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carpal tunnel syndrome (median neuropathy)

Entrapment of the median nerve at the carpal tunnel (wrist). Etiology: 1) idiopathic 2) occupational - repetitive wrist & had movements - working with vibrating tools - prolonged wrist flexion & extension - sustained wrist pressure [23] 3) pregnancy 4) hypothyroidism 5) rheumatoid arthritis 6) injury (Colles fracture) 7) amyloidosis 8) acromegaly 9) multiple myeloma 10) T-cell lymphoma [17] 11) diabetes mellitus [8] 12) obesity Epidemiology: - 3% of U.S. population - more common in females [23] Pathology: - nerve impingement syndrome due to compression of the median nerve as it passes through the carpal tunnel - thickening from tendinitis or other swelling can narrow the carpal tunnel & causes the median nerve to be compressed Genetics: - associated with defects in transthyretin (type 1) Clinical manifestations: 1) pain & paresthesias, especially at night - often relieved by shaking affected wrist/hand [23] 2) wrist pain & numbness that worsens with repetitive activity 3) sensory abnormalities on palmar surface of radial 3 & 1/2 fingers (includes thumb) [4] 4) Tinel's sign (limited discrimination utility) [4] 5) Phalen's sign (limited discrimination utility) [4] 6) Durkan maneuver (64% sensitive, 83% specific) 7) pain may refer to the forearm or shoulder 8) thenar atrophy & muscle weakness occurs with more severe cases [13] Laboratory: 1) thyroid function tests 2) erythrocyte sedimentation rate 3) complete blood count 4) fasting serum glucose 5) serum protein electrophoresis, urine protein electrophoresis if multiple myeloma suspected Special laboratory: - EMG, nerve conduction study if surgery contemplated a) slowed impulse conduction in the median nerve b) include entire upper extremity in study c) more proximal nerve entrapment may produce similar symptoms d) active denervation is an indication for surgical decompression - ultrasound, neuromuscular - measurement of median nerve cross-sectional area [9] Radiology: - magnetic resonance imaging of unclear value [4] Differential diagnosis: 1) C6, C7 radiculopathy 2) tenosynovitis & osteoarthritis 3) polyneuropathy 4) proximal median nerve injury (at elbow) 5) brachial plexus lesion Complication: - increased risk of later amyloidosis (0.10% vs 0.006%) [20] - increased risk of later heart failure (5.3% vs 3.2%) [20] Management: 1) avoidance of repetitive motions - wrist splint that holds wrist straight or extended not greater than 15 degrees (at night) 2) occupational therapy [4] 3) anti-inflammatory agents a) prednisone 20 mg PO QD for 1 week, then 10 mg QD for 1 week b) NSAIDs as needed - ketoprofen phonophoresis gel [15] 4) glucocorticoid injection [5] a) more effective than oral glucocorticoid b) 0.25 mg of Kenalog (40 mg/mL) + 0.75 mL of 1% lidocaine c) injection into flexor retinaculum adjacent to median nerve or just proximal to the carpal tunnel [3] d) outcomes are better when carpal tunnel injection is performed under ultrasound guidance [16] e) relief of symptoms strongly supports diagnosis f) early improvement in symptoms, but most patients still opt for surgery [10] g) intermediate-term outcomes similar for glucorticoid injection vs slinting but glucorticoid injection resulted in fewer lost work days [19] h) ultrasound-guided perineural injection with D5W superior to glucocorticoid injection [18] 5) ice pack to the palm side of the wrist 6) splinting [19] 7) surgical decompression [5] - release of transverse carpal ligament [15] - prevent irreversible muscle weakness [4] - indications: - active denervation on nerve conduction studies - muscle weakness & muscle atrophy (thenar atrophy) [4] - intolerable pain [4] - not responsive to conservative measures [4] - useful for patients without denervation [7] - superior to medical management [21] 8) improve control of comorbidities - diabetes mellitus [4] 9) 50 mg of vitamin B6 BID may be of benefit 10) indications for follow-up a) severe pain not relieved by rest, ice, & anti-inflammatory agents b) hand grip becomes weak c) numbness persisting more than one month 11) prognosis a) thenar atrophy & weakness of pinch or opposition strength are late motor signs that may respond poorly to surgical or medical management b) better symptom relief with steroid injection than surgery in 1st few months; no difference at 6 months [5]

Related

carpal tunnel (carpal canal) tarsal tunnel syndrome (posterior tibial neuropathy)

General

entrapment neuropathy; nerve entrapment syndrome; pinched nerve median neuropathy repetitive strain disorder; repetitive motion disorder; cumulative trauma disorder; overuse syndrome

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 803-805, 1016-18
  2. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 872
  3. Journal Watch vol 19 #22, pg 177, Nov 15, 1999
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018.
  5. Journal Watch 25(6):52, 2005 Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005 Feb;52(2):612-9. PMID: 15692981
  6. Jarvik JG et al Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial The Lancet 2009, 374:1074-1081 PMID: 19782873 - Atroshi I and Gummesson C Non-surgical treatment in carpal tunnel syndrome The Lancet 2009, 74:1042-1044 PMID: 19782855
  7. Jarvik JG et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: A randomised parallel-group trial. Lancet 2009 Sep 26; 374:1074. PMID: 19782873
  8. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  9. Cartwright MS et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve 2012 Aug;46(2):287-93 PMID: 22806381
  10. Atroshi I et al Methylprednisolone Injections for the Carpal Tunnel Syndrome: A Randomized, Placebo-Controlled Trial. Ann Intern Med. 2013;159(5):309-317 PMID: 24026316 http://annals.org/article.aspx?articleid=1733275
  11. D'Arcy CA, McGee S. Clinical diagnosis of carpal tunnel syndrome JAMA. 2000 Oct 18;284(15):1924-5. No abstract available. PMID: 11035885 - D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA. 2000 Jun 21;283(23):3110-7. Review. PMID: 10865306
  12. Huisstede BM, Hoogvliet P, Randsdorp MS et al Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):981-1004. PMID: 20599038 - Huisstede BM, Randsdorp MS, Coert JH et al Carpal tunnel syndrome. Part II: effectiveness of surgical treatments--a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):1005-24 PMID: 20599039
  13. The NNT: Carpal Tunnel Syndrome http://www.thennt.com/lr/carpal-tunnel-syndrome/
  14. Alfonso C, Jann S, Massa R, Torreggiani A. Diagnosis, treatment and follow-up of the carpal tunnel syndrome: a review. Neurol Sci. 2010 Jun;31(3):243-52 PMID: 20145967
  15. Young K, Sofair A, Chavey WE Carpal Tunnel Syndrome Guidelines Published Physician's First Watch, March 4, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Guideline on the Treatment of Carpal Tunnel Syndrome American Association of Orthopedic Surgeons (AAOS) http://www.aaos.org/Research/guidelines/CTStreatmentguide.asp - Carpal tunnel syndrome appropriate use criteria American Academy of Orthopaedic Surgeons (AAOS) http://www.orthoguidelines.org/go/auc/default.cfm?auc_id=224989&actionxm=Terms
  16. Evers S, Bryan AJ, Sanders TL, Selles RW, Gelfman R, Amadio PC. Effectiveness of ultrasound-guided compared to blind steroid injections in the treatment of carpal tunnel syndrome. Arthritis Care Res (Hoboken) 2017 Jul; 69:1060 PMID: 27696773
  17. Chevalier X, Hermine O, Authier FJ, Gaulard P, Gherardi RK. Carpal tunnel syndrome due to T cell lymphoma. Arthritis Rheum. 1995 Nov;38(11):1707-9. PMID: 7488294
  18. Wu YT, Ke MJ, Li TY. Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol 2018 Sep 5 PMID: 30187524 https://onlinelibrary.wiley.com/doi/abs/10.1002/ana.25332
  19. Chesterton LS et al. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): An open-label, parallel group, randomised controlled trial. Lancet 2018 Oct 20; 392:1423. PMID: 30343858 Free PMC Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31572-1/fulltext
  20. Fosbol EL, Rorth R, Leicht BP et al Association of Carpal Tunnel Syndrome With Amyloidosis, Heart Failure, and Adverse Cardiovascular Outcomes. J Am Coll Cardiol. Volume 74, Issue 1, July 2019 PMID: 31272537 http://www.onlinejacc.org/content/74/1/15 - Ton VK, Patel S, Gottlieb SS Carpal Tunnel Syndrome and Future Amyloidosis. Time to Heed the Warning Sign. J Am Coll Cardiol. Volume 74, Issue 1, July 2019 PMID: 31272547 http://www.onlinejacc.org/content/74/1/24
  21. Blom AW, Donovan RL, Beswick AD et al. Common elective orthopaedic procedures and their clinical effectiveness: Umbrella review of level 1 evidence. BMJ 2021 Jul 7; 374:n1511 PMID: 34233885 PMCID: PMC8262448 Free PMC article https://www.bmj.com/content/374/bmj.n1511
  22. Currie KB, Tadisina KK, Mackinnon SE Common Hand Conditions. A Review. JAMA. 2022;327(24):2434-2445. June 28 PMID: 35762992 https://jamanetwork.com/journals/jama/fullarticle/2793654
  23. NEJM Knowledge+ Neurology
  24. NINDS Carpal Tunnel Syndrome Information Page https://www.ninds.nih.gov/disorders/all-disorders/carpal-tunnel-syndrome-information-page - Carpal Tunnel Syndrome Fact Sheet https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Carpal-Tunnel-Syndrome-Fact-Sheet

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OMIM 115430 images related to carpal tunnel syndrome