Has the median nerve involvement in rheumatoid arthritis been overemphasized? / O envolvimento do nervo mediano na artrite reumatoide tem sido excessivamente valorizado?

Abstract Rheumatoid arthritis (RA) is a well and widely recognized cause of carpal tunnel syndrome (CTS). In the rheumatoid wrist, synovial expansion, joint erosions and ligamentous laxity result in compression of the median nerve due to increased intracarpal pressure. We evaluated the published studies to determine the prevalence of CTS and the characteristics of the median nerve in RA and its association with clinical parameters such as disease activity, disease duration and seropositivity. A total of 13 studies met the eligibility criteria. Pooled data from 8 studies with random selection of RA patients revealed that 86 out of 1561 (5.5%) subjects had CTS. Subclinical CTS, on the other hand, had a pooled prevalence of 14.0% (30/215). The cross sectional area of the median nerve of the RA patients without CTS were similar to the healthy controls. The vast majority of the studies (8/13) disclosed no significant relationship between the median nerve findings and the clinical or laboratory parameters in RA. The link between RA and the median nerve abnormalities has been overemphasized throughout the literature. The prevalence of CTS in RA is similar to the general population without any correlation between the median nerve characteristics and the clinical parameters of RA.

Resumo A artrite reumatoide (AR) é uma causa bem e amplamente reconhecida de síndrome do túnel do carpo (STC). No punho acometido pela artrite reumatoide, a expansão sinovial, as erosões articulares e a frouxidão ligamentar resultam em compressão do nervo mediano decorrente do aumento da pressão intracarpal. Avaliaram-se os estudos publicados para determinar a prevalência de STC e as características do nervo mediano na AR e sua associação com parâmetros clínicos, como a atividade e duração da doença e a soropositividade. Preencheram os critérios de elegibilidade 13 estudos. Os dados agrupados dos oito estudos com seleção aleatória de pacientes com AR revelaram que 86 de 1.561 (5,5%) indivíduos tinham STC. Por outro lado, a STC subclínica teve uma prevalência combinada de 14% (30/215). A área de seção transversa do nervo mediano dos pacientes com AR sem STC foi semelhante à de controles saudáveis. A grande maioria dos estudos (8/13) não apresentou relação significativa entre os achados no nervo mediano e os parâmetros clínicos ou laboratoriais na AR. A ligação entre a AR e as anormalidades do nervo mediano foi excessivamente valorizada em toda a literatura. A prevalência de STC na AR é semelhante à da população em geral, sem qualquer correlação entre as características do nervo mediano e os parâmetros clínicos da AR.

Principales causas de recidivas en el túnel del carpo / Principal causes for recurrent carpal tunnel syndrome

Resumen: Se analizaron las causas frecuentes del síndrome del túnel del carpo recidivante. Seguimiento de una serie de casos del 1 de Enero al 31 Diciembre 2011; se estudiaron nueve pacientes mediante examen físico y de gabinete. A todos se les evaluó el dolor con escala visual análoga, cuestionario de Brigham and Women's Hospital para conocer la discapacidad. Siete pacientes correspondieron al género femenino y dos al masculino, con un promedio de edad de 52 años. Entre las principales causas de recidiva se encontró la fibrosis postquirúrgica acompañada de una liberación incompleta en siete pacientes; en dos pacientes se observó una liberación incompleta y se les realizó abordajes mínimos invasivos. Tres pacientes de los nueve presentaron cicatrices retráctiles. La principal causa de recidiva es la fibrosis postquirúrgica asociada al abordaje mínimamente invasivo.

Abstract: The frequent causes of relapsing carpal tunnel syndrome were analyzed. Nine patients were followed-up from January 1st to December 31st, 2011. They underwent a physical exam and imaging tests. Pain was measured in all of them with the VAS, and the Brigham and Women's Hospital questionnaire was used to assess disability. Patients included seven females and two males; mean age was 52 years. Major causes for relapse included postoperative fibrosis with incomplete release in seven patients and incomplete release in two patients in whom minimally invasive approaches were used. Three of the nine patients had retractile scars. The main cause of relapse was postoperative fibrosis associated with the minima­lly invasive approach.

Retalho tenar adipofascial reverso para cobertura do nervo mediano hipertrofiado em macrodactilia / The reverse adipofascial thenar flap for coverage of the hypertrophied median nerve in macrodactyly

A macrodactilia é uma anomalia congênita infrequente, caracterizada pelo crescimento desproporcional dos tecidos ósseo, gorduroso, nervoso, vascular e dérmico nos dedos das mãos ou dos pés. Existem muitas teorias sobre a sua etiopatogenia, sendo a mais aceita a hiperestimulação por fatores de crescimento enviados através dos nervos. Foram descritos alguns casos associados com a síndrome do túnel do carpo. Apresenta-se um caso clínico de síndrome do túnel do carpo por hipertrofia do nervo mediano, evidenciando um aumento de conteúdo dentro do retináculo flexor, o qual foi tratado cirurgicamente com sucesso pela realização de uma retinaculotomia do ligamento anular do carpo junto a um retalho de transposição tenar adipofascial reverso da região tenariana hipertrofiada visando à cobertura do nervo mediano na região do punho.

Macrodactyly is a rare congenital anomaly characterized by the disproportionate growth of bone, fat, nervous, vascular, and dermal tissue in the digits . There are many different theories about its etiopathogenesis, the most accepted being a hyperstimulation by growth factors conducted through nerves. A few cases have been described in conjunction with carpal tunnel syndrome. Here, a clinical case of carpal tunnel syndrome due to hypertrophy of the median nerve is presented, showing an increase of content within the flexor retinaculum. Successful surgical treatment was accomplished by conducting a retinaculotomy of the anterior annular ligament along with a reverse transposition adipofascial flap of the hypertrophied thenar region for coverage of the median nerve at the wrist.

Estudo da auditoria de contas em um hospital de ensino / Estudio de la auditoría de cuentas en un hospital de enseñanza / Study of billing audits in a teaching hospital

RESUMOObjetivos:verificar os itens componentes das contas hospitalares, conferidos por enfermeiros auditores, que mais recebem ajustes no momento da pré-análise; identificar o impacto dos ajustes no faturamento das contas analisadas por enfermeiros e médicos auditores e identificar as glosas relacionadas aos itens conferidos pela equipe de auditoria.Método:pesquisa quantitativa exploratória, descritiva, do tipo estudo de caso único.Resultados:após a análise de 2.613 contas constatou-se que o item mais incluído por enfermeiros foram gases (90,5%) e o mais excluído medicamentos de internação (41,2%). Materiais de hemodinâmica; gases e equipamentos foram os que mais impactaram nos ajustes positivos. Os ajustes negativos decorreram de lançamentos indevidos nas contas e não geraram prejuízos de faturamento. Do total de glosas 52,24% referiu-se à pré-análise dos enfermeiros e 47,76% a dos médicos.Conclusão:a presente investigação do processo de pré-análise fornece subsídios que contribuem para o avanço no conhecimento sobre a auditoria de contas hospitalares.

RESUMENObjetivos:comprobar los elementos que componen las cuentas del hospital, controladas por enfermeras auditores que reciben más ajustes en el momento de pre-análisis, identifi car el impacto de los ajustes a la facturación de las cuentas examinadas por las enfermeras y los médicos auditores; identifi car las glosas relacionadas con los puntos otorgados por equipo de auditoría.Método:estudio cuantitativo, exploratorio, descriptivo, tipo de investigación de caso único.Resultados:después de análisis de 2613 cuentas se encontró que el elemento más incluido por el enfermeros fue gas (90,5%) y lo más excluido fue hospitalización medicamentos (41,2%). Materiales de gases y equipos hemodinámicamente fueron los más afectados en los ajustes positivos. Los ajustes negativos fueron el resultado de errores en las cuentas y no generan pérdidas de ingresos. El rechazo total fue de 52,24% en relación a la pre-análisis de las enfermeras y de 47,76% de los médicos.Conclusión:esta investigación del proceso de preanálisis proporciona subsidios que contribuyen al avance de los conocimientos sobre la auditoría de las cuentas de los hospitales.

ABSTRACTObjectives:to determine which component items of hospital bills, examined by nurse auditors, were adjusted the most during pre-analysis; to identify the impact upon revenue caused by the adjustments to bills analyzed by physician and nurse auditors; and to identify disallowances related to items checked by the audit team.Method:quantitative, exploratory, descriptive, singlecase study.Results:after analysis of 2,613 bills, it was found that the item most included by nurses was gas (90.5%) and the most excluded was inpatient drugs (41.2%). Hemodynamics materials, gases and equipment had the greatest impact on upward adjustments. Downward adjustments were the result of improper entries on bills and did not generate revenue losses. Of total disallowances, 52.24% were related to the pre-analysis of nurses and 47.76% to that of physicians.Conclusion:this study of the pre-analysis process provides input that enhances knowledge about hospital bill audits.

Anatomia patológica da sinóvia de pacientes submetidos à liberação do túnel do carpo / Pathological study of the synovial tissue of patients who underwent open carpal tunnel release

OBJETIVO: Verificar se a biópsia da sinóvia do túnel do carpo é capaz de identificar patologias sistêmicas que não foram diagnosticadas clinicamente ou por exames laboratoriais. MÉTODO: 46 exames anatomopatológicos da sinóvia dos tendões flexores no túnel do carpo de pacientes submetidos à liberação aberta para o tratamento desta síndrome compressiva foram, retrospectivamente, analisados. Os autores propuseram uma nova classificação para a lesão de acordo com a intensidade do processo inflamatório. RESULTADOS: O exame anatomopatológico mostrou que 56,6 por cento das lâminas foram classificadas como grau I (sem alterações inflamatórias), 32,6 por cento, grau II (infiltrado leucocitário e fibrose discretos, além de hialinose), 4,3 por cento, grau III (infiltrado leucocitário e fibrose intensos, presença de fibrina e neoformação vascular) e 6,5 por cento, grau IV (as alterações acima descritas associadas à presença de calcificação local e células gigantes). Dois pacientes com amiloidose foram classificados como graus I e II e não foram encontrados depósitos de material amilóide em suas lâminas. Dois pacientes portadores de hiperparatireoidismo e outro com insuficiência renal crônica foram classificados como grau IV. CONCLUSÃO: A realização da biópsia da sinóvia do túnel do carpo, além de agregar custos adicionais ao procedimento, não possibilitou o diagnóstico precoce de doenças sistêmicas em pacientes portadores de síndrome do túnel do carpo.

OBJECTIVE: To determine whether a biopsy of the synovia of the carpal tunnel is able to identify systemic diseases that were not diagnosed by clinical examination and laboratory tests. METHODS: Anatomical pathology P examinations of synovial tissue were performed in 46 patients that underwent open carpal tunnel release. Anatomical pathology examination with hematoxylin-eosin staining determined the intensity of the inflammatory process and the authors proposed a new classification of the injury according to the intensity of the inflammatory process. RESULTS: The anatomical pathology examination showed that 56.6 percent were classified as grade I (unchanged inflammation), 32.6 percent, grade II (leukocyte infiltration and discreetmoderate fibrosis), 4.3 percent, grade III (leukocyte infiltrate and intense fibrosis, the presence of fibrin and vascular neoformation) and 6.5 percent, grade IV (changes described above associated with the presence of local calcification and giant cells). Two patients with amyloidosis were classified as grade I and II and no stockpiles of amyloid material were found on their slides. Two patients with hyperparathyroidism and another with chronic kidney failure were classified as grade IV. CONCLUSION: Synovial biopsy of the carpal tunnel did not make early diagnosis of potential systemic diseases possiblein patients with carpal tunnel syndrome, and adds extra costs to the procedure.

Hamartoma fibrolipomatoso de nervo mediano: relato de caso / Fibrolipomatous hamartoma of the median nerve: case report

Fibrolipomatous hamartoma is a rare benign neoplasm that in some cases is associated with macrodactylia. We describe a 31-year-old man who had a tissue enlargement in the wrist, second and third fingers of the left hand since infancy. At 23-years-old he began with continuous, progressive and high intensity pain that occurred more frequently at night, localized in the left hand. It was associated with paraesthesias and hypostesias predominantly at the fingers described above. Investigation with X-ray, ultrasonography, electrodiagnosis, magnetic resonance image of the left wrist and hand showed carpal tunnel syndrome with macrodactylia by fibrolipomatous hamartoma of the median nerve. The patient did not a have good response to clinical therapy, so he was submitted to a surgical decompression of the left carpal tunnel, and after three months of follow up is asymptomatic.

O hamartoma fibrolipomatoso é neoplasia benigna rara que em alguns casos esta associada com macrodactilia. Descrevemos o caso de homem de 31 anos que apresentava desde o nascimento aumento de volume em região de punho, segundo e terceiro quirodáctilos da mão esquerda. Aos 23 anos iniciou dor contínua, de forte intensidade, predominante no período noturno e de evolução progressiva em mão esquerda. Associada à dor havia hipoestesia e parestesias de predomínio nos segundo e terceiro quirodáctilos esquerdos. A investigação complementar com radiografia, ultrassonografia, estudo eletrofisiológico e ressonância magnética de mão e punho esquerdos confirmaram a suspeita de síndrome do túnel do carpo secundária a macrodactilia com hamartoma fibrolipomatoso do nervo mediano. O paciente foi submetido à descompressão cirúrgica do túnel do carpo esquerdo devido a ausência de resposta ao tratamento clínico e evoluiu com melhora dos sintomas em avaliação após três meses do procedimento.

Síndrome del túnel carpiano: vinculación básico clínica / Syndrome of the carpal tunnel: basic-clinic tie

Se comenta acerca de la importancia de la mano en la evolución del hombre y la necesidad de su integridad anatómica para mantener su funcionalidad. Se realiza vinculación básico-clínica con una patología de relativa frecuencia como es el Síndrome del Túnel Carpiano, señalando algunos factores que inciden en su etiología y poniendo a consideración la posibilidad de su prevención...

Axonal degeneration in association with carpal tunnel syndrome

Median nerve entrapment in the palm to wrist segment is known as carpal tunnel syndrome (CTS). Electromyography is the best evaluation test to confirm the disease, as it shows a median reduced conduction velocity and/or conduction block; however, the usual CTS electrodiagnostic tests do not separate segmental demyelination alone from segmental demyelination plus secondary axonal degeneration. We studied 100 hands from CTS patients (classified as mild, moderate, and severe), and 50 hands from normal subjects. The median palmar sensory nerve action potential (SNAP) amplitude was measured and compared between the two groups. It would be expected that SNAP was normal if no axonal degeneration had occurred. The results showed that in mild CTS group and part of moderate CTS group SNAP amplitude was normal, whereas in severe CTS group, and part of moderate group SNAP amplitude was reduced, proving that axonal degeneration was involved. As it is well stated that axonal lesions have worse prognosis than segmental demyelinating ones, this simple test may help to preditic the CTS outcome and treatment

Carpal tunnel syndrome

This is a retrospective study of 635 patients suffering from carpal tunnel syndrome [CT Sydrome], who were referred to department of Physical Medicine and Rehabilitation of Combined Military Hospital, Rawalpindi. In this article we have presented our nine years experience [Jan 1987 to Dec 1995] of incidence, symptoms, signs, clinical diagnosis and electrophysiological studies. Nerve conduction studies [NCS] were performed with MS6 system [MEDELEC] using surface electrodes. Concentric needle electromyograph [NEMG] was performed using NEUROPACK electromyographic model MEM-7102 K. Out of 635 patients studied, CT syndrome was four times more common in women. It most commonly affected in the fourth or fifth decade. Most frequent symptoms were paraesthesia, numbness affecting the flexor aspect of the thumb, index and middle finger with or without pain. Phalen's manoeuvre was positive in 394 patients [62%] and Tinel's sign was positive in 476 patients [75%]. CT Syndrome most commonly affected the dominant hand in 255 patients [40%], bilateral in 224 patients [35%] and left sided in 156 patients [25%]- Nerve conduction studies [NCS] using surface electrodes and concentric needle electromyography [NEMG] were very useful in confirming the diagnosis