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Carpal Tunnel Syndrome

J. Hobby
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Carpal Tunnel Syndrome is a common condition with 37,745 carpal tunnel decompressions performed by the NHS in England in 2001.1 The prevalence of carpal tunnel syndrome in the general population has been studied in several countries, with reports ranging from 2.7 – 5.8%.2-6 There is evidence that the incidence of carpal tunnel syndrome is increasing.5,7,8

Carpal tunnel syndrome is approximately three times commoner in women than men.  The prevalence is greater in patients over 55 yrs of age, and the obese.2,9  Carpal tunnel syndrome is commoner in heavy manual workers and those that work with vibrating tools, but is unaffected by repetitive administrative tasks such as.typing.9-11 The incidence is increased in patients with Rheumatoid Arthritis, but population studies do not support a link with Diabetes or thyroid disease.2

There is considerable controversy as to the need for electrophysiology in carpal tunnel syndrome. Electrophysiology has been proposed as the standard of care for diagnosing carpal tunnel syndrome with a recommendation that it should be performed before surgery in all cases.12 This view has been supported by recent articles in the JAMA13 and the BMJ.14

However this position is not universally accepted, and many studies have questioned the need for nerve conduction studies.15-21 Median nerve conduction is abnormal in a proportion of asymptomatic individuals.4,22-24 It is also well recognised that there are patients with symptoms of carpal tunnel syndrome, but normal nerve conduction, who respond to surgery.16,18,19,25 Several authors have found that nerve conduction studies do not improve,16,19 or predict the clinical outcome of carpal tunnel surgery.19,26,27 However there is a correlation between electrophysiological recovery and pre-operative nerve conduction studies.27-29 Three studies, which have used response to surgery as the gold standard, have reported that the sensitivity and specificity of clinical assessment and neurophysiological examinations are similar.16,20,22

A fundamental problem is the lack of an accepted “gold standard” for the diagnosis of carpal tunnel syndrome.  Surveillance criteria have been proposed, pain or paraesthesia or numbness in the radial three digits of the hand combined with one or more of the following: a positive Tinel’s sign; nocturnal exacerbation of symptoms; wasting of APB; abnormal nerve conduction studies.30

Not all patients with carpal tunnel symptoms require treatment, but a recent study suggests that 0.7% of the Swedish population has carpal tunnel symptoms sufficiently severe to warrant intervention.31 Most patients will respond to a steroid injection, but the symptoms recur in at least 50%.32,33 Surgery is probably the most effective treatment for patients with severe or recurrent symptoms.32,34-36 There is some evidence that the outcome of carpal tunnel release is worse in patients who have experienced prolonged delays in diagnosis and treatment,34,37,38  although this finding has not been supported by more recent studies.39  The results of surgery are less predictable in the very elderly.40-42 There is little or no advantage to endoscopic techniques.43-44

 

References

 

1. Department of Health. Hospital episode statistics. http://www.dh.gov.uk

2. Atroshi I, Gummerson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA 1999;282:152–8.

3. de Krom MC, Knipschield PG, Kester ADM, Thijs CT, Boekkooi PF Spaans F (1992). Carpal tunnel syndrome: prevalence in the general population. J Clin Epidemiol 1992;45:373-6.

4. Ferry S, Pritchard T, Keenana J, Croft P, Silman A. Estimating the prevalence of delayed median nerve conduction in the general population. Br J Rheumatol  1998;37:630-5.

5. Nordstrom DL, De Stefano F, Vierkant RA, Layde PM. Incidence of diagnosed carpal tunnel syndrome in a general population. Epidemiology 1998;9:342–5.

6. Papanicolaou GD, McCabe SJ, Firrell J. The prevalence and characteristics of nerve compression symptoms in the general population. J Hand Surg 2001;26:460–6.

7. Stevens JC, Sun S, Beard CM, O’Fallon WM, Kurland LT. Carpal tunnel syndrome in Rochester, Minnesota, 1961 –1980. Neurology 1988;38:134–8.

8. Chung KC. Commentary: severe carpal tunnel syndrome. J Hand Surg [Am] 2003;28:645-6.

9. Lam N, Thurston A. Association of obesity, gender, age and occupation with carpal tunnel syndrome. Aust N Z J Surg  1998;68:190-3.

10. Atroshi I, Gummerson C, Ornstein E, Johnsson R, Ranstam. Carpal tunnel syndrome and keyboard use at work: a population based study. Arthritis Rheum 2007;56:620–5.

11. Nathan PA, Istvan JA, Meadows KD. A longitudinal study of predictors of research-defined carpal tunnel syndrome in industrial workers: findings at 17 years. J Hand Surg 2005;30; 593–8.

12. Jabelecki C, Andary M, So Y, Wilkins D, Williams F. AAEM Quality Assurance Committee: Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. Muscle Nerve 1993;16:1392-1414.

13. D’Arcy CA, McGee S. Does this patient have carpal tunnel syndrome? JAMA 2000;283: 3110-17.

14. Bland JDP. Carpal tunnel syndrome: clinical review. BMJ 2007;335:343-6.

15. Ebskov L, Boekstyns M, Sorensen AI. Operative treatment of carpal tunnel syndrome in Denmark; results of a postal questionnaire. J Hand Surg [Br] 1997;22:761-3.

16. Finsen V, Russwurm H. Neurophysiology not required before surgery for typical carpal tunnel syndrome. J Hand Surg [Br] 2001;26:61-4.

17. Smith N. Nerve conduction studies for carpal tunnel syndrome: essential prelude to surgery or expensive luxury? J Hand Surg [Br] 2002;27:83-5.

18. Grundberg A. Carpal tunnel decompresion in spite of normal electromyography. J Hand Surg [Am] 1983;8:348-9.

19. Glowacki K, Breen C, Sachar K, Weiss A. Electrodiagnostic testing and carpal tunnel outcome. J Hand Surg [Am] 1996;21:117-122.

20. Szabo R, Slater R, Farver T, Stanton D, Sharman W. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg [Am] 1999;24:704-14.

21. Kamath V, Stothard J. Clinical questionnaire for the diagnosis of carpal tunnel syndrome. J Hand Surg [Br] 2003;28:455-9.

22. Gunnarson LG, Amilon A, Hellstrand P, Leissner P, Phiipson L. The diagnosis of carpal tunnel syndrome. J Hand Surg [Br] 1997;22:34-7.

23. Kuntzer T. Carpal tunnel syndrome in 100 patients: sensitivity, specificity of multi-electrophysiological procedures and estimation of axonal loss of motor, sensory and sympathetic median nerve fibres. J Neurol Sci 1994;127:221-9.

24. Redmond M, Rivner M. False positive electrodiagnostic tests in carpal tunnel syndrome. Muscle Nerve 1988;11:511-17.

25. Louis D, Hankin F. Symptomatic relief following carpal tunnel decompression with normal electromyographic studies. Orthopaedics 1987;10:434-6.

26. Longstaff L, Milner R, O'Sullivan S, Fawcett P. Carpal tunnel syndrome: The correlation between outcome, symptoms and nerve conduction study findings. J Hand Surg [Br] 2001;26:475-80.

27. Mondeli M, Reale F, Sicurelli F, Padua L. Relationship between the Boston Questionnaire and electrophysiological findings in follow-up of surgically treated carpal tunnel syndrome. J Hand Surg [Br] 2000;25:128-134.

28. Padua L, le Monaco M, Padua R, Tamburelli F, Gregori B, Tonali P. Carpal tunnel syndrome neurophysiological results of surgery based upon preoperative electrophysiological testing. J Hand Surg [Br] 1997;22:599-601.

29. Bland JDP. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve 2001;24:935-40.

30. Harrington JM, Carter JT, Birrell L, Gompertz D. Surveillance case definitions for work related upper limb pain syndromes. Occup Environ Med 1998;55:264–71.

31. Atroshi I, Gummerson C, Johnsson R, McCabe SJ, Ornstein E. Severe carpal tunnel syndrome potentially needing surgery in a general population. J Hand Surg [Am] 2003;28:639-44.

32. Katz J, Keller R, Simmons B, et al. Maine carpal tunnel study: outcome of operative and non-operative therapy for carpal tunnel syndrome in a community based cohort. J Bone Joint Surg [Am] 1998;23-A:697-710.

33. Dammers J, Veering M, Vermuelen M. Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial. BMJ 1999;319:884-6.

34. DeStefano F, Nordstrom DL, Vierkant RA. Long-term symptom outcomes of carpal tunnel syndrome and its treatment. J Hand Surg [Am] 1997;22:200-10.

35. Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de Krom MC, Bouter LM.

Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA 2002;288:1245-51.

36. Wilgis EF. Treatment options for carpal tunnel syndrome. JAMA 2002;288:1281-2.

37. Kaplan SJ, Glickel SZ, Eaton RG. Predictive factors in the non-surgical treatment of carpal tunnel syndrome. J Hand Surg [Br] 1990;15:106-8.

38. Semple JC, Cargill AO. Carpal-tunnel syndrome: results of surgical decompression.

Lancet 1969;1:918-19.

39. Burke FD, Wiglis EFW, Dubin HD et al. Relationship between the duration and severity of symptoms and the outcome of carpal tunnel surgery. J Hand Surg [Am] 2003; 31:1478-82.

40. Porter P, Venkateswaran B, Stephenson H, Wray CC. The influence of age on outcome after operation for the carpal tunnel syndrome: a prospective study. J Bone  Joint Surg 2002;84B: 688-691.

41. Greenslade JR, Mehta RL, Belward P, Warwick DJ. DASH and Boston questionnaire assessment of carpal tunnel syndrome: what is the responsiveness of an outcome questionnaire? J Hand Surg, [Br] 2004;29:159-64.

42. Hobby JL, Venkatesh R, Motkur P. The impact of age and gender upon symptoms, self –reported disability and surgical outcomes in carpal tunnel syndrome. J Hand Surg [Br] 2005;30:599-604.

43. MacDermid JC, Richards RS, Roth JH, et al. Endoscopic versus open carpal tunnel release: a randomised trial. J Hand Surg [Am] 2003; 28:475-80.

44. Atroshi I, Larsson GU, Ornstein E et al. Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial. BMJ. 2006;332:1473.