. These results suggest that the inlet-to-outlet ratio reflected the severity of carpal tunnel syndrome.

PROSPECTIVE COMPARISON OF ENDOSCOPIC AND OPEN SURGICAL METHODS FOR CARPAL TUNNEL SYNDROME

Objective To compare outcomes of patients undergoing either open or endoscopic carpal tunnel release for the treatment of idiopathic carpal tunnel syndrome. Methods A prospective, randomized study was performed on 70 hands in 62 patients with idiopathic carpal tunnel syndrome from April 2000 to April 2004. Either open (36 hands in 30 patients) or endoscopic (34 hands in 32 patients) carpal tunnel release was performed randomly. Symptom improvement, complications, and the time of operation, in-hospital stay, and return to work between the two groups were assessed with average 2 years of follow-up. The electromyography was tested pre- and 3 months post-operation. Results There were no significant differences between the two surgical groups with regard to postoperative improvements of symptom, electromyography tests, and the incidence of complications. But it was statistically less in the rate of scar tenderness, the time of operation, in-hospital stay, and return to work in the endoscopic group compared with the open group (P<0.05). Conclusions The endoscopic carpal tunnel release is a reliable method in the treatment of idiopathic carpal tunnel syndrome. And it has the advantages of slight scar tenderness, less operation time, less in-hospital stay, early functional recovery, safety, and high satisfaction rate compared with open methods.

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.

Axonal degeneration of the ulnar nerve secondary to carpal tunnel syndrome: fact or fiction?

The distribution of sensory symptoms in carpal tunnel syndrome is strongly dependent on the degree of electrophysiological dysfunction of the median nerve. The association between carpal tunnel syndrome and ulnar nerve entrapment is still unclear. In this study, we measured ulnar nerve function in 82 patients with carpal tunnel syndrome. The patients were divided into group I with minimal carpal tunnel syndrome （n = 35） and group II with mild to moderate carpal tunnel syndrome （n = 47） according to electrophysiological data. Sixty-one age- and sex-matched subjects without carpal tunnel syndrome were used as a control group. There were no significant differences in ulnar sensory nerve peak latencies or conduction velocities from the 4th and 5th fingers between patients with carpal tunnel syndrome and the control group. The ulnar sensory nerve action potential amplitudes from the 4th and 5th fingers were lower in patients with carpal tunnel syndrome than in the control group. The ratios of the ulnar sensory nerve action potential amplitudes from the 4th and 5th fingers were almost the same in patients with carpal tunnel syndrome as in the control group. These findings indicate that in patients with minimal to moderate carpal tunnel syndrome, there is some electrophysiological evidence of traction on the adjacent ulnar nerve fibers. The findings do not indicate axonal degeneration of the ulnar nerve.

Exploratory use of ultrasound to determine whether demyelination following carpal tunnel syndrome co-exists with axonal degeneration

Carpal tunnel syndrome （CTS） accompanied by secondary axonal degeneration cannot be clearly dis- criminated using the current cross-validated ultrasound severity classification system. This study aimed at exploring cut-off values of ultrasound parameters, including wrist cross-sectional area （W-CSA）, wrist perimeter （W-P）, ratio of cross-sectional area （R-CSA） and perimeter （R-P）, changes of CSA and P from wrist to one third distal forearm （△CSA＆AP） for differentiation. Seventy-three patients （13 male and 60 female） were assigned into group A （demyelination only, n = 40） and group B （demyelination with secondary axonal degeneration, n = 33） based on the outcomes of nerve conduction studies （NCS）. Receiver Operative Characteristics （ROC） curves were plotted to obtain sensitivity, specificity, and accuracy of cut- off values for all the ultrasound parameters. The overall identified cut-off values （W-CSA 12.0 mm2, W-P 16.27 mm, R-CSA 1.85, R-P 1.48, △CSA 6.98 mm2, △P 5.77 mm） had good sensitivity （77.1-88.6%）, fair specificity （40-62.2%） and fair-to-good accuracy （0.676-0.758）. There were also significant differences in demographics （age and severity gradation, P 〈 0.001）, NCS findings （wrist motor latency and conduction velocity, P 〈 0.0001; wrist motor amplitude, P 〈 0.05; distal sensory latency, P 〈 0.05; sensory amplitude, P 〈 0.001） and ultrasound measurements （W-CSA, W-P, R-CSA, R-P, △CSA＆△P, P 〈 0.05） between groups. These findings suggest that ultrasound can be potentially used to differentiate demyelinating CTS with sec- ondary axonal degeneration and provide better treatment guidance.

Clinical characteristics,neurophysiological grade and outcome of patients with carpal tunnel syndrome A retrospective study

BACKGROUND： Carpal tunnel syndrome （CTS） is diagnosed mainly according to clinical symptoms, physical sign and neurodiagnostic laboratory examination. The therapeutic effect of conservative management and surgical operation in treating CTS need to be further observed and evaluated. OBJECTIVE： To analyze the clinical characteristics, neurophysiological grade and outcome in patients with CTS. DESIGN： Retrospective case-analysis. SETTING： Department of Neurology, First Affiliated Hospital, Medical College, Xi＇an Jiaotong University. PARTICIPANTS： Totally 161 patients with suspected CTS from National Neuroscience Institute of Singapore referred to the Neurodiagnostic Laboratory for the confirmatory testing between January and September 2002. The involved patients, 137 male and 24 female, were aged 21 - 85 years. METHODS： ①The condition of diabetes mellitus complicated by abnormal thyroid function was observed.② The effect on predominant hand, and paraesthesia were observed. ③Neuroelectrophysiological studies were performed and the results were graded into mild, moderate and severe CTS according to the American Association of Electrodiagnostic Medicine （AAEM） criteria.④ Conservative management and surgical intervention were followed up 3 months later, and symptoms and physical sign basically disappeared, and function was basically recovered, which indicated that disease condition improved. MAIN OUTCOME MEASURES： ①Condition of CTS complicated by metabolic disease; ②Effects on predominant hand and paraesthesia; ③Electrophysiological grading; ④Prognosis. RESULTS： Totally 161 patients participated in the final analysis. ①Condition of CTS complicated by metabolic disease： Among 161 patients, 17.4% （28/161） were documented to have diabetes mellitus and 7（4.3%） had hypothyroidism. ②Effects on predominant hand and paraesthesia： Dominant hand involvement was present in 134 patients （83.2%） and more than 75% had onset of symptoms in the dominant hand. Sensory symptoms like numbness and paresthesias were the predominant symptoms, accounting for 89.1% （134/161）, this discomfort was felt in all 5 digits of the hand in 47.6%, and lateral three and half digits in 21.4%. The noctural symptoms were present in 30.4% （49/161） patients. ③Electrophysiological typing： The most frequent abnormality was that of the prolonged mid-palm median and ulnar latency difference in 146（54.7%） hands; 103（38.6%） hands had prolonged median motor distal latency. Absent response from thenar muscle was present in 35 （13.1%） hands. Nerve conduction study showed bilateral CTS in 105 （65.2%） patients and unilateral CTS in 56 （34.8%） patients. Sixteen patients with bilateral CTS had symptoms in one hand only. Overall, 36.8% had mild, 49.2 % had moderate and 13.9 % had severe CTS, with median duration of symptoms of 6, 9 and 14 months, respectively. ④Delay in diagnosis： 37（22.9%） patients delayed in diagnosis from 1-4 months, 16（43.2%） were misdiagnosed as cervical spondylosis; 6（16.2%） were ignored due to their condition by busy work; 15（40.5%） were unware of their symptoms. ⑤Prognosis： Follow up data was available for only 72.7% （117/161） patients. Conservative management was conducted in 73.5% （86/117）. Clinical symptoms were resolved or improved in 65.1% （56/86） patients with 17 mild CTS, 29 moderate CTS, and 10 severe CTS. 26.5% （31/117） patients underwent surgery for CTS release, and clinical symptoms were improved in 12（38.7%） with moderate CTS and 2 （6.5%） with severe CTS at 3 months of follow up. CONCLUSION： ①Sensory symptoms in CTS are more in severe and common in dominant hand. ②Conservative management showed resolution or improvement for mild and moderate CTS. Surgical intervention shows either resolution or improvement in clinical symptoms in moderate CTS. ③The common reasons for delay in diagnosis were due to misdiagnosis as cervical spondylosis and lack of awareness of the condition.④Assessment on severity of CTS by electrophysiological grade is of important significance for determining therapeutic mean.

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.

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.