Hidrodisección guiada por ultrasonido para el tratamiento de pacientes con sindrome del tunel carpiano / Ultrasound-Guided hydrodissection for treatment of Patients with Carpal Tunnel Syndrome

El estudio tuvo como objetivo comparar el grupo de hidrodisección de solución salina normal guiada por ultrasonido más esteroides y el grupo de hidrodisección de solución salina normal guiada por ultrasonido sola en pacientes con síndrome del túnel carpiano (STC), y determinar su relevancia clínica en relación con los resultados del tratamiento. Realizamos 60 hidrodisecciones guiadas por ecografía con solución salina normal con y sin inyecciones de corticosteroides en 51 pacientes con STC y evaluamos los resultados de la ecografía antes y después de la inyección. Clasificamos estas inyecciones en dos grupos según la solución salina normal más corticosteroide (grupo de esteroides). solución salina normal (grupo de control) y también registramos datos clínicos que incluían el sexo, la edad, el lado de la inyección, el peso corporal y la duración de las molestias relacionadas con el STC antes de la inyección. Los resultados se midieron mediante la escala analógica visual que se asignó para evaluar el resultado primario. Los resultados secundarios se evaluaron mediante el cuestionario del síndrome del túnel carpiano de Boston, el área transversal del nervio mediano y estudios electrofisiológicos. La evaluación se realizó antes de la inyección y 1, 3 y 6 meses después de la inyección, y se comparó el alivio de los síntomas para los pacientes que recibieron la inyección de solución salina normal y de esteroides. Comparamos las hidrodisecciones con la solución salina normal y las inyecciones de corticosteroides. Los datos clínicos, las puntuaciones de CSA-MN antes de la inyección en la entrada del túnel carpiano y las puntuaciones de BCTQ antes de la inyección no mostraron diferencias significativas entre los grupos (p> 0,05). Todos los pacientes (datos de 30 muñecas en cada grupo) completaron el estudio. En comparación con el grupo de control, en todos los momentos posteriores a la inyección, ambos grupos tuvieron una reducción significativa del dolor y la discapacidad, una mejora en las medidas de respuesta electrofisiológica y una disminución del área transversal del nervio mediano. Nuestro estudio revela que la solución salina normal guiada por ecografía con y sin hidrodisección de corticosteroides tiene un efecto terapéutico en los pacientes con STC. Se demostró que la hidrodisección nerviosa es potencialmente beneficiosa para los pacientes con STC antes de la cirugía. La hidrodisección es un procedimiento simple y mínimamente invasivo que se puede realizar utilizando únicamente NS. Además, en comparación con la inyección a ciegas, la hidrodisección bajo guía ecográfica puede reducir las posibilidades de lesión nerviosa

The study aimed to compare Ultrasound-Guided Normal saline plus steroid hydrodissection group and Ultrasound-Guided normal saline alone hydrodissection group in patients with carpal tunnel syndrome (CTS), and to determine their clinical relevance in relation to treatment outcomes. We performed 60 US-guided hydrodissections Normal saline with and without corticosteroid injections in 51 patients with CTS and evaluated their pre- and post-injection US findings. We categorized these injections into two groups based on the normal saline plus corticosteroid (steroid group). normal saline (control group) and we also recorded clinical data including gender, age, side of injection, BW, and the duration of preinjection CTS related discomfort. The outcomes were measured using the visual analog scale was assigned to assess the primary outcome. The secondary outcomes were assessed using the Boston Carpal Tunnel Syndrome Questionnaire, cross-sectional area of the median nerve, and electrophysiological studies. The assessment was performed prior to injection, and 1-, 3-, and 6-months' post-injection, and the symptom relief for the patients receiving normal saline and steroid injection were compared. We compared hydrodissections with normal saline and corticosteroid injections The clinical data, pre injection CSA-MN at the inlet of the carpal tunnel, and pre-injection BCTQ scores showed no significant intergroup differences (p > 0.05). All patients (data from 30 wrists in each group) completed the study. Compared both the control group, at all post-injection time points, both groups had a significant reduction in pain and disability, improvement on electrophysiological response measures, and decreased cross-sectional area of the median nerve. Our study reveals that ultrasound-guided Normal saline with and without corticosteroid hydrodissection has therapeutic effect in patients CTS. Nerve hydrodissection was shown to be potentially beneficial for CTS patients' pre-surgery. Hydrodissection is a simple, minimally invasive procedure that can be performed using only NS. In addition, compared to blind injection, hydrodissection under ultrasound guidance can lower the chances of nerve injury

Hidrodisección guiada por ultrasonido para el tratamiento de pacientes con sindrome del tunel carpiano / Ultrasound-Guided hydrodissection for treatment of Patients with Carpal Tunnel Syndrome

El estudio tuvo como objetivo comparar el grupo de hidrodisección de solución salina normal guiada por ultrasonido más esteroides y el grupo de hidrodisección de solución salina normal guiada por ultrasonido sola en pacientes con síndrome del túnel carpiano (STC), y determinar su relevancia clínica en relación con los resultados del tratamiento. Realizamos 60 hidrodisecciones guiadas por ecografía con solución salina normal con y sin inyecciones de corticosteroides en 51 pacientes con STC y evaluamos los resultados de la ecografía antes y después 21. Evers S, Thoreson AR, Smith J, Zhao C, Geske JR, Amadio PC. Ultrasound-guided hydrodissection decreases gliding resistance of the median nerve within the carpal tunnel. Muscle Nerve 2017 June 16. doi: 10.1002/mus.25723. 22. Smith J, Wisniewski S, J, Finnoff JT, Payne JM. Sonographically Guided Carpal Tunnel Injections. J Ultrasound Med 2008;27:1485-1490. 23. Trescott AME. Peripheral Nerve Entrapments: Clinical Diagnosis and Management. Switzerland: Springer International Publishing; 2016 24. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2002(4). 25. Atroshi I, Flondell M, Hofer M, Ranstam J. Methyprednisolone Injections for the Carpal Tunnel Syndrome: A randomized Placebo-Controlled Trial. Ann Int Med 2013;159:309-317. 26. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC family practice 2010;11:54. 27. Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Tsai CK, et al. Six-month efficacy of perineural dextrose for carpal tunnel syndrome: A prospective, randomized, double-blind, controlledtrial. Mayo Clinic proceedings 2017;92:1179-1189. 28. Kirwan J. Is there a place for intra-articular hyaluronate in osteoarthritis of the knee? The Knee 2001;8:93-101. 29. Saltzman BM, Leroux T, Meyer MA, Basques BA, Chahal J, Bach BR, Jr., et al. The therapeutic effect of intra-articular normal saline injections for knee osteoarthritis: Ameta-analysis of evidence level 1 studies. The American journal of sports medicine 2017;45:2647-2653. 30. Padua L, Padua R, Aprile I, Pasqualetti P, Tonali P. Multiperspective follow-up of untreated carpal tunnel syndrome: a multicenter study. Neurology. 2001;56(11):1459­ 66 31. Ortiz-Corredor F, Enriquez F, Diaz-Ruiz J, Calambas N. Natural evolution of carpal tunnel syndrome in untreated patients. Clinical neurophysiology: official journal of the International Federation of Clinical Neurophysiology 2008;119:1373-1378 32. Gordon T, Brushart TM, Chan KM. Augmenting nerve regeneration with electrical stimulation. Neurol Res 2008; 30:1012- 1022. 33. Aulisa L, Tamburrelli F, Padua R, Romanini E, Lo Monaco M, Padua L. Carpal tunnel syndrome: Indication for surgical treatment based on electrophysiologic study. J Hand Surg Am 1998; 23:687-691. 34. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom- de Jong B. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC Fam Pract. 2010;11:54. 35. Girlanda P, Dattola R, Venuto C, Mangiapane R, Nicolosi C, Messina C. Local steroid treatment in idiopathic carpal tunnel syndrome: short- and longterm efficacy. J Neurol. 1993; 240(3):187- 190. 36. Karadas¸ Ö, Tok F, Ulas¸ UH, Odabas¸i Z. The effectiveness of triamcinolone acetonide vs. procaine hydrochloride injection in the management of carpal tunnel syndrome: a double blind randomized clinical trial. Am J Phys Med Rehabil. 2011; 90(4):287-292. 128 LA PRENSA MÉDICA ARGENTINA Ultrasound-Guided hydrodissection for treatment of Patients with Carpal Tunnel Syndrome V.107/Nº 2 de la inyección. Clasificamos estas inyecciones en dos grupos según la solución salina normal más corticosteroide (grupo de esteroides). solución salina normal (grupo de control) y también registramos datos clínicos que incluyen el sexo, la edad, el lado de la inyección, el peso corporal y la duración de las molestias relacionadas con el STC antes de la inyección. Los resultados se midieron mediante la escala analógica visual que se asignó para evaluar el resultado primario. Los resultados secundarios se evaluaron mediante el cuestionario del síndrome del túnel carpiano de Boston, el área transversal del nervio mediano y estudios electrofisiológicos. La evaluación se realizó antes de la inyección y 1, 3 y 6 meses después de la inyección, y se comparó el alivio de los síntomas de los pacientes que recibieron la inyección de solución salina normal y de esteroides. Comparamos las hidrodisecciones con la solución salina normal y las inyecciones de corticosteroides; los datos clínicos, la preinyección de CSA-MN en la entrada del túnel carpiano y las puntuaciones de BCTQ antes de la inyección no mostraron diferencias significativas entre los grupos (p> 0,05). Todos los pacientes (datos de 30 muñecas en cada grupo) completaron el estudio. En comparación con el grupo de control, en todos los momentos posteriores a la inyección, ambos grupos tuvieron una reducción significativa del dolor y la discapacidad, una mejoría en las medidas de respuesta electrofisiológica y una disminución del área transversal del nervio mediano. Nuestro estudio revela que la solución salina normal guiada por ecografía con y sin hidrodisección de corticosteroides tiene un efecto terapéutico en los pacientes con STC. Se demostró que la hidrodisección nerviosa es potencialmente beneficiosa para los pacientes con STC antes de la cirugía. La hidrodisección es un procedimiento simple y mínimamente invasivo que se puede realizar utilizando únicamente NS. Además, en comparación con la inyección a ciegas, la hidrodisección bajo guía ecográfica puede reducir las posibilidades de lesión nerviosa.

The study aimed to compare Ultrasound-Guided Normal saline plus steroid hydrodissection group and Ultrasound-Guided normal saline alone hydrodissection group in patients with carpal tunnel syndrome (CTS), and to determine their clinical relevance in relation to treatment outcomes. We performed 60 US-guided hydrodissections Normal saline with and without corticosteroid injections in 51 patients with CTS and evaluated their pre- and post-injection US findings. We categorized these injections into two groups based on the normal saline plus corticosteroid (steroid group). normal saline (control group) and we also recorded clinical data including gender, age, side of injection, BW, and the duration of pre-injection CTS related discomfort. The outcomes were measured using the visual analog scale was assigned to assess the primary outcome. The secondary outcomes were assessed using the Boston Carpal Tunnel Syndrome Questionnaire, cross-sectional area of the median nerve, and electrophysiological studies. The assessment was performed prior to injection, and 1, 3, and 6 months' post-injection, and the symptom relief for the patients receiving normal saline and steroid injection were compared. We compared hydrodissections with normal saline and corticosteroid injections the clinical data, pre injection CSA-MN at the inlet of the carpal tunnel, and pre-injection BCTQ scores showed no significant intergroup differences (p > 0.05). All patients (data from 30 wrists in each group) completed the study. Compared both the control group, at all post-injection time points, both groups had a significant reduction in pain and disability, improvement on electrophysiological response measures, and decreased cross-sectional area of the median nerve. Our study reveals that ultrasound-guided Normal saline with and without corticosteroid hydrodissection has therapeutic effect in patients CTS. Nerve hydrodissection was shown to be potentially beneficial for CTS patients' pre-surgery. Hydrodissection is a simple, minimally invasive procedure that can be performed using only NS. In addition, compared to blind injection, hydrodissection under ultrasound guidance can lower the chances of nerve injury.

Yoga para o tratamento de dor crônica e aguda em adultos e idosos: qual a eficácia/efetividade e a segurança do yoga para tratamento da dor aguda ou crônica em população adulta? / Yoga for the treatment of chronic and acute pain in adults and the elderly: what is the efficacy/effectiveness and safety of yoga for the treatment of acute or chronic pain in an adult population?

O yoga caracteriza-se como uma prática integrativa de origem oriental que combina posições corporais, técnicas de respiração, meditação e relaxamento. É indicada no tratamento de sistemas musculoesquelético, endócrino, respiratório, além de outros agravos à saúde, e estimula as funções cognitivas. Qual a eficácia/efetividade e a segurança do yoga para tratamento da dor aguda ou crônica em população adulta? As buscas foram realizadas nas bases de dados Pubmed, HSE-Health Systems Evidence, Epistemonikos, Portal Regional da BVS, HE-Health Evidence e Embase, em 27 de setembro de2019. Foram incluídas revisões sistemáticas (RS), com ou sem metanálises, publicadas em inglês, espanhol e português, e que que avaliavam o yoga no tratamento de dor crônica e aguda na população adulta e/ou idosa. Não houve restrição em relação ao ano de publicação. As estratégias de busca foram utilizadas com base na combinação de palavras-chave estruturadas a partir do acrônimo PICOS, usando os termos MeSH no Pubmed e DeCS na BVS, adaptando-os ao HSE, Epistemonikos, HE e Embase. A qualidade metodológica das revisões sistemáticas selecionadas foi avaliada segundo a ferramenta Assessing the Methodological Quality of Systematic Reviews(AMSTAR 2). De 693 artigos identificados, dez revisões sistemáticas foram selecionadas, oito delas com meta-análises. Com relação à qualidade metodológica, três revisões foram consideradas de qualidade moderada, duas de baixa qualidade e cinco de qualidade criticamente baixa. Na lombalgia crônica, a prática de yoga, quando comparada a atividades passivas, cuidado habitual, educação, atendimento médico padrão, controle de atenção, lista de espera, sem exercícios físicos, mostrou ser eficaz na diminuição da dor em curto, médio e longo prazos. Os resultados são mais consistentes com relação aos efeitos em curto e médio prazos. Na comparação de yoga com exercícios físicos as evidências resultam de poucos estudos e são controversas, mostrando benefício em curto e médio prazos no controle de lombalgia ou diferenças estatisticamente não significantes. Yoga, em comparação a intervenções passivas, sem exercícios físicos, mostrou ser benéfico também para melhorar quadros de incapacidade específica relacionada à lombalgia, em curto, médio e longo prazos. Além disso, houve melhora clínica dos casos de lombalgia a favor de yoga em curto e médio prazos. Na dor cervical crônica, as revisões mostraram evidências de efeitos benéficos de yoga para redução da dor quando comparado a cuidados habituais ou exercícios, entretanto não houve diferença com pilates ou medicina complementar e alternativa Da mesma forma, yoga mostrou-se superior a cuidados habituais e exercícios na redução da incapacidade relacionada dor cervical. A qualidade de vida e o humor melhoraram com yoga em relação a cuidados habituais. Yoga parece trazer benefícios também para pessoas com quadros de dor relacionados a osteoartrite e artrite reumatoide, fibromialgia, síndromes do túnel do carpo e do intestino irritável. No entanto, os resultados são menos consistentes. Com relação à segurança da prática de yoga, as evidências mostraram eventos adversos em geral sem gravidade. E quando comparado a exercícios não houve diferença no relato de eventos adversos. As revisões sistemáticas apresentaram resultados favoráveis à prática de yoga em relação aos cuidados habituais, particularmente nos casos de dor lombar e cervical. Há menos evidências acerca da superioridade do yoga em comparação a intervenções ativas. Em outras situações estudadas, como a dor associada a fibromialgia, osteoartrite, artrite reumatoide, síndromes do túnel do carpo e do intestino irritável, as evidências são menos consistentes. É importante ressaltar que as revisões sistemáticas incluídas nesta revisão rápida foram consideradas de baixa confiança na avaliação com a ferramenta AMSTAR 2. Além disso, os resultados têm como base estudos primários com amostras pequenas, com heterogeneidade na aplicação das intervenções, e considerável risco de viés. Isso remete à necessidade de se realizar ensaios clínicos, bem como revisões sistemáticas, com melhor qualidade metodológica

Double Crush Syndrome of the Median Nerve: A Literature Review

Double crush syndrome (DCS) is defined as the compressive involvement of the same peripheral nerve in different segments.When this syndrome affects the median nerve, a proximal compression of a spinal nerve that will constitute this structure (often the spinal nerve at the C6 vertebra) is usually noted at the cervical spine level as a herniated disc and as a distal compression at the level of the carpal tunnel. Epidemiological data on median nerve compromise by DCS are still very scarce in the medical literature. The diagnosis can be inferred by symptoms and signs occurring proximally and distally in the arm, as well as by alterations revealed by upper limb electromyography and neuroimaging studies, such as magnetic resonance imaging (MRI) of the cervical spine. Nowadays, information on which compressed neuroanatomical point should be initially addressed still depends on further studies. Limited data infer that these patients, when submitted to surgical treatment in only one of the median nerve compression points, evolve with worse functional outcomes than the surgically-treated group with carpal tunnel syndrome without DCS.

Síndrome do túnel do carpo associada à amiloidose / Carpal tunnel syndrome associated with amyloidosis

Introdução: A amiloidose é caracterizada pela deposição de proteínas nos órgãos e tecidos, e tem sido associada à síndrome do túnel do carpo (STC) quando ocorre no punho. O objetivo é descrever uma série de casos de pacientes submetidos à cirurgia para STC associado à amiloidose. Métodos: O estudo incluiu 12 pacientes que se submeteram à cirurgia para tratar a STC cuja biópsia identificou amiloidose; o seguimento foi de cinco anos. Os pacientes foram avaliados por testes clínicos, eletroneuromiografia, imagens radiológicas e biópsia. Resultados: Todos os pacientes apresentaram queixas musculoesqueléticas, sintomas severos de compressão do nervo mediano, alterações nos testes neurofisiológicos. Realizou-se a cirurgia, sinovectomia e biópsia. No pós-operatório, cinco pacientes (41%) desenvolveram dor crônica e distrofia simpático-reflexa. Conclusão: Observou-se maior frequência de dor pós-operatória na amostra, o que revela a necessidade de atenção na abordagem e tratamento dessa associação.

Introduction: Amyloidosis features protein deposition in the organs and tissues and has been associated with carpal tunnel syndrome (CTS) when it occurs in the wrist. The objective is to describe a case series of patients undergoing surgery for CTS associated with amyloidosis. Methods: The study included 12 patients who underwent surgery to treat CTS in whom amyloidosis was proven by biopsy; the follow-up period was 5 years. The patients were evaluated by clinical tests, electroneuromyography, radiological images, and biopsy. Results: All patients presented with musculoskeletal complaints, severe symptoms of median nerve compression, and changes on neurophysiological tests. Surgery, synovectomy, and biopsy were performed. In the postoperative period, five patients (41%) developed chronic pain and reflex sympathetic dystrophy. Conclusion: A higher frequency of postoperative pain was observed in the patients, demonstrating the need for caution in the approach and treatment of this association.

Conservative therapeutic management of carpal tunnel syndrome / Manejo terapêutico conservador da síndrome do túnel do carpo

ABSTRACT Carpal tunnel syndrome is the most prevalent nerve compression and can be clinically or surgically treated. In most cases, the first therapeutic alternative is conservative treatment but there is still much controversy regarding the most effective modality of this treatment. In this study, we critically evaluated the options of conservative treatment for carpal tunnel syndrome, aiming to guide the reader through the conventional options used in this therapy.

RESUMO A síndrome do túnel do carpo é a compressão de nervo mais prevalente e seu tratamento pode ser clínico ou cirúrgico. Na maioria dos casos o tratamento conservador é a primeira alternativa terapêutica mas ainda há muitas controvérsias a respeito do tratamento mais eficaz. Neste estudo avaliamos de forma crítica as opções de tratamento conservador da síndrome do túnel do carpo, objetivando guiar o leitor no uso racional deste tipo de terapêutica.

Tratamiento quirúrgico del síndrome de túnel del carpo en adultos mayores / Surgical treatment of carpal tunnel syndrome in older adults / Traitement chirurgical du syndrome du canal carpien chez les personnes âgées

INTRODUCCIÓN: el síndrome del túnel del carpo constituye el diagnóstico más común para cirujanos de mano. Se han descrito diversos métodos quirúrgicos para su tratamiento, con reportes de buenos resultados. OBJETIVO: mostrar los resultados del tratamiento quirúrgico del síndrome del túnel del carpo, con empleo de anestesia local, incisión razonable y movilidad precoz en pacientes mayores de 65 años de edad. MÉTODO: estudio de intervención longitudinal prospectivo con pacientes mayores de 65 años de edad diagnosticados e intervenidos por síndrome del túnel del carpo entre el 1ro. de enero 2010 y el 1ro. de julio del 2014, y evaluados 1 año después de dicho tratamiento en el CITED. RESULTADOS: serie constituida por 194 pacientes, predominó el sexo femenino (81,44 %), se encontró asociación de síndrome del túnel del carpo con: realización de actividades manuales previas, posibilidad de afectación bilateral, antecedente de fractura de radio distal ipsilateral, comorbilidad con otras enfermedades como diabetes, artritis reumatoide y afecciones de tendones y sus vainas. La mejoría en síntomas, dolor y función al año fue superior al 98 %. CONCLUSIONES: el tratamiento quirúrgico del síndrome del túnel del carpo, con empleo de anestesia local, incisión de piel razonable y movilidad precoz, ocasiona significativa mejoría de los síntomas, del dolor y la función en adultos mayores de 65 años de edad.

INTRODUCTION: Carpal tunnel syndrome is the most common diagnosis for hand surgeons. They described various surgical methods for treatment, with reports of good results. OBJECTIVE: Show the results of surgical treatment of carpal tunnel syndrome using local anesthesia, reasonable incision and early mobility in patients older than 65 years old. METHOD: Prospective longitudinal intervention study with patients older than 65 years of age diagnosed and surgically treated for carpal tunnel syndrome from January 2010 to July 2014 and they were evaluated one year after treatment at CITED. RESULTS: In the series consisting of 194 patients, women predominated (81.44%). Association of carpal tunnel syndrome was found with holding prior manual activities, the possibility of bilateral involvement, history of fracture of ipsilateral distal radius, comorbidity with other diseases such as diabetes, rheumatoid arthritis and diseases of tendons. The improvement of symptoms, pain and function after a year was higher than 98%. CONCLUSIONS: Surgical treatment of carpal tunnel syndrome using local anesthesia, reasonable skin incision and early mobility causes significant improvement in symptoms, pain and function in adults older than 65 years old.

INTRODUCTION: Le syndrome du canal carpien est le diagnostic le plus souvent trouvé par les chirurgiens spécialisés en main. Plusieurs techniques chirurgicales ont été décrites pour son traitement, avec de très bons résultats. OBJECTIFS: Ce travail a le but de montrer les résultats du traitement chirurgical du syndrome du canal carpien à l'aide de l'anesthésie locale, d'une incision raisonnable et d'une mobilité précoce chez les patients âgés de plus de 65 ans. MÉTHODE: Une étude interventionnelle, longitudinale et prospective de patients âgés de plus de 65 ans, diagnostiqués et traités pour syndrome de canal carpien entre le 1er janvier 2010 et le 1er juillet 2014, et évalués un an après, a été effectuée au CITED. RÉSULTATS: Dans une série de 194 patients, où le sexe féminin était en majorité (81,44 %), on a trouvé que le syndrome du canal carpien était associé aux activités manuelles, à un possible trouble bilatéral, à une histoire de fractures du radius distal ipsilatéral, et à une comorbidité avec d'autres maladies telles que le diabète, l'arthrite rhumatoïde et les atteintes des tendons et leurs gaines. Les symptômes, la douleur et la fonction ont amélioré un an après l'opération dans 98 % de cas. CONCLUSIONS: En utilisant de l'anesthésie locale, une incision raisonnable et une mobilité précoce, le traitement chirurgical du syndrome du canal carpien entraîne une significative amélioration des symptômes, de la douleur et de la fonction chez les personnes âgées de plus de 65 ans.

Schwannoma como etiologia de síndrome do túnel do carpo ­ relato de caso / Schwannoma as a Cause of Carpal Tunnel Syndrome ­ a Case Report

A síndrome do túnel do carpo (STC) é uma condição clínica resultante da compressão do nervo mediano no túnel do carpo. É a neuropatia de maior incidência no membro superior e apresenta diferentes etiologias, entre elas o distúrbio osteomuscular relacionado ao trabalho (DORT) e, mais raramente, a tumores de nervo periférico. O DORT é a etiologiamais comum da STC e vemaumentando sua incidência por causa de sua associação com o trabalho. Eentre os tumores que envolvem o nervo mediano está o schwannoma, ou neurilemoma, que também é o tumor benigno mais comum de nervos periféricos. Este relato almeja descrever um caso de schwannoma como etiologia da STC.

The carpal tunnel syndrome (CTS) is a clinical condition resulting from compression of the median nerve in the carpal tunnel. It is the neuropathy of higher incidence in the upper limb and as different etiologies, is related to work-related musculoskeletal disorders (WMSDs) and rarely tumors of peripheral nerve. The WMSDs are the most common, and its incidence is increasing more andmore due to the intimate association with type of work. Among the tumors involving median nerve is the Schwannoma, or neurilemoma. The Schwannoma is the most common benign tumor of the peripheral nerve. This report aims to describe a case of schwannoma as a cause of CTS.

Síndrome de túnel carpiano en el embarazo: revisión de literatura y presentación de un caso clínico / Carpal tunnel syndrome in the pregnancy: literature review and presentation of a clinical case

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy in the general population. In pregnant women the prevalence increases to 31-62 percent probably by edema secondary to the hormonal changes of pregnancy. The definitive treatment is surgical decompression, but in pregnant reserves only in exceptional cases where other treatments have failed. This population receives mainly conservative therapy consisting of splints, physical therapy and infiltration. Objective: To review the management of CTS in pregnant about a case. Methods: The clinical case of a pregnant patient with CTS managed conservatively was revised, based on this existing literature was reviewed. Results: 32 years old woman, studying 18 weeks pregnancy, consultation by paresthesia and loss of strength of both hands since1.5 months, more than right. Physical examination was consistent with bilateral CTS. Use of night splint is indicated. The electrodiagnostic evaluation reporting neuropathic sensitive-motor commitment severe intensity, subacute bilateral median nerve, with moderate denervation. Patient with symptoms persist, it is decided to perform infiltration of carpal tunnel steroid with good clinical and electrophysiological response. Conclusions: This case exemplifies the conservative treatment of CTS in pregnancy delivered good results. The literature supports the use of splints and steroid injections in this population...

Carpal tunnel syndrome - Part II (treatment)

The treatments for non-deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini-open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long-term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2–0.5%...

Os tratamentos nas formas não déficitárias da síndrome do túnel do carpo (SCC) são a infiltração de corticoide e/ou uma órtese de imobilização noturna. O tratamento cirúrgico, que compreende a secção do retináculo dos flexores (retinaculotomia), é indicado em caso de resistência ao tratamento conservador nas formas déficitárias ou, mais frequentemente, nas formas agudas. Nas técnicas minimamente invasivas (endoscópica e miniopen), indepen-dentemente de a curva de aprendizado ser mais longa, parece que a recuperação funcional é mais precoce em relação à cirurgia clássica, mas com os resultados em longo prazo idênticos. A escolha depende do cirurgião, do paciente, da gravidade, da etiologia e da disponibili-dade do material. Os resultados são próximos de 90% de casos satisfatórios. A recuperação da força necessita de quatro a seis meses após a regressão das dores do tipo dor do pilar (pillar pain). Essa cirurgia tem a reputação de ser benigna e apresenta de 0,2% a 0,5% de complicações...

Effects of placebo-controlled continuous and pulsed ultrasound treatments on carpal tunnel syndrome: a randomized trial

OBJECTIVE: The aim of this placebo-controlled study was to evaluate the effects of pulsed and continuous ultrasound treatments combined with splint therapy on patients with mild and moderate idiopathic carpal tunnel syndrome. METHODS: The study included 46 carpal tunnel syndrome patients who were randomly divided into 3 groups. The first group (n = 15) received a 0 W/cm2 ultrasound treatment (placebo); the second group (n = 16) received a 1.0 W/cm2 continuous ultrasound treatment and the third group (n = 15) received a 1.0 W/cm2 1:4 pulsed ultrasound treatment 5 days a week for a total of 15 sessions. All patients also wore night splints during treatment period. Pre-treatment and post-treatment Visual Analogue Scale, Symptom Severity Scale and Functional Status Scale scores, median nerve motor conduction velocity and distal latency and sensory conduction velocities of the median nerve in the 2nd finger and palm were compared. Clinicaltrials.gov: NCT02054247. RESULTS: There were significant improvements in all groups in terms of the post-treatment Functional Status Scale score (p<0.05 for all groups), Symptom Severity Scale score (first group: p<0.05, second group: p<0.01, third group: p<0.001) and Visual Analogue Scale score (first and third groups: p<0.01, second group: p<0.001). Sensory conduction velocities improved in the second and third groups (p<0.01). Distal latency in the 2nd finger showed improvement only in the third group (p<0.01) and action potential latency in the palm improved only in the second group (p<0.05). CONCLUSION: The results of this study suggest that splinting therapy combined with placebo and pulsed or continuous ultrasound have similar effects on clinical improvement. Patients treated with continuous and pulsed ultrasound showed electrophysiological improvement; however, the results were not superior to those of the placebo. .

Valoración clínica y neurofisiológica del tratamiento rehabilitador en pacientes con síndrome del túnel carpiano / Clinical and neurophysiological evaluation of the rehabilitation treatment in patients with carpal tunnel syndrome

Se realizó un ensayo clinicoterapéutico, multicéntrico, de fase III, en 42 pacientes con síndrome del túnel carpiano, atendidos en los servicios de rehabilitación integral de los policlínicos 30 de Noviembre y Josué País García de Santiago de Cuba, desde junio de 2009 hasta igual mes de 2010, para evaluar la efectividad del tratamiento rehabilitador. Los integrantes de la casuística fueron asignados aleatoriamente a 2 grupos: los que recibieron laserterapia (grupo de estudio) y los tratados con terapia medicamentosa y postural (grupo control). Se aplicó la prueba de Ji al cuadrado (p<0,05) y se utilizó el porcentaje como medida de resumen. En la serie predominaron el sexo femenino y el grupo etario de 50-59 años. Luego del proceder aplicado se logró la analgesia en 33,3 por ciento de los afectados. En el primer grupo hubo variación electrofisiológica hacia el patrón neurógeno crónico (47,0 por ciento), con mejoría del grado de compromiso nervioso, y los resultados finales fueron parcialmente óptimos (26,2 por ciento), de manera que el tratamiento rehabilitador resultó efectivo (42,9 por ciento). Se concluyó que la fisioterapia es capaz de modificar evolutivamente parámetros clínicos y neurofisiológicos en quienes presentan esta afección

A clinical and therapeutic multicentric phase III trial was carried out in 42 patients with carpal tunnel syndrome, assisted in the comprehensive rehabilitation services of 30 de Noviembre and Josué País García polyclinics in Santiago de Cuba, from June, 2009 to the same month of 2010, to evaluate the effectiveness of the rehabilitation treatment. The members of the case material were randomly assigned to 2 groups: those who received laser therapy (study group) and those treated with drug and postural therapy (control group). Chi-square test was applied (p<0.05) and the percentage was used as summary measure. Female sex and the age group 50-59 years prevailed in the series. After the procedure, the analgesia was achieved in 33.3 percent of the affected patients. In the first group there was electrophysiological variation toward the chronic neurogenic pattern (47.0 percent), with improvement in the magnitude of nervous compromise, and the final results were partially optimal (26.2 percent), so that the rehabilitation treatment was effective (42.9 percent). It was concluded that the physiotherapy can progressively modify clinical and neurophysiological parameters in those presenting this disorder

Aspectos clínicos y rehabilitadores en pacientes con síndrome del túnel carpiano tratados con láser / Clinical and rehabilitation aspects in patients with carpal tunnel syndrome treated with laser

Se realizó una intervención terapéutica en 21 pacientes con síndrome del túnel carpiano, atendidos en los servicios de rehabilitación integral de los policlínicos 30 de Noviembre y Josué País García de Santiago de Cuba, desde junio de 2009 hasta igual mes de 2010, con vistas a describir aspectos clínicos de interés y la respuesta al tratamiento con láser blando semiconductor a 6 J/cm2. Las principales variables analizadas fueron: edad, sexo, demanda funcional, mano afectada, síntomas y signos e intensidad del dolor. Se aplicó la prueba de Ji al cuadrado (p<0,05) y se utilizó el porcentaje como medida de resumen. En la serie predominaron el sexo femenino y el grupo etario de 50-59 años. Luego de la terapia aplicada disminuyó el dolor y se logró la analgesia en 66,7 por ciento de los afectados; asimismo, la mejoría se obtuvo principalmente entre las 16 y 20 sesiones. Se concluyó que la fisioterapia es capaz de modificar evolutivamente parámetros clínicos en quienes presentan esta afección

A therapeutical intervention in 21 patients with carpal tunnel syndrome, assisted in the services of comprehensive rehabilitation of the polyclinics 30 de Noviembre and José País García in Santiago de Cuba was carried out from June, 2009 to the same month of 2010, aimed at describing clinical aspects of interest and the response to the treatment with semiconductor soft laser at 6 J/cm2. The main variables were analyzed: age, sex, functional demands, affected hand, symptoms and signs and intensity of pain. The chi-square test was applied (p <0.05) and the percentage was used as summary measure. In the series the female sex and the age group 50-59 years prevailed. After the applied therapy, the pain decreased and the analgesia was achieved in 66.7 percent of those affected; likewise, the improvement was mainly obtained between the 16 and 20 sessions. It was concluded that the physiotherapy can progressively modify clinical parameters in those who present this disorder

Síndrome del Túnel Carpal / Carpal Tunnel Syndrome

El Síndrome del Túnel Carpal (CTS) es una de las neuropatías periféricas más comunes. Afecta principalmente a mujeres de edad media. En la mayoría de los pacientes la causa exacta y la patogénesis no está clara. Varias ocupaciones se han relacionado con aumento de la incididencia y prevalencia de CTS. El riesgo de CTS es alto en personas con ocupaciones que implican la exposición a alta presión, mucha fuerza, trabajo repetitivo, y herramientas que vibran. Los síntomas clásicos de CTS incluyen dolor nocturno asociado con hormigueo y entumecimiento en la distribución del nervio mediano. La prueba estándar de oro son los estudios de conducción nerviosa. El diagnóstico de CTS debe basarse en la anamnesis, exploración física y resultados de los estudios electrofisiológicos. El paciente con síntomas leves de CTS se puede controlar con tratamiento conservador. Sin embargo, en casos moderados a severos, la cirugía es el único tratamiento que ofrece cura.

Impacto de la terapia celular en el síndrome del túnel carpiano / Impact of cell therapy in carpal tunnel syndrome

Se expone una pequeña serie de pacientes con síndrome del túnel del carpo a quienes se les realizó implante de células mononucleares autólogas de sangre periférica para evaluar la factibilidad y seguridad de estas al sexto mes de realizado el proceder. Se incluyeron 6 pacientes atendidos en el Servicio de Ortopedia del Hospital General Docente Enrique Cabrera . La mejoría de los síntomas comenzó a la semana de realizado el proceder. El dolor y el calambre fueron los primeros en desaparecer; la mejoría aumentó al mes y se mantuvo hasta el sexto mes de evaluados. Las manifestaciones clínico-neurológicas mejoraron en el 80,3 por ciento de los pacientes con mejoría, además, en el estudio de conducción motora y sensitiva. No hubo reacción al implante. La mejoría de las manifestaciones clínicas y de los estudios de conducción apoyan la mediación de las células madre en la acción antiinflamatoria, la revascularización y la remielinización del nervio mediano, lo que se expresa en las respuestas favorables obtenidas

We present a small series of patients with carpal tunnel syndrome who underwent implantation of autologous mononuclear cells from peripheral blood to assess the feasibility and safety of these in the sixth month after that procedure. We included 6 patients treated at the Department of Orthopedic in The Enrique Cabrera General Teaching Hospital. The improvement in symptoms began one week after the procedure. Pain and cramping were the first to disappear, the improvement increased one month after and it was maintained until the sixth month of evaluation. The clinical-neurological manifestations improved in 80.3 percent of patients, as well as in the study of motor and sensory conduction. There was no reaction to the implant. The improvement of the clinical manifestations and conduction studies support the mediation of stem cells in inflammatory action, revascularization and remyelination of the median nerve, which is expressed in the positive responses obtained

Uso de la medicina regenerativa en el tratamiento del síndrome del túnel del carpo / Use of regenerative medicine for the treatment of the carpal tunnel syndrome

Se realiza una breve reseña sobre el uso de la medicina regenerativa y se enfatizó sobre su empleo en la especialidad de ortopedia y traumatología, específicamente en el tratamiento del síndrome del túnel del carpo. Se comentó sobre esta afección y los reportes cubanos sobre las dolencias tratadas con medicina regenerativa en este campo de la medicina. Se hace referencia a 2 pacientes con síndrome del túnel del carpo tratados con células madre adultas autólogas, con resultados favorables. Hasta donde se conoce, estos son los primeros casos con síndrome del túnel del carpo comunicados en la literatura tratados con células madre adultas

A brief review was made on the use of regenerative medicine in the field of orthopedics and traumatology, making emphasis on the treatment of the carpal tunnel syndrome. Some comments about this illness and the Cuban reports on ailments treated with regenerative medicine in this medical field were presented. Reference was made on 2 patients suffering this type of syndrome, who were treated with autologous adult stem cells and the achieved results were good. As far as it is known, these are the first two cases with the carpal tunnel syndrome reported on the literature as having been treated with the adult stem cell method

Osteoarticular complications related to HIV infection and highly active antiretroviral therapy

With the significant increase in life expectancy for HIV-infected patients in the era of high potency antiretroviral therapy, major metabolic changes have been observed due to the prolonged period of the viral infection and the treatment itself. Osteoarticular changes resulting from these processes are mainly reported in long term HIV-infected patients receiving high potency antiretroviral therapy and include osteopenia/osteoporosis, osteonecrosis, carpal tunnel syndrome and adhesive capsulitis of the shoulder.

Wrist immobilization after carpal tunnel release: a prospective study / Avaliação prospectiva da imobilização do pulso após descompressão cirúrgica do nervo mediano no túnel do carpo

This prospective study evaluates the possible advantages of wrist imobilization after open carpal tunnel release comparing the results of two weeks immobilization and no immobilization. Fifty two patients with idiopathic carpal tunnel syndrome were randomly selected in two groups after open carpal tunnel release. In one group (A, n=26) the patients wore a neutral-position wrist splint continuosly for two weeks. In the other group (B, n=26) no wrist immobilization was used. Clinical assessment was done pre-operatively and at 2 weeks follow-up and included the two-point discrimination test at the second finger and two questionnaires as an outcome measurement of symptoms severity and intensity. All the patients presented improvement in the postoperative evaluations in the three analyzed parameters. There was no significant difference between the two groups for any of the outcome measurements at the final follow-up. We conclude that wrist immobilization in the immediate post-operative period have no advantages when compared with no immobilization in the end result of carpal tunnel release.

Neste estudo prospectivo avaliamos se há vantagens na imobilização pós-operatória do pulso após a cirurgia para o tratamento da síndrome do túnel do carpo comparando este tratamento com a ausência de imobilização. Cinqüenta e dois pacientes portadores de síndrome do túnel do carpo idiopática foram randomizados em dois grupos após a cirurgia. Em um grupo (grupo A, n=26) os pacientes utilizaram uma tala em posição neutra para imobilização do pulso por duas semanas. No outro grupo (B, n=26), nenhum tipo de imobilização foi adotada. A avaliação foi realizada antes da cirurgia e repetida após duas semanas e incluiu a mensuração da sensibilidade discriminatória no segundo dedo e dois questionários que avaliaram a gravidade e intensidade dos sintomas. Em todos os pacientes houve melhora nos parâmetros avaliados. Não houve diferença estatisticamente significativa entre os dois grupos considerando os parâmetros avaliados. Concluímos que a imobilização do pulso no período pós-operatório imediato não apresenta vantagens quando comparada com a ausência de imobilização após a descompressão cirúrgica do nervo mediano no punho.

Avaliação clínica a longo prazo - pelo sinal de Phalen, Tinel e parestesia noturna - dos pacientes submetidos a cirurgia de liberação do túnel do carpo com instrumento de Paine®

A liberação do retináculo dos flexores para o tratamento da síndrome do túnel do carpo (STC) é uma das cirurgias mais realizadas. Existem diversos métodos para a realização deste procedimento cirúrgico, como endoscópicos, via aberta clássica e mini-incisões. A longo prazo, poucos trabalhos mostram os resultados destas cirurgias. Este estudo tem como finalidade avaliar os pacientes submetidos à liberação do túnel do carpo com instrumento de Paine®, com no mínimo 84 meses de pós-operatório. Foram avaliados os parâmetros clínicos: teste de Phalen, sinal da percussão dolorosa e a queixa de parestesia noturna no pré e pós-operatório. Os resultados mostram que há significante melhora dos sinais avaliados (p.....), quando comparados com a avaliação inicial, e que estes sinais clínicos permanecem negativos ao longo do tempo.

The release of flexors retinaculum for carpal tunnel syndrome (CTS) treatment is one of the most frequently performed surgeries. There are many methods for performing this surgical procedure, such as endoscopic, classical open port and mini-incisions. Few papers show the long-term results of those surgeries. This study is aimed to evaluate patients submitted to carpal tunnel syndrome release using the Paine® instrument, in at least 84 months postoperatively. The following clinical parameters were assessed: Phalen test, painful percussion sign, and complaints of nighttime paresthesia pre- and postoperatively. The results show that there is a significant improvement of the signs assessed (p.....), when compared to baseline evaluation, and that those clinical signs remain negative with time.

Tratamento conservador da síndrome do túnel do carpo: revisão de literatura / Conservative treatment of carpal tunnel syndrome: review of literature

A síndrome do túnel do carpo (STC) é a neuropatia compressiva mais prevalente na população. Seu tratamento ainda é controversp, particularmente no que se refere à eficácia do tratamento conservador. Os autores revisam importantes trabalhos sobre o tratamento não operatório da STC e sugerem esquemas de tratamento de acordo com a severidade dos sintomas.