Electrophysiological responsiveness and clinical outcomes of local corticosteroid injection in the treatment of carpal tunnel syndrome / Responsividade eletrofisiológica e desfechos clínicos da injeção local de corticosteroide no tratamento da síndrome do túnel do carpo

ABSTRACT Carpal tunnel syndrome (CTS) is the most common mononeuropathy caused by entrapment of the median nerve at the wrist. Common treatment options for CTS include oral analgesics, splinting, hand therapy, local injections with steroids or surgery. Objective: The aim of the present study was to assess the short-term clinical and electrophysiological outcomes of local corticosteroid injection (LCI) in patients with symptomatic CTS. Methods: Electrophysiological parameters were evaluated before and three months after LCI. Moreover, the Numeric Rating Scale (NRS), the Boston Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) were administered before and after the injection. A mixture of 1 mL (40 mg) of methylprednisolone and 1 mL of 0.5% bupivacaine were injected blindly on the volar side of the forearm between the tendons of the radial carpal flexor muscle and long palmar muscle. Results: A total of 25 patients (45 hands) were enrolled in the study. Twenty women and five men with a mean age of 49.28 ± 11.37 years were included. A statistically significant difference was noted for improvement of sensory conduction velocities, sensory peak latency, and motor distal latency (p = 0.001) after LCI. A significant difference was recorded between pre- and post-injection for NRS, SSS and FSS scores (p = 0.000). Conclusion: Local corticosteroid injection for CTS provides a short-term improvement in neurophysiological and clinical outcomes such as pain intensity, symptom severity and functional ability.

RESUMO A síndrome do túnel do carpo (STC) é a mononeuropatia mais comum causada pelo aprisionamento do nervo mediano no punho. Opções comuns de tratamento para STC incluem analgésicos orais, splinting, terapia de mão, injeções locais com esteroides ou cirurgia. Objetivo: O objetivo do presente estudo foi avaliar os resultados clínicos e eletrofisiológicos de curto prazo da injeção de corticosteroide local (ICL) em pacientes com STC sintomática. Métodos: Os parâmetros eletrofisiológicos foram avaliados antes e três meses após a ICL. Além disso, a Escala Numérica de Avaliação (NRS), a Escala de Gravidade de Sintomas de Boston (BSS) e a Escala de Status Funcional (FSS) foram administradas antes e após a injeção. Uma mistura de 1 ml (40 mg) de metilprednisolona e 1 ml de bupivacaína a 0,5% foi injetada cegamente no lado do antebraço entre os tendões do músculo flexor radial do carpo e o músculo palmar longo. Resultados: Um total de 25 pacientes (45 mãos) foi incluído no estudo. Vinte mulheres e cinco homens com idade média de 49,28 ± 11,37 anos foram incluídos. Foi observada diferença estatisticamente significante para melhora das velocidades de condução sensitiva, latência de pico sensorial, latência motora distal (p = 0,001) após a ICL. Uma diferença significativa foi registrada entre pré e pós-injeção para os escores NRS, BSS e FSS (p = 0,000). Conclusão: A ICL para STC fornece uma melhoria a curto prazo em resultados neurofisiológicos e clínicos, tais como intensidade da dor, gravidade dos sintomas e capacidade funcional.

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.

A correlation between clinical severity and functional state with nerve conduction studies findings in patients with carpal tunnel syndrome: a systematic review / Correlação entre gravidade clínica e estado funcional com achados eletroneuromiograficos, em pacientes com síndrome do túnel do carpo: uma revisão sistemática

Carpal Tunnel Syndrome is the most common compressive neuropathy in the general population, and it may lead to disabling symptoms and significant functional limitation. This systematic review covered Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS, and SCIELO databases, with no time or language delimitations. The PICO strategy defined the search strategy with keywords extracted from the Medical Subjects Headings, and the quality of the studies was evaluated by the Agency for Healthcare Research and Quality (AHRQ) scale. Overall, 857 studies were identified, of which only 10 fulfilled the inclusion criteria. Despite the good results shown, a noticeable heterogeneity was observed among the studies included, associated with methodological discrepancy and to limited sample size in a few of them. Four studies showed no correlation between electrophysiological findings and clinical symptoms and signs, whereas three could demonstrate such association and other three studies had equivocal results. Other studies are necessary, with better methodological standards and more homogeneous and precise evaluations, so as to improve the level of scientific evidence

A síndrome do Túnel do Carpo é a neuropatia compressiva mais frequente na população geral que pode levar a sintomas incapacitantes e significativa limitação funcional. Uma revisão sistemática foi realizada nas bases de dados Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS e SCIELO, sem delimitação de tempo ou idioma. Utilizou-se da estratégia PICO para a pesquisa, palavras-chave extraídas dos Descritores de Ciências da Saúde (Decs) e a qualidade dos estudos foi avaliada através da escala Agency for Healthcare Research and Quality (AHRQ). Identificaram-se 857 estudos dos quais, somente 10 obedeceram aos critérios de inclusão. Apesar dos bons resultados apresentados, verificou-se uma expressiva heterogeneidade existente entre os estudos incluídos, associado à discrepância metodológica, e um limitado tamanho amostral em alguns deles. São necessários estudos com melhor padrão metodológico, bem como avaliações mais homogêneas e precisas, a fim de melhorar o nível de evidência científica

Descripción electrofisiològica del síndrome de túnel carpiano según edad en pacientes adultos / Electrophysiological severity of carpal tunnel syndrome according to age in adult patients

Background: Carpal tunnel syndrome (CTS) represents 90% of entrapment neuropathies. Severity may be greater in older patients. Aim: To describe the electrophysiological findings in adult patients with CTS and determine if severity is related to age. Material and Methods: Descriptive and retrospective study of electrophysiological findings in patients over 18 years of age with clinical suspicion of CTS, studied between January 2011 and December 2015. Neurophysiological severity was classified in 3 grades, comparing them by age, gender and laterality. Results: Of 1156 patients subjected to electrophysiological studies due to a clinical suspicion of CTS, 690 (60%) had electrophysiological features of the disease. In 274 patients (24%) the compromise was mild, in 162 (14%) it was moderate and in 254 (22%) it was severe. There was a positive association between age and CTS severity (p < 0.01). Severity was significantly greater in males than females (p < 0.01). Bilateral CTS was present in 471 patients (68%), which was associated with increased age and severity (p < 0.01). Conclusions: Electrophysiological severity in CTS increases with age. Other factors associated with higher severity are male gender and bilateral disease.

Síndrome do túnel do carpo na esfera trabalhista / Carpal tunnel syndrome in labor field

Contexto: As doenças do sistema musculoesquelético continuam a figurar entre as maiores causas de incapacidade e absenteísmo na população de trabalhadores em geral. O impacto dessas afecções reflete-se em número considerável de reclamações e processos trabalhistas. O perito médico e o médico do trabalho precisam estar familiarizados com essas doenças e seus fatores de risco para que os primeiros possam realizar uma avaliação isenta e embasar seus laudos tecnicamente, e os segundos, atuar na sua prevenção e em diagnóstico precoces. Objetivos: Realizar revisão bibliográfica para estabelecer o "estado da arte" do conhecimento médico acerca da síndrome do túnel do carpo, voltado para as práticas de Medicina do Trabalho e Perícias Médicas. Métodos: Levantamento bibliográfico dos últimos cinco anos referente aos aspectos clínicos da STC, com especial ênfase à sua epidemiologia, fisiopatologia, principais diagnósticos diferenciais, tratamento e prognóstico, assim como dos chamados riscos ocupacionais. Para contextualização do tema no universo médico pericial trabalhista, enquadramento de deficiências e prognóstico de retorno ao trabalho, foram selecionadas publicações de fontes nacionais e internacionais. Resultados: Pela Cochrane, foram apresentados 28 artigos por meio das buscas, dos quais 7 foram selecionados e 21 descartados; e, pela PubMed, foram apresentados 39 artigos, dos quais 11 foram selecionados e 28 descartados. Conclusões: A síndrome do túnel do carpo, mononeuropatia compressiva mais comum dos membros superiores, apresenta características peculiares quanto à sua etiologia e ao seu prognóstico, que devem ser bem conhecidos pelo médico perito e pelo médico do trabalho, o qual pode agir na prevenção e no diagnóstico precoce da doença.

Context: The musculoskeletal system diseases remain among the major causes of disability and absenteeism in the population of general workers . The impact of these diseases is reflected in a considerable number of complaints and labor proceedings. The medical expert and occupational physician need to be familiar with these diseases and their risk factors so that the former can carry out a free evaluation and provide technical support to their reports, whereas the latter can act in their early prevention and diagnosis. Objectives: To perform a literature review to establish the "state-of-the-art" of medical knowledge about carpal tunnel syndrome, directed to the practices of Occupational Medicine and Medical Expertise. Methods: Bibliographic survey of the last five years with regard to the clinical aspects of the carpal tunnel syndrome, with special emphasis on its epidemiology, pathophysiology, main differential diagnosis, treatment and prognosis, as well as so-called "occupational hazards". Publications from national and international sources were selected to contextualize the theme in the labor expertise medical universe, in the disability framing, and in the work return prognosis. Results: Cochrane presented 28 articles through searches, of which 7 were selected and 21 were removed. PubMed displayed 39 articles, of which 11 were selected and 28 were removed. Conclusions: Carpal tunnel syndrome, the most common compression mononeuropathy of the upper limbs, has peculiar characteristics as to its etiology and prognosis that should be well-known by the Medical Expert and the Occupational Physician, who can act in the prevention and early diagnosis of such disease.

Alteración de las fibras finas A-delta por entrampamiento del nervio mediano en la muñeca utilizando el período silente cutáneo / The impairment of A-delta fibers in median nerve compression at the wrist, using the cutaneous silent period

El síndrome del túnel carpiano (STC) es una neuropatía por entrampamiento a nivel de la muñeca que cursa con dolor, parestesias y disestesias dolorosas. El diagnóstico electrofisiológico se basa en el estudio de la neuroconducción de las fibras gruesas. Nuestra hipótesis consiste en la existencia del compromiso de las fibras nerviosas finas y que este compromiso se correlaciona con el grado de gravedad. Se evaluaron retrospectivamente 69 manos correspondientes a 47 pacientes, varones y mujeres (edad media 53.8, rango 22-87 años) y como grupo contro, 21 manos correspondientes a los lados asintomáticos de estos casos. Se realizaron estudios de neuroconducción motora, sensitiva y ondas F para clasificar a las manos según el grado de gravedad. Se realizó el período silente cutáneo (PSC) en todas las manos. Se evaluaron latencias medias y duraciones medias del PSC. Las latencias medias se hallaron significativamente prolongadas en las manos con neuropatía (84.3 ± 16.3 mseg) con respecto a las manos sin neuropatía (74.8 ± 11.6 mseg), p < 0.05. Las latencias medias se hallaron más prolongadas en las manos con neuropatía de mayor gravedad (p < 0.05). En los 3 pacientes con neuropatía grado más grave no se halló el PSC. Se demostró el compromiso de las fibras finas A-delta en los pacientes con STC, con mayor compromiso a mayor severidad. El PSC puede usarse como complemento de los estudios de neuroconducción motora y sensitiva.

Carpal tunnel síndrome (CTS) is an entrapment neuropathy of the median nerve at the wrist, that leads to pain, paresthesia and painful dysesthesia. The electrophysiological diagnosis is based upon nerve conduction studies which evaluate thick nerve fibers. Our hypothesis is that there is an additional dysfunction of small fibers in CTS, which correlates with the degree of severity of the neuropathy. A retrospective study of 69 hands that belonged to 47 patients of both sexes (mean age 53.8, years, range 22-87) was performed, and, as a control group, 21 hands which corresponded to the asymptomatic side of those patients were evaluated. Motor and sensory conduction studies, as well as F-waves were performed to classify the neuropathy according to the degree of severity. Cutaneous silent period (CSP) was elicited in all hands. Mean onset latencies and durations of CSP were evaluated. Mean onset latencies were significantly prolonged in neuropathic hands (84.3 ± 16.3 msec) compared to asymptomatic hands (74.8 ± 11.6 msec) (p < 0.05). Mean latencies of the CSP were even prolonged (p < 0.05) in hands affected by a more severe neuropathy. In the 3 hands with most severe neuropathy, a CSP could not be elicited. In CTS an impairment of A-delta fibers was recorded through the CSP. The more severe the neuropathy is, the more impairment of A-delta fibers can be found. CSP may be assessed as a complement of motor and sensory nerve conduction studies in this neuropathy.

Carpal tunnel syndrome - Part I (anatomy, physiology, etiology and diagnosis)

Carpal tunnel syndrome (CTS) is defined by compression of the median nerve in the wrist. It is the commonest of the compressive syndromes and its most frequent cause is idiopathic. Even though spontaneous regression is possible, the general rule is that the symptoms will worsen. The diagnosis is primarily clinical, from the symptoms and provocative tests. Elec-troneuromyographic examination may be recommended before the operation or in cases of occupational illnesses...

A sindrome do túnel do carpo (STC) é definida pela compressão do nervo mediano no punho. É a mais frequente das sindromes compressivas e a causa mais frequente é a idiopática. Ainda que as regressões espontâneas sejampossiveis, o agravamento dos sintomas é a regra. O diagnóstico é, acima de tudo, clinico pelos sintomas e testes provocativos. Um exame eletroneuromiográfico pode ser recomendado no pré-operatório ou em caso de doença laboral...

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...

Obesity Affects Median Nerve Conduction - A Study in Armed Forces Individuals.

Background: Obesity, a growing public health concern, is associated with various disorders. Studies have suggested obesity as an independent risk factor that influences the prevalence of carpal tunnel syndrome (CTS) among active workers. The present study is an attempt to establish relationship between median nerve conduction velocity and obesity in people who do not have any other contributory factor for CTS other than obesity. CTS is the commonest entrapment neuropathy where the median nerve is compressed. Methods: The study was conducted in 15 obese subjects with Body Mass Index (BMI)>30 (group III) and 15 overweight subjects with BMI between 25&29.9 (group II) and 15 control subjects with BMI <25 (group I). The subjects were personnel from armed forces. Their body density was estimated using hydro-densitometry and the body fat percentage was calculated from density. The distal motor latency (DML) and the sensory conduction velocity (SCV) across the wrist on stimulation of median nerve at wrist 3cm proximal to distal crease were assessed in all subjects. Results: The mean values of DML in group I, II, and III were 3.52±0.25 ms, 3.50±0.30 ms and 3.65±0.20 ms respectively. Mean value of SCV among these groups were 48.99±3.23 m/s, 49.32±3.35 m/s and 48.69±4.00 m/s. Conclusion: No relationship could be established between BMI and DML as well as BMI and SCV. The relationship between percentage body fat and DML and SCV also found to be statistically insignificant. However, there was a correlation between BMI and body fat percentage. Carpal tunnel syndrome is uncommon even in obese armed forces personnel, which might be due to their regular body and hand exercise thereby having increased tone in hand muscles.

Responsiveness of the Korean Version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (K-DASH) after Carpal Tunnel Release

BACKGROUND: The Korean version of the Disability of the Arm, Shoulder and Hand Questionnaire (K-DASH) was recently validated, but its responsiveness, which is the degree to which an instrument is sensitive to change, has not been thoroughly evaluated in a specific condition in Koreans. We evaluated the responsiveness of the K-DASH in a homogenous cohort of patients with carpal tunnel syndrome (CTS) and we compared it with that of the disease-specific Carpal Tunnel Questionnaire (CTQ). METHODS: Fifty-six patients with CTS prospectively completed the K-DASH and CTQ before and 6 months after surgery. The responsiveness statistics were assessed for both the K-DASH and CTQ by using the standardized response mean (SRM) and the effect size (ES). Pearson correlation coefficients were calculated between the K-DASH and CTQ. RESULTS: The SRM and ES of the K-DASH were all 0.8. The SRM of the symptom and function part of the CTQ was 1.5 and 1.1, and the ES was 1.5 and 1.1, respectively. The K-DASH had moderate correlations with the symptom and function parts of the CTQs, but the postoperative K-DASH had a weak correlation with the symptom part of the postoperative CTQ. CONCLUSIONS: The K-DASH was found to have a large degree of responsiveness (SRM, ES > or = 0.8) after carpal tunnel release in Korean patients with CTS, which is comparable to the other language versions of the DASH. Although it was less responsive than the CTQ, which is disease-specific, the region-specific K-DASH can be used as an effective outcome measurement tool for CTS, and especially for research that compares CTS with other upper limb conditions.

Carpal tunnel syndrome: long-term nerve conduction studies in 261 hands / Síndrome do tunel do carpo: estudo evolutivo de parâmetros de condução nervoso em 261 mãos

OBJECTIVE: To compare a long-term carpal tunnel syndrome (CTS) on nerve conduction studies (NCS) in hands treated non-surgically. METHOD: We retrospectively selected 261 symptomatic CTS hands (166 patients), all of them confirmed by NCS. In all cases, at least 2 NCS were performed in an interval greater than 12 months. Cases with associated polyneuropathy were excluded. NCS parameters for CTS electrodiagnosis included a sensory conduction velocity (SCV) <46.6 m/s (wrist to index finger, 14 cm) and distal motor latency (DML) >4.25 ms (wrist to APB, 8 cm). RESULTS: 92.8 percent were women; mean age was 49 years (20-76); the mean interval between NCS was 47 months (12-150). In the first exam, the median sensory nerve action potential (SNAP) and the compound action muscular potential were absent in 9.8 percent and 1.9 percent, respectively. In the second/last exam, SCV worsened in 54.2 percent, remained unchanged in 11.6 percent and improved in 34.2 percent. SNAP amplitude worsened in 57.7 percent, remained unchanged in 13.1 percent and improved in 29.2 percent. DML worsened in 52.9 percent, remained unchanged in 7.6 percent and improved in 39.5 percent. Overall, NCS parameters worsened in 54.9 percent, improved in 34.3 percent and remained unchanged in 10.8 percent. CONCLUSION: Long-term changing in NCS of CTS hands apparently were not related to clinical symptomatology and could lead to some difficulty in clinical correlation and prognosis. Aging, male gender and absent SNAP were more related to NCS worsening, regardless the mean interval time between the NCS.

OBJETIVO: Comparar evolutivamente parâmetros de condução nervosa (CN) na síndrome do túnel do carpo (STC) em mãos não submetidas à cirurgia. MÉTODO: Foram selecionadas retrospectivamente 261 mãos (166 pacientes) com STC sintomática confirmadas por CN e que posteriormente realizaram exame controle com intervalo >12 meses; foram excluídos casos com polineuropatia. Os parâmetros eletrodiagnósticos anormais foram: velocidade de condução sensitiva (VCS) <46,6 m/s, segmento pulso-II dedo, e latência distal motora (LDM) >4,25 ms, segmento pulso-APB (8 cm). RESULTADOS: 92,8 por cento eram mulheres; a média de idade foi 49 anos (20-76); o tempo médio entre os exames foi 47 meses (12-150); 9,8 por cento e 1,9 por cento não apresentaram potenciais de ação do nervo sensitivo (PANS) e potenciais de ação muscular compostos, no primeiro exame. No segundo exame a VCS piorou em 54,2 por cento, ficou igual em 11,6 por cento e melhorou em 34,2 por cento; a amplitude do PANS piorou em 57,7 por cento, ficou igual em 13,1 por cento e melhorou em 29,2 por cento; a LDM piorou em 52,9 por cento, ficou igual em 7,6 por cento e melhorou em 39,5 por cento. Incluindo todos os parâmetros eletrofisiológicos, houve piora em 54,9 por cento, melhora em 34,3 por cento e permaneceram sem alterações 10,8 por cento. CONCLUSÃO: As anormalidades da CN na STC podem oscilar ao longo do tempo e aparentemente independem da sintomatologia clínica, dificultando a correlação e prognóstico; idade mais avançada, sexo masculino e PANS ausentes no primeiro exame foram as variáveis que tiveram menor percentual de melhora evolutiva, independentemente do intervalo entre os exames.

Correlación entre estudio ultrasonográfico (US) y estudio electromiográfico (EMG) en el diagnóstico del síndrome del túnel carpiano (STC) / Correlation between ultrasonographic (US) and electromyographic study (EMG) in the diagnosis of carpal tunnel syndrome (CTS)

Objetivo y método: Evaluar la correlación entre la electromiografía (EMG) y la ultrasonografía (US) de 19 pacientes con síndrome del túnel carpiano (STC) clínico. Resultados: Debieron ser descartados dos pacientes por presentar nervios medianos bíjidos. Se hallaron 15 nervios medianos con US alterada y18 nervios medianos con electromiografía alterada. Se encontró correlación positiva entre US y electromiografía en 12/24 túneles carpianos, y se observó una concordancia de lateralidad entre el tamaño del nervio y su alteración electrofisiológica en cinco pacientes. Se detectó sinovitis de muñeca en seis túneles carpianos (dos pacientes con artritis reumatoide, uno con osteoartritis erosiva). Conclusión: La US músculo-esquelética es una herramienta complementaria a la electromiografía en el estudio del STC en el paciente reumático, aportando información adicional con relación a la patología de base.

Objective: Compare high-resolution ultrasonography (US) and electromyography (EMG) of 19 patients with carpal tunnel syndrome (CTS) Results: Two patients were ruled out because of bifid median nerves. We found 15 median nerves with abnormal US appearance and 18 median nerve with abnormal EMG. We found a positive correlation between US and EMG in 12/24 carpal tunnels, and lateral agreement between nerve size and EMG alteration in 5 patients. Wrist synovitis was detected in six carpal tunnels (two patients with rheumatoid arthritis and one with osteoarthritis). Conclusion: Musculoskeletal ultrasound is a complementary tool to electromyography in the CTS study of rheumatologic patients, thus providing additional information in relation to the basal pathology.

Cooling modifies mixed median and ulnar palmar studies in carpal tunnel syndrome / Influência do resfriamento nos parâmetros de condução nervosa mista do mediano e ulnar na síndrome do túnel do carpo

Temperature is an important and common variable that modifies nerve conduction study parameters in practice. Here we compare the effect of cooling on the mixed palmar median to ulnar negative peak-latency difference (PMU) in electrodiagnosis of carpal tunnel syndrome (CTS). Controls were 22 subjects (19 women, mean age 42.1 years, 44 hands). Patients were diagnosed with mild symptomatic CTS (25 women, mean age 46.6 years, 34 hands). PMU was obtained at the usual temperature, >32°C, and after wrist/hand cooling to <27°C in ice water. After cooling, there was a significantly greater increase in PMU and mixed ulnar palmar latency in patients versus controls. We concluded that cooling significantly modifies the PMU. We propose that the latencies of compressed nerve overreact to cooling and that this response could be a useful tool for incipient CTS electrodiagnosis. There was a significant latency overreaction of the ulnar nerve to cooling in CTS patients. We hypothesize that subclinical ulnar nerve compression is associated with CTS.

Temperatura é uma variável comum e importante que modifica os parâmetros de condução nervosa na prática eletrodiagnóstica. Neste trabalho nós estudamos o efeito do esfriamento na diferença de latências palmares entre o nervo mediano e ulnar (PMU), segmento palma-pulso, utilizada rotineiramente para o eletrodiagnóstico da síndrome do túnel do carpo (STC). Foram estudados 22 controles (19 mulheres, média de idade 42,1 anos, 44 mãos) e 25 pacientes (25 mulheres, média de idade 46,6 anos, 34 mãos) com diagnóstico de STC leve. PMU foi obtida em temperatura usual (>32°C), e após resfriamento de mão/pulso em água com gelo (<27°C). Após o resfriamento houve aumento significativo na PMU e na latência mista palmar do nervo ulnar nos pacientes quando comparados aos controles. Nós concluímos que o resfriamento modifica significativamente a PMU e propomos que as latências obtidas em nervos submetidos à compressão reagem de maneira mais acentuada ao frio e isso poderia ser uma arma útil para o eletrodiagnóstico da STC incipiente. Da mesma forma, houve reação mais acentuada ao frio no estudo da latência mista palmar do nervo ulnar nos pacientes mas não nos controles, que poderia levantar a hipótese de compressão subclínica do nervo ulnar.

Classificação neurofisiológica da Síndrome do Túnel do Carpo / Neurophysiological classification of the Carpal Tunnel Syndrome

O objetivo deste trabalho foi avaliar a correlação clínica da escala neurofisiológica da Síndrome do Túnel do Carpo (STC). As mãos foram classificadas em 6 graus: mínimo/grau 1 (teste comparativo/segmento curto alterado, conduções sensitiva e motora normais), leve/grau 2 (condução sensitiva alterada, condução motora normal), moderada/grau 3 (conduções sensitiva e motora alteradas, amplitude sensitiva normal), moderada/grau 4 (conduções sensitiva e motora alteradas, amplitude sensitiva baixa), grave/grau 5 (condução sensitiva ausente, condução motora alterada) e extremo/grau 6 (conduções sensitiva e motora ausentes). Foi realizado um estudo prospectivo em 400 mãos com STC. Foram classificadas 56 mãos (14,0%) como grau 1, 109 mãos (27,3%) como grau 2, 129 mãos (32,3%) como grau 3, 78 mãos (19,5%) como grau 4, 22 mãos (5,5%) como grau 5 e 6 mãos (1,5%) como grau 6. Houve uma correlação positiva significativa (p<0,01) da escala neurofisiológica da STC com a idade dos pacientes, o tempo de duração da STC, a freqüência de relato de história clássica de STC e a freqüência dos sintomas dor noturna, parestesia e dormência. Também houve uma correlação positiva significativa entre a freqüência do sinal de Tinel, hipoestesia no 2° dedo, fraqueza e hipotrofia dos músculos tenares com a escala neurofisiológica da STC.

The aim of this study was to evaluate the clinical correlation of the neurophysiological scale of the Carpal Tunnel Syndrome (CTS). The hands were classified in 6 grades: minimum/grade 1 (comparative test / altered short segment, normal sensitive and motor conductions), mild/grade 2 (altered sensitive conduction, normal motor conduction), moderate/grade 3 (altered sensitive and motor conductions, normal sensitive amplitude), moderate/grade 4 (altered sensitive and motor conductions, low sensitive amplitude), severe/grade 5 (absent sensitive conduction, altered motor conduction) and extremely severe/grade 6 (absent sensitive and motor conductions). A prospective study was carried out in 400 hands with CTS. 56 hands (14%) were classified as grade 1,109 hands (27.3%) as grade 2, 129 hands (32.3%) as grade 3, 78 hands (19.5%) as grade 4, 22 hands (5.5%) as grade 5 and 6 hands (1.5%) as grade 6. There was a significant positive correlation (p < 0.01) between the neurophysiological scale of CTS and the patients? ages, the duration of CTS, the frequency of reported classical CTS history and the frequency of night pain symptoms, paresthesia and numbness. Additionally, there was a significant positive correlation between the neurophysiological scale and the frequency of Tinel`s sign, hypoesthesia on the 2nd digit, weakness and hypotrophy of the thenar muscles.

Carpal tunnel syndrome and manual milking: nerve conduction studies in 43 cases / Síndrome do túnel do carpo e ordenha: estudo de condução nervosa em 43 casos

From 1989 to 2004, 3125 consecutive patients had electrodiagnosis of carpal tunnel syndrome (CTS); from these 43 cases (1.38 percent) were associated to manual milking; mean age was 44.9 years and 88.4 percent were male. The mean time in the milking profession was 247 months; the mean daily milking time was 146 minutes; symptoms referred at electrodiagnostic consultation had lasted on average 34 months, 83 percent were bilateral. The median sensory nerve conduction study was abnormal in 75.6 percent to the right and 66.7 percent to the left hand. The median nerve motor distal latency (MDL) was abnormal in 92.1 percent to the right and in 80.0 percent to the left hand. There were no differences between right and left for all electrophysiological parameters. In CTS related to manual milking most cases were men, with the MDL more affected than the sensory distal latencies and the electrophysiological abnormalities were found to be symmetric. Manual milking could be a natural model for occupational CTS. In contrast to idiopathic CTS, there was a greater involvement of motor fascicles; this finding is remarkable for CTS.

No período de 1989 a 2004 foram diagnosticados por meio de eletroneuromiografia 3125 casos consecutivos de Síndrome do túnel do carpo (STC) e destes, 43 (1,38 por cento) estavam associados com ordenha; a média de idade foi 44,9 anos e 88,4 por cento eram do sexo masculino. O tempo médio de atividade profissional era 247 meses; o tempo médio de ordenha diária era 146 minutos; a sintomatologia referida na consulta eletrodiagnóstica tinha em média 34 meses de duração e 83 por cento a referiam bilateralmente. O estudo da condução senstiva do nervo mediano estava anormal em 75,6 por cento na mão direita e em 66,7 por cento da mão esquerda. A latência distal motora (LDM) do nervo mediano estava anormal em 92,1 por cento à direita e em 80 por cento à esquerda. Não havia diferença significante dos parâmetros eletrofisiológicos entre os lados direito e esquerdo. Na STC associada a ordenha, a maioria dos casos é de homens, a LDM está mais afetada que as latências distais sensitivas e as anormalidades eletrofisiológicas são simétricas. A ordenha poderia ser considerada um modelo para STC ocupacional e diferente da STC idiopática, há maior envolvimento dos fascículos motores.

Valor diagnóstico de los síntomas y signos clinicos en el Síndrome Tunelar Carpiano / Diagnosis value of clinics symptoms and signs in the Carpal Tunnel Syndrome

El Síndrome Tunelar Carpiano (S.T.C.) es la neuropatía por atrapamiento más frecuente del miembro superior. Existe en la literatura considerable discrepancia respecto a la sensibilidad y especificidad de síntomas y signos relacionados al S.T.C.. El objetivo de esté estudio fue determinar la validez diagnóstica de los síntomas y signos clínicos típicos de S.T.C. en pacientes con diagnósticos positivos por Estudio neurofisiológico (Gold Standard diagnóstico). Se estudiaron prospectivamente 73 manos con diagnóstico presuntivo de S.T.C.. Los mejores predictores de diagnóstico positivo de S.T.C. fueron: parestesias nocturnas que mejoran con el "shaking", falta de discriminación de dos puntos y atrofia tenar.

Carpal Tunner Syndrome (C.T.S.) is the most frequently recognized entrapment neuropathy on upper limbs. In the literature, there is a considerable disagreement about signs` and symptoms` sensibility and specificity related to C.T.S.. Our objective was to determine the diagnosis validity of typical signs and symptoms of C.T.S. in patients with positive neurophysiologic diagnosis (Gold Standard diagnosis). In a prospective way, we studied 73 hands with presumptive diagnosis of C.T.S.. The best predictors for a positive diagnosis were: numbness at night that reduce with shaking, impossibility to discriminate two points and thenar atrophy.

Relação entre tensão neural adversa e estudos de condução nervosa em pacientes com sintomas da sídrome do túnel do carpo / Relationship between adverse neural tension and nerve conduction studies in patients with symptoms of the carpal tunnel syndrome

O propósito deste estudo foi avaliar, através de uma série de casos, a relação entre tensão neural adversa do nervo mediano (TNAm) e o parâmetro eletrofisiológico em 38 pacientes com sintomas da síndrome do túnel do carpo (STC), submetidos a estudos de condução nervosa (ECN). As principais medidas foram a TNAm obtida no teste de provocação de tensão neural (TPTN) e parâmetros dos ECN, dividindo-se os braços avaliados em três grupos: normal, com alteração eletrofisiológica sem gravidade e com alteração eletrofisiológica grave. Correlação significante entre TNAm e parâmetros dos ECN foram encontrados (p<0,05), bem como entre a TNAm e os três grupos definidos pela alteração eletrofisiológica (r s=+0.437, p=0,002). Valores de TNAm foram significantemente maiores nos braços com diagnóstico eletrofisiológico (p=0,007). Sugere-se que a TNAm tem participação na fisiopatologia da STC, indicando o uso de procedimentos terapêuticos que diminuam ou previnam a tensão neural.

Avaliação do questionário de Boston aplicado no pós-operatório tardio da síndrome do tunel do carpo operados pela técnica de retinaculótomo de paine por via palmar / Evaluation of Boston questionnaire applied at late pos-operative period of carpal tunnel syndrome operated with the paine retinaculatome through palmar port

Entre os anos de 1995 e 1998, foram realizadas 112 cirurgias para tratamento da Síndrome do Túnel do Carpo (STC) pela técnica de incisão palmar e utilização do retináculo de Paine. Com o objetivo de avaliar os resultados em longo prazo, os pacientes foram convocados. Houve o retorno de 44 pacientes. Deste total, três pacientes, por terem doenças associadas, foram excluídos, resultando, um total de 53 mãos analisadas. Apresentaremos os resultados da avaliação subjetiva, obtidos através da aplicação de um teste de auto-avaliação chamado de questionário de Boston. Este questionário consiste em perguntas que avaliam a gravidade dos sintomas e o estado funcional no momento da aplicação do mesmo. Através da aplicação do referido questionário encontramos um escore de 1,41 ± 0,57 para gravidade dos sintomas e 1,59 ± 0,93 para o estado funcional. Como este questionário não foi aplicado no pré-operatório deste grupo de pacientes analisados, comparou-se a pontuação obtida com as encontradas na literatura pertinente. Os resultados obtidos demonstraram que as pontuações pós-operatórias são similares àquelas existentes na literatura, mesmo sendo referidas a tempos diferentes de seguimento pós-operatórios, concluindo que havendo uma melhora dos sintomas, o questionário de Boston é sensível a esta mudança clínica.

Between the years of 1995 and 1998, 112 surgeries were performed for treating Carpal Tunnel Syndrome (CTS) using the technique of palmar incision employing the Paine retinaculum. With the objective of analyzing results in the long-term, the patients were called for review. Forty four patients returned. From these, three patients were excluded due to associated diseases, thus resulting in a total of 53 hands assessed. Here we present the results of the subjective evaluation achieved by applying a self-assessment test called Boston questionnaire. This questionnaire consists of questions evaluating symptoms severity and functional status at the moment of its application. By applying this questionnaire, we found a score of 1.41 ± 0.57 for symptoms severity and of 1.59 ± 0.93 for functional status. As this questionnaire was not applied at the pre-operative period for those patients assessed, its scores were thus compared to those found in pertinent literature. The achieved results show that post-operative scores are similar to those described in literature, even when reported in different postoperative follow-up times, thereby concluding that when symptoms are improved, the Boston questionnaire is sensitive to that clinical change.

Avaliação de questionário sobre sintomas e estado funcional de pacientes com síndrome do túnel do carpo / Evaluation of a questionnaire on symptom severity and functional status of patients with carpal tunnel syndrome

Este estudo consistiu na avaliação do questionário de Levine et al. (1993) Boston Carpal Tunnel Questionnaire, de avaliação da gravidade dos sintomas - em domínios críticos na STC, como dor, parestesias, adormecimento, fraqueza, sintomas noturnos - e uma escala de estado funcional.

This study aimed at assessing the Boston Carpal Tunnel Questionnaire by Levine et. al. (1993), a self administered instrument for evaluating severity of symptoms and functional status in patients with carpal tunnel syndrome (CTS)...

Sindrome do tunel do carpo / carpal tunnel syndrome

A sindrome do tunel do carpo (STC) e a neuropatia de maior incidencia no membro superior e consiste na compressao do nervo mediano no interior do tunel do carpo.Atualmente, essa alteracao neuromuscular tem atingido um numero de pessoas cada vez maior, principalmente trabalhadores que desempenham atividades de intensa movimentacao do punho. Uma serie de estudos tem procurado investigar a fisiopatologia, o diagnostico e o tratamento para a STC. No entanto, os mecanismos neuromusculares envolvidos em seu desenvolvimento ainda n'ao sao totalmente compreendidos, o que dificulta um diagnostico mais sensivel e capaz de detectar inclusive a presenca de dupla compressao (coluna cervical e tunel carpo), assim como o tratamento adequado...