Treatment of carpal tunnel syndrome
In September 2008, the Board of Directors of the American Academy of Orthopaedic Surgeons approved a clinical practice guideline on the treatment of carpal tunnel syndrome. This guideline was subsequently endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The guideline makes nine specific recommendations: A course of nonsurgical treatment is an option in patients diagnosed with carpal tunnel syndrome. Early surgery is an option with clinical evidence of median nerve denervation or when the patient so elects. Another nonsurgical treatment or surgery is suggested when the current treatment fails to resolve symptoms within 2 to 7 weeks. Sufficient evidence is not available to provide specific treatment recommendations for carpal tunnel syndrome associated with such conditions as diabetes mellitus and coexistent cervical radiculopathy. Local steroid injection or splinting is suggested before considering surgery. Oral steroids or ultrasound are options. Carpal tunnel release is recommended as treatment. Heat therapy is not among the options to be used. Surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum is recommended. Routine use of skin nerve preservation and epineurotomy is not suggested when carpal tunnel release is performed. Prescribing preoperative antibiotics for carpal tunnel surgery is an option. It is suggested that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. It is suggested that instruments such as the Boston Carpal Tunnel Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire be used to assess patient responses to carpal tunnel syndrome treatment for research.
Available from: Javier Vaquero
- "Endoscopic CTR has shown clinical superiority to classic open CTR (OCTR)     , however, concerns persist over incomplete releases in cadavers      and complications to neurovascular structures and tendons    . Mini-OCTR has matched endoscopic CTR in clinical results and morbidity     , however there is concern that part of the procedure is performed blindly (Blind mini-OCTR)    . "
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Authors have reported better outcomes, by reducing surgical dissection for carpal tunnel syndromes requiring surgery. Recently, a new sonographically guided technique for ultra minimally invasive (Ultra-MIS) carpal tunnel release (CTR) through 1 mm incision has been described.
We hypothesized that a clinical trial for comparing Ultra-MIS versus Mini-open Carpal Tunnel Release (Mini-OCTR) was feasible.
Materials and methods
To test our hypothesis, we conducted a pilot study for studying Ultra-MIS versus Mini-OCTR respectively performed through a 1 mm or a 2 cm incision. We defined success if primary feasibility objectives (safety and efficacy) as well as secondary feasibility objectives (recruitment rates, compliance, completion, treatment blinding, personnel resources and sample size calculation for the clinical trial) could be matched. Score for Quick-DASH questionnaire at final follow-up was studied as the primary variable for the clinical trial. Turnover times were studied for assessing learning curve stability.
Forty patients were allotted. Primary and secondary feasibility objectives were matched with the following occurrences: 70.2% of eligible patients finally recruited; 4.2% of randomization refusals; 26.6 patients/month recruited; 100% patients receiving a blinded treatment; 97.5% compliance and 100% completion. A sample size of 91 patients was calculated for clinical trial validation. At final follow-up, preliminary results for Quick-Dash substantially favored Ultra-MIS over Mini-OCTR (average 14.54 versus 7.39) and complication rates were lower for Ultra-MIS (5% versus 20%). A stable learning curve was observed for both groups.
The clinical trial is feasible. There is currently no evidence to contraindicate nor withhold the use of Ultra-MIS for CTR.
Level of evidence
Available from: Raviraj Nataraj
- "While CTS is noted as a peripheral neuropathy, its effects on central-level changes have been demonstrated by altered representations at the primary sensory cortex . Characterizing the underlying effects of CTS may provide further insight into its functional consequences and guide considerations for its diagnosis and treatment , . "
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ABSTRACT: Carpal tunnel syndrome (CTS) compromises fine sensorimotor function during activities of daily living. Reach-to-pinch for a small object requires not only dexterity of the grasping digits, but also coordinated transport of the hand to the target. This study examined the effects of CTS on the kinematic performance of reach-to-pinch maneuver.
Eleven CTS subjects and 11 able-bodied (ABL) controls donned markers for motion capture of the hand, thumb and index finger during reach-to-pinch. Subjects were presented with a virtual target they could see without seeing their reaching upper-extremity. Subjects were instructed to reach to and grasp a virtual object as accurately and precisely as possible. Performance was assessed by variability of the movement trajectories of the digits and hand, the accuracy relative to the target, and precision of pinch contact over repetitive trials.
The CTS group demonstrated significantly increased movement variability in inter-pad distance, joint angles, and transport of the hand compared to ABL controls (p<0.01). CTS subjects also exhibited reductions in accuracy (41%) and precision (33%) of their pinch contact location (p<0.05).
CTS adversely affects the ability to execute the reach-to-pinch maneuver. Reduced performance was shown in terms of increased variability for both grasp and transport and the ability to locate the grasping digits relative to a target-object. These performance indices could be used for diagnostic and evaluative purposes of CTS.
Available from: Saeid Khosrawi
- "According to the recommendations of American Association of Orthopedic Surgeons (AAOS), conservative treatments include splinting, local steroid injection, ultrasound, and oral steroids that are effective in patients with mild to moderate symptoms. Surgery is suggested if conservative treatments fail.5 "
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ABSTRACT: Carpal tunnel syndrome (CTS) is the most preva lent form of peripheral neuropathy. The efficacy of acupuncture in management of mild to moderate CTS has been investigated in limited studies with controversial results. The aim of this study was to assess the short-term effects of acupuncture in treatment of mild to moderate carpal tunnel syndrome.
In a randomized controlled trial study, participants were randomly assigned to either control group which night splinting, vitamin B1, B6 and sham acupuncture for four weeks were administered, or intervention group that underwent acupuncture in 8 sessions over 4 weeks and night splinting. The clinical symptoms using global symptom score (GSS) and electrophysiological parameters were assessed at baseline and four weeks after the intervention.
Of 72 patients met the inclusion criteria, 64 patients actually completed the 4 week intervention and were evaluated for the outcome. There was a statistically significant difference in GSS between two arms of treatment after the intervention (p < 0.001) Using repeated measure ANOVA, the GSS in acupuncture group was significantly different after 4 weeks (p <0.001). Among electrophysiological parameters, nerve conduction velocity (NCV) was significantly different between two groups after 4 weeks (p = 0.02). Other parameters showed no statistically significant difference after intervention (p > 0.05).
Our findings indicated that the acupuncture can improve the overall subjective symptoms of carpal tunnel syndrome and could be adopted in comprehensive care programs of these patients.
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