[Carpal tunnel syndrome. Results of electrodiagnostic studies.].

The results of electrodiagnostic studies on 557 hands of 383 patients with the clinical diagnosis of carpal tunnel syndrome (CTS) are described. History taking, examination and electrodiagnostic studies were performed by the same neurologist (MPH). The diagnostic sensitivity for the distal motor latency (DML) was 68%, while the sensitivity for the distal sensory latency (DSL) was 77% and the combined sensitivity for these parameters was 83%. With various "unconventional" studies 91% of hands were diagnosed with CTS. From our results the cause for slowing of median motor nerve conduction velocity (m-MNCV) in the forearm seems to be both demyelination at the wrist and axonal degeneration. However, hands with denervation had more slowing of m-MNCV in the forearm than hands without denervation. Hands with clumsiness, subjective weakness, objective weakness and thenar atrophy, compared to hands without these symptoms and signs, had a higher estimate of the relative risk of abnormal DML, DSL, compound motor action potential (CMAP), compound sensory nerve action potential (CSNAP), m-MNCV in the forearm and electromyography (EMG) on abductor pollicis brevis (APB) and from less severe to more severe motor symptoms and signs the odds ratio steadily increased for all tested parameters. Hands with Phalen's sign had more prolonged DML and abnormal EMG on APB compared to hands without Phalen's sign but other test parameters showed no difference. No difference could be found for any test parameters between hands with or without Tinel's sign, neither between hands without pain or with pain, whether in the hand or more proximally in the upper extremity, nor between hands of 150 patients with bilateral CTS who claimed one hand worse than the other. In hands with decreased pin prick, decreased touch or hyperesthesia, compared to hands with a normal sensory examination, the DML, CMAP, and EMG on APB were significantly more often abnormal but no difference was found for any of the sensory conduction test parameters. With increasing duration of symptoms there were significantly more abnormal results for all tested parameters except CMAP, especially when the symptoms had lasted for more than 10 years.

[Carpal tunnel syndrome].

Analysed are the clinical data of 557 involved hands in 383 patients with carpal tunnel syndrome (CTS) diagnosed and treated in a private neurological practice in Reykjavik, Iceland over a seven year period. The subjects form a selected group as the patients are referred by medical practitioners or seek assistance on their own initiative. The study involved 241 females and 142 males. Age ranged from 14 to 91 years, mean 49 ± 16.5 years at the time of diagnosis. Both hands were involved in 45.5% of patients, judged clinically. Even though the mean age at diagnosis and duration of symptoms were similar to other studies patients in younger age groups were more common in this study (figure 1). Occupation was known for 376 patients. The occupational classes for the patients are shown in table IV compared to a recent national survey on occupational classification in Iceland. Of 239 females 193 (80.6%) were housewives and of those 152 (78.7%) were also employed. Of the employed patients 82.3% males and 48.8% females were in occupational classes involving manual work compared to 49.5% males and 24.3% females in the control group. The dominant hand was the only hand involved or with worse symptoms in 67.2% of patients (table I). Is CTS an occupational disease? Definite conclusions can not be drawn from these results. Manual workers might seek medical attention more frequently for their symptoms. Symptoms and signs in the 577 hands are shown in table II. Further study on the incidence of CTS in Iceland and it's relationship to the patient's occupation is needed.

Effect of total lymphoid irradiation on functional status in chronic multiple sclerosis: importance of lymphopenia early after treatment--the pros.

To determine whether immunosuppression by total lymphoid irradiation (TLI) slowed deterioration of chronic progressive multiple sclerosis (MS), functional impairment score and blood lymphocyte counts were compared at 6-month intervals through 4 years following treatment of MS patients by either TLI (n = 27) or sham irradiation (n = 21). At each interval, 20 to 30% fewer TLI-treated patients had deteriorated (p less than 0.05 at 6, 12, and 18 months), and the difference in mean functional impairment score between groups became progressively greater (p less than 0.01 at 42 and 48 months). Benefit accrued principally to the 17 TLI-treated patients with absolute blood lymphocyte counts less than 900/mm3 3 months after treatment, whose mean functional impairment score remained within 0.6 units of baseline (p = NS), whereas the ten TLI patients with higher post-treatment lymphocyte counts had progressive deterioration (p less than 0.05 to p less than 0.001 versus TLI-treated patients with lower lymphocyte counts at all intervals except 30 months) and had deteriorated by more than 5 functional scale units by 42 and 48 months. Side effects were minor and complications rare in TLI-treated patients, but one TLI-treated patient developed staphylococcal sepsis. Thus, TLI slows deterioration of chronic progressive MS, with what appears to be enduring benefit through 4 years compartmented to patients with greater induced lymphopenia. Modification of lymphoid irradiation regimens to increase the proportion of MS patients who achieve a favorable degree of lymphopenia and to avert functional hyposplenism may further improve the benefit/risk ratio.

Total lymphoid irradiation for multiple sclerosis.

Although chemical immunosuppression has been shown to benefit patients with chronic progressive multiple sclerosis (MS), it appears that chemotherapy has an appreciable oncogenic potential in patients with multiple sclerosis. Accordingly, we developed a modified total lymphoid irradiation (TLI) regimen designed to reduce toxicity and applied it to a randomized double blind trial of TLI or sham irradiation in MS. Standard TLI regimens were modified to reduce dose to 1,980 rad, lowering the superior mantle margin to midway between the thyroid cartilage and angle of the mandible (to avert xerostomia) and the lower margin of the mantle field to the inferior margin of L1 (to reduce gastrointestinal toxicity by dividing abdominal radiation between mantle and inverted Y), limiting spinal cord dose to 1,000 rad by custom-made spine blocks in the mantle and upper 2 cm of inverted Y fields, and also protecting the left kidney even if part of the spleen were shielded. Clinical efficacy was documented by the less frequent functional scale deterioration of 20 TLI treated patients with chronic progressive MS compared to to 20 sham-irradiated progressive MS patients after 12 months (16% versus 55%, p less than 0.03), 18 months (28% versus 63%, p less than 0.03), and 24 months (44% versus 74%, N.S.). Therapeutic benefit during 3 years follow-up was related to the reduction in lymphocyte count 3 months post-irradiation (p less than 0.02). Toxicity was generally mild and transient, with no instance of xerostomia, pericarditis, herpes zoster, or need to terminate treatment in TLI patients. However, menopause was induced in 2 patients and staphylococcal pneumonia in one. Our data suggest that this modified TLI regimen has clinical efficacy and sufficiently low toxicity to make it suitable for investigative immunosuppressive treatment of patients with progressive MS or other non-malignant conditions.

Effect of total lymphoid irradiation in chronic progressive multiple sclerosis.

Total lymphoid irradiation (TLI; 1980 cGy) or sham irradiation was given to 40 patients with chronic progressive multiple sclerosis (MS) in a prospective, randomised, double-blind study. During mean follow-up of 21 months, MS patients treated with TLI had less functional decline than sham-irradiated MS patients (p less than 0.01). A significant relation was noted between absolute blood lymphocyte counts in the first year after TLI and subsequent course, patients with higher lymphocyte counts generally having a worse prognosis (p less than 0.01). TLI was well tolerated and associated with only mild short-term, and to date, long-term side-effects.

The effect of oral corticosteroid dosage on CT enhancing multiple sclerosis plaques.

Fifty high-dose delayed CT scans were performed on 36 patients with definite MS within 4 months of a clinical relapse. The number of enhancing lesions visualized was compared in patients being treated with high- or low-dose oral corticosteroids and untreated controls. High-dose oral corticosteroid treatment significantly but incompletely reduced enhancement of MS plaques. Lower doses were less effective, especially when the latter were given on alternate days.