Carpal Tunnel Relief

Pregnancy-Related Carpal Tunnel Syndrome

2011-03-15T22:10:00.000-07:00

A high rate of pregnancy-related CTS was highlighted in an article in the Canadian Medical Association Journal in 1983, vol 128, indicating that 25% of 1000 consecutive postpartum women experienced CTS during pregnancy; 3/4 of them that experienced this had bilateral symptoms. Half of the multigravidas had had similar symptoms in previous pregnancies.

Most recently attention to this gestational complication in an article by Padua et al in Muscle & Nerve, Nov 2010, pp 697-702 in a thorough patient and literature review. They discussed some of the literature specifically trying to address the incidence of CTS and performed a metanalysis. A big problem in assuming rather than confirming CTS with NCS was identified in most of the over 200 papers they reviewed. They felt that the natural history of pregnancy-related CTS (PRCTS) varies considerably and often fails to resolve after child delivery and lactation, but that only 1/3 of the cases would resolve after 1 year and up to 2/3 after 3 years.

This study coincides with the literature reflecting that about 1/6 adults ultimately will develop CTS about 90% of whom will come in for treatment-if ever-after age 30. All studies agree that the likelihood of a woman developing CTS is twice that of a man. This correlates well with congenital narrowness of the carpal tunnel confirmed in previous research by Dekel et al as reported in their article Idiopathic Carpal Tunnel Syndrome Caused by Carpal Tunnel Stenosis, in the British Medical Journal, May 1980, and other reports reflecting sthe strong familial likelihood of developing CTS. This correlates well with other studies on carpal tunnel size as well as elevated carpal tunnel pressure in people with CTS and elimination of the elevated pressure after carpal tunnel release. Quite likely, if followed past age 30 I suspect over 80% of the subjects with NCS proved CTS will go on to require surgery i.e., the increased fluid of pregnancy serves as a challenge in congenitally narrowed carpal tunnels while the remainder of the physiologic triggers evolve by age 30 or so.

Dorsal First Web Space Pain

2011-03-15T22:01:00.000-07:00

Ache experienced in the first dorsal web space of the hand, ie the area between the thumb and the index metacarpal, is not a common complaint. Once arthritis and ulnar nerve entrapment have been excluded the pain occurring in this area may be related to muscle activity resulting in elevated pressure in this muscle compartment. I am only aware of three references to dynamic first dorsal interosseous compartment syndrome in the literature. All three reports occurred within four years of one another in the Journal of Hand Surgery . The diagnosis can be made with intracompartmental pressure measurement as is done for other sites for compartment syndrome with a wick catheter or Stryker device. A. Lee Dellon reported the use of a stress test he used in one patient monitoring key pinch for weakening with repetitious pinching in association with development of first dorsal interosseus area pain. The pain resolved with surgical decompression and the pinch strength was regained, I have no personal experience in seeing anyone with this diagnosis, but as with other rare entities one must maintain an open mind when establishing a differential diagnosis.

2011-03-07T11:43:00.000-08:00

Another Blow to NC-Stat and Other Automated Hand-Held Nerve Conduction Devices

In the most recent study published by Schmidt et al in Muscle & Nerve 2011, Vol 43, the diagnostic accuracy of the NC-Stat system in 50 patients with unilateral leg symptoms and 25 asymptomatic control subjects was studied. The research was done in a rigorous manor by experienced evaluators at the EMG lab of the Mayo clinic. The tests were all performed by technicians blinded to the findings of a standard electrodiagnostic evaluation, which was also performed. The NC-Stat resulted in very low specificity, thus a high false positive rate, in both symptomatic patients and in normal controls with an overall specificity for the NC-Stat of only 0.32.

In the same issue of Muscle & Nerve, John England and Gary Franklin concluded that because of the extremely low sensitivity the NC-Stat cannot be recommended as a diagnostic test for patients with lower extremity complaints. They quoted Armstrong et al from the J. of Occupational & Environmental Medicine, 2008, in the study on median and ulnar nerve conduction studies at the wrist that "NC-Stat is not designed to replace traditional methods of NCS".

From my experience in evaluating the upper extremity and seeing patients come into the office who have had NC-Stat studies, I am underwhelmed with the lack of utility of this tool especially because there is no way to really proof the work that is being done and signed off by a computer in Massachusetts to which all the data is sent. The NC-Stat is very limited with regard to interpretation of ulnar nerve dysfunction with the findings limited to those that can be obtained at the wrist which, for the most part, is a moot point. Most people who have ulnar nerve entrapment at the wrist also have concomitant median nerve entrapment. Carpal tunnel release surgery decompresses both nerves simultaneously. However, entrapment of the ulnar nerve at the elbow occurring in about 1of 5 patients presenting with CTS goes undiagnosed. The NC-Stat relies on f-wave interpretation to suggest "further evaluation". This important diagnosis is hard to confirm even with conventional NCS with or without EMG. Clinical exam by a skilled physician is paramount.

Attention medical office biller: New NCS code

2010-01-13T10:16:00.000-08:00

Pre configured electrode "NCS" tests are at best a screening test for high volume HR situations with a revolving door high turnover situation. I have discussed the shortcomings of this testing methodology in the recent past. The new code to be used as of January 1, 2010 is 95905 to distinguish this type of simplified test from conventional, more thorough NCS. Further information can be found under Practice Issues a http://www.aanem.org/. According to the AANEM the Centers for Medicare & Medicaid services (CMS) has assigned a work RVU of 0.05 and a practice expense RVU of 2.04 and a malpractice RVU of 0.02. Thus depending upon practice locale these values will equate with Medicare reimbursement of about $70 per limb. I'm not sure what this will equate to in net terms.

2009-12-28T19:26:00.000-08:00

Anyone considering undergoing definitive carpal tunnel release surgery would be well advised to read the article: Touch Allodynia Following Endoscopic or Open Decompression for Carpal Tunnel Syndrome by Povlsen, Tegnell, Revell and Adolfsson published in The Journal of Hand Surgery, British 1997, volume 22B pp 325-327. They performed a prospective, scientific assessment of the amount of soreness present in direct relation to measured palmar pressure in patients undergoing open or endoscopic carpal tunnel release. This clear and concise study is usually overlooked by physicians when debating the optimal treatment. They showed significantly less sensitivity/ soreness in the patients treated endoscopically versus the open "filet of wrist" group of patients both early and late. At three months the endoscopic group was back to control level while the open release group was still significantly abnormal

Annotated Bibliography

2009-11-17T06:52:00.000-08:00

I have a huge reference list of good articles regarding all aspects of nerve entrapment, in particular carpal and cubital tunnel syndrome. If you are looking for a very specific topic, perhaps you can ask the question and I can give you the answer and provide some appropriate references for you. Previously I had so much on the internet it was burdensome.

Should ultrasound be the diagnostic test of choice or used interchangeably with nerve conduction studies in the diagnosis of CTS?

2009-10-26T08:47:00.001-07:00

Ultrasound has been a tool in search of business as far as I can discern. The only nerve in the body where the ultrasound has seemingly been useful for a diagnosis of entrapment is that of carpal tunnel syndrome. There have been a number of public articles in the medical journals in the past 10 years related to trying to define the potential benefit of ultrasound and the diagnosis of carpal tunnel syndrome and delineating the changes in median nerve size from pressure on the median nerve at the carpal tunnel and subsequent decrease in the size postoperatively. There is extreme patient bias exhibited in those that undergo surgery such as in the article by Smidt and Visser from the Netherlands published in Muscle and Nerve, August 2008, Volume 38, pages 97-101, wherein they were trying to determine the value of postoperative sonogram and the correlation between sonography and the clinical outcome after surgery. Though they initially started with a group of 172 patients, only 88 of them underwent surgery! Additionally, the mean time of symptoms of the patients prior to surgery was a year. Americans generally want results yesterday. They don’t want to wait forever for treatment and, as pointed out in my previous blog, early intervention tends to yield better results overall. Additionally, as Smidt and Visser point out with their limited study which is larger patient volume than the prior publications, “from the available data we conclude that sonography of the median nerve cannot be used to assess whether re-exploration of the carpal tunnel is needed in an individual patient with poor outcome after surgery”. It is particularly important because in their series there were a high percentage of unsatisfied patients. In fact, of the 79 patients that they operated on only 56%, i.e. 44, reported complete recovery or much improvement; 3% reported no change and 12% reported worsening of their symptoms, i.e. bad results in 15% and only excellent results in 56%. This compares unfavorably with the published results for ECTR and in my personal experience with over 5,000 procedures. Indirectly their article supports the application of endoscopic over open carpal tunnel release and early treatment rather than late. It certainly does not support the use of sonography in the evaluation of carpal tunnel patients given the overall inferior results that they had to offer in their patients treated.

Ad sonography to the same junk pile that the Neurometrix NC-Stat on-call belongs in, i.e. worthless.

Golf Cart Driving Injuries May Increase Your Handicap

2009-10-23T06:24:00.000-07:00

I have experienced poor driving behavior by my 16-year-old son with a golf cart- I was thrown out and the cart wheel hit my ankle. Another time we were mired in mud off the path. A four-year study from the University of Alabama at Birmingham indicated that about 1,000 Americans are hurt on golf carts every month with young men ages 10-19 and people over the age of 80 with the highest injury rate. In a report from the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio, it has been indicated that falling or jumping out of carts accounted for 38% of the injuries, the largest percentage. Half of the injuries occurred on golf courses and the rest occurred off of the golf course. The Ohio study has suggested a minimum driving age of 16 for golf carts with the rules banishing children under 6 from riding in them.

In addition to the dangers from falling out of a golf cart, golf cart over-turning or striking a tree, etc., youngsters gaining their driving wings on a golf cart may also pick up bad habits such as erratic driving, swerving, abrupt stopping and starting, that don’t translate into comfortable and safe driving of motor vehicles on the highway. I recommend encouraging youth who are allowed to operate a golf cart in your presence to drive carefully and not erratically such that the driving skills exhibited are comparable to those used for comfortable and safe driving in automobiles.

Golfers... Repair your rotator cuff!

2009-10-22T14:29:00.000-07:00

I frequently treat golfers having difficulty with shoulder pain. In my last blog I wrote about delay in treatment and how it affects the outcome using nerve entrapment syndromes as an example. Another clear-cut example in how a person may regain normalcy in a part of their body where there is an injury is that which was pointed out by Michael J. Vives, M.D., et al. from the Department of Orthopaedic Surgery at Jefferson Medical College of Thomas Jefferson University in Philadelphia as reported in Arthroscopy, volume 17, No. 2 to 172, in their article entitled “Repair of Rotator Cuff Tears in Golfers”. Of 30 golfers who underwent 32 rotator cuff repairs, the average age at surgery was 60 years with a range of 39 to 76 years. At average follow-up of 3 years ranging from 2-5 years, of the 27 patients who were still playing golf there was no significant difference in handicaps or drive distances compared to pre-symptomatic handicaps and drive distances. Three of the patients reported playing at a lower competitive level than before and, logically therefore, Vives et al. concluded that acromioplasty (trimming of the prominent bone in the shoulder) and rotator cuff repair predictably allow for eventual return to pain-free golfing at a similar competitive level for most recreational level athletes.

The hazard of delaying treatment with rotator cuff tears lies in the fact that if the tear is large enough the muscle may irreversibly retract, scar down a new position, and prevent eventual late repair and, in a small percentage of these individuals, they will have progressive degeneration in the shoulder joint leading to what is known as cuff tear arthropathy and generally poor outcomes even if possibly offered a reverse total shoulder or latissimus dorsi muscle transfer. That is not to say that all rotator cuff tears need to be repaired, but early physician involvement is important to prevent catastrophic result.

Are we ever really the same after an injury?

2009-10-21T08:40:00.000-07:00

The statement is often made by patients I see that “I know I’ll never be the same as I was before the injury”. This is usually not a correct assumption. Though there is not an absolute relationship between stage of disease and magnitude and quality of correction, early treatment in general yields the best results depending upon what is being treated. In the case of nerve injuries, we are predominantly treating nerve entrapment syndromes where pressure is applied to a nerve such as carpal tunnel syndrome, cubital tunnel syndrome, and tarsal tunnel syndrome. The majority of people who are treated end up with no residual complaints or impairment. The longer a person has pressure upon a nerve the greater the potential for nerve cell damage. A co-existing illness such as diabetes, alcoholism, and advanced age may affect both the delay in presentation to the doctor and the results of surgical treatment. Thus, it makes sense to offer definitive treatment earlier in the course of an ailment rather than waiting until the symptoms and physical findings become severe. Placebo treatment in the treatment of carpal tunnel syndrome such as wrist braces, vitamins, copper bands, crystals, liniment (“carpal tunnel cream”), and PT (exercise of the wrist), which have no proven long-term benefit, just prolong the duration of pressure on the nerve and the potential advancement of the disease. The magnitude of this problem cannot be highlighted better than in the case of cubital tunnel syndrome wherein the ulnar nerve is pinched in the retrocondylar groove or just beyond it as the nerve enters the flexor carpi ulnaris at the elbow- www.carpaltunnelrelief.net/cubital_tunnel.shtml. Early symptoms of tingling intermittently and perhaps some clumsiness progress into continuous numbness and weakness and ultimately there is measurable weakness, profound numbness, and muscle wasting (“claw hand deformity”). People with objectively verifiable weakness and profound abnormalities of sensibility often times do not get completely back to normal or take at least a couple of years to achieve that normalcy. Muscle wasting never regenerates in the case of ulnar nerve entrapment at the cubital tunnel. It is of paramount importance to establish the correct diagnosis early, thus we must encourage people to be seen early, we need to examine them thoroughly and outline the choices and recommendation based on the available science.

Suprascapular nerve entrapment- The newest cause of intractable shoulder pain

2009-10-20T07:05:00.000-07:00

The suprascapular nerve is extremely important to shoulder function. It comes off high in the brachial plexus and is felt to supply about 70% of the sensory input to the shoulder while innervating the majority of the rotator cuff. Thus, it is important both in pain perception as well as in providing the innervation to the muscle that stabilizes the shoulder. There is a tendency for it to be compressed in people performing vigorous frequent overhead sports such as weight lifters and volleyball players, but it also may affect the average individual. Most recently it has been noticed to be irritated in association with massive tears of the rotator cuff with retracted muscle. This was pointed out most poignantly by Costouros et al. of the Harvard Shoulder Service, Department of Orthopaedic Surgery, as published in Arthroscopy, Volume 23, No. 11, 2007, pages 152-1161. They noted that about 10% of their patients presenting with tears of the rotator cuff had massive tears. Patients had pain and marked weakness. Electrodiagnostic studies which are not normally performed on shoulder patients presenting with a rotator cuff tear were performed in their patients. Seven of these twenty-six patients, i.e. 38%, had suprascapular nerve dysfunction and interestingly, with repair of the rotator cuff, repeat electrodiagnostic studies performed after six months postoperatively revealed partial or full recovery of the suprascapular nerve palsy which correlated with complete pain relief and marked improvement in function. What needs to be determined thus is if simple decompression of the suprascapular nerve in these patients would suffice in giving the people pain relief particularly in those who are more intolerant of the prolonged immobilization of the shoulder and wherein it would be necessary to recuperate from the reconstruction of a massive rotator cuff tear. Certainly more research is needed in this repair.

Decompression of the suprascapular nerve when identified as the sole cause of a person’s shoulder pain is very rewarding, does not hurt much for the patient and, in the patients I have treated, allows them to return to work within a day or so of the operation.

Greater Risk of Pain and Dysfunction After Open Carpal Tunnel Release

2009-10-19T09:52:00.000-07:00

The article so entitled by Boya et al. published in Muscle and Nerve, November 2008, Volume 38, pages 1443-1446, pointed out the frequent postoperative problems after open carpal tunnel release such as persistent weakness, pillar pain (deep-seated ache or pain over the thenar or hypothenar region or both), and scar tenderness contribute greatly to patient dissatisfaction. In 50 patients in whom they performed open carpal tunnel release and given an average of 20 months of recovery time, 7% still had scar tenderness, 13% had pillar pain, and 18% had burning discomfort. Boya et al. attributed this to the surgical technique in treating the patient. These authors made a strong point in support of endoscopic carpal tunnel release and quoted Polysen et al, Journal of Hand Surgery British, 1997, Volume 22, pages 325-327, as reporting less pillar pain at the end of 3 months following endoscopic carpal tunnel release (ECTR). Younk et al. of Journal of Hand Surgery, 2005, Volume 10, pages 29-35, noted 9% of their patients still had pillar pain at 18 months and Bradley et al. as reported in Hand Surgery, 2003, Volume 8, pages 59-63, found persistent pain in 20% of hands 12 months after open carpal tunnel release. This is probably because the subcutaneous nerves that had been proven in careful dissection are probably injured in open carpal tunnel release but are completely avoided in using properly applied endoscopic technique.

I don’t feel that it is really fair to compare open carpal tunnel release with endoscopic carpal tunnel release because endoscopic carpal tunnel release patients do recover so much quicker and in general have such a good outcome in contrast to open carpal tunnel release patients. It is also important to note that the fear of the morbidity and side-effects from the open carpal tunnel technique tend to make patients procrastinate in getting to surgery until they are more likely to have poor outcomes anyway, thus implicating delay in treatment in some of the poor results. The least discomfort, more aesthically pleasing, and safer techniques that we can employ are at greater advantages for our patients. It is for this reason that I have been offering endoscopic carpal tunnel release for the past 18-1/2 years with an extremely high satisfaction, low-complication rate.