© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.

© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (4): ITC4-1.

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in the clinic

Carpal Tunnel Syndrome


Who is at risk for carpal tunnel syndrome?

Occupational risk factors

Repetitive forceful hand work with wrist extension

Plus vibration or cold environment

Workers at increased risk

Aircraft engine workers and metal casting workers

Appliance and automobile manufacturers

Construction workers and electronic and forestry workers

Dental hygienists

Fish processing and cannery workers;

Frozen food/meat workers

Furniture factory, garment and textile


Non-occupational Risk Factors

Female gender

Age

Pregnancy

Obesity

Wrist ratio*

Family history

Renal failure/dialysis

Amyloidosis

Drug treatment with aromatase inhibitors

Diabetes

Hypothyroidism

Acromegaly

Previous wrist fracture

Collagen vascular disease

Osteoarthritis of the wrist

Lipid abnormalities**

*anterior to posterior wrist dimension divided by medial to lateral wrist dimension **Studies have shown conflicting data regarding this association of lipid abnormalities with carpal tunnel syndrome


Are there measures that can prevent it?

Prevention measures that may be beneficial

Modification of work environment

Alternation of tasks to reduce high repetition work, vibration, and forceful hand exertion

Weight loss

Smoking cessation

Among hemodialysis patients: switch from conventional to high-flux membrane and use ultra-pure dialysate


CLINICAL BOTTOM LINE: Screening and Prevention...

Several occupational and nonoccupational risk factors may predispose to CTS

No evidence-based guidelines on the choice, usefulness, indications, and cost-effectiveness of sceening tools

Knowing important risk factors may be useful to implement preventive measures


What symptoms suggest CTS?

Pain in the hand and arm

Numbness and paresthesias in the hand

Weakness or clumsiness in the hand

Early stage often presents with nocturnal paresthesias

Hand diagram may help patient localize the symptoms


Hand diagram showing median nerve sensory territory and location of paresthesias in CTS


Elements of History Dull, aching discomfort in hand, forearm, upper arm

Paresthesias in the hand

Hand weakness or clumsiness

Dry skin, swelling, or color changes in the hand

Age >40 years

Nocturnal paresthesias

Provocative factors

Worsening of symptoms at night

Sustained hand or arm positions

Repetitive hand and wrist movements

Improvement with changing position or shaking the hand


What physical examination findings are helpful in making a diagnosis?

Mild CTS

Nocturnal paresthesias

Swelling and pain relieved by shaking hand or changing hand position

Moderate CTS

Symptoms persist during the day

Decreasing sensation results in finger clumsiness

Severe CTS

Numbness without pain

Atrophy of the thenar eminence may occur


Physical Examination Elements

Hypalgesia in median nerve territory

2-point discrimination; using calibers points 4-6mm apart

Atrophy restricted to thenar

Weak thumb abduction

Decreased vibratory sensation

Tinel sign

Phalen sign

Hand elevation test


What other conditions should be considered?

Cervical radiculopathy

Polyneuropathies or multiple mononeuropathies

Brachial plexopathy

Vascular disorders (Raynaud's)

Cervical myelopathy

Other CNS disorders

Other painful articular and soft tissue disorders

Proximal median neuropathy

Pronator teres syndrome (rare)

Anterior interosseus syndrome (rare)


What is the role of NCS and EMG? Gold standard

Confirm diagnosis

Determine degree of severity based on nerve function

Exclude other neuromuscular conditions

Degree of functional impairment of median nerve (NCS)

Recommended when

Clinical diagnosis uncertain

Only a few or atypical clinical features are present

Other neurologic diagnoses are suspected

No response to conservative therapy

Thenar atrophy and/or persistent numbness present

Invasive treatment is considered


What is the role of imaging studies?

Useful when suspecting local structural disease

Wrist films or CT: to evaluate osseous carpal stenosis or bony tumors

MRI or ultrasonography: to visualize soft tissues

Specificity of MRI for diagnosing CTS is rather low

Emerging role for high-frequency ultrasound exam of of the median nerve


Tests for CTS

NCS and electromyography

High-resolution sonography of the carpal tunnel

High-resolution CT of the wrist

MRI of the wrist

Wrist x-ray

Cervical spine MRI

Chest x-ray and/or MRI of brachial plexus

Polyneuropathy evaluation


What other laboratory studies may be useful when diagnosing CTS?

In patients with secondary CTS

Fasting plasma glucose for suspected diabetes

Thyroid function tests for suspected hypothyroidism

Renal function test and uric acid for suspected renal failure or gout

Rheumatoid factor, ESR, antinuclear antibodies, for suspected RA or other connective tissue disorders

Somatomedin-C, prolactin and phosphate levels, and growth hormone suppression test for suspected acromegaly

Serum protein immunofixation for paraproteinemia

Tissue biopsy for amyloid


Doubt about the diagnosis

Conservative treatment failed

Considering surgery or other invasive treatment

To assist with confirmatory NCS/EMG

Ultrasonographic diagnosis

When should clinicians refer patients to a specialist for diagnosis?


CLINICAL BOTTOM LINE: Diagnosis... Highly suggestive signs and symptoms of CTS

Pain in the hand and arm

Numbness and paresthesias in the hand

Weakness or clumsiness in the hand

Electrodiagnostic NCS/EMG confirmation and ultrasonographic evaluation often needed

Several conditions cause similar symptoms and findings

Imaging studies useful to detect rare structural anomalies

Further lab studies may confirm suspected secondary CTS


How should clinicians manage patients with CTS?

First-line treatment for mild CTS

Conservative non-drug modalities

Focused on symptom relief

Drug therapy may also be temporarily effective

If these modalities fail or nerve compression is advanced

Surgical decompression

Patients with secondary CTS

Target treatment at the primary disease


Splinting

Inexpensive and few complications

Mild to moderate CTS: first treatment option

Severe CTS: symptomatic relief while awaiting surgery

Use for at least 4 weeks

Full-time splinting more effective than night only

Neutral position splints relieve symptoms more than cock-up (extension) splints

Aerobic exercise for weight reduction may be useful

What is the role of conservative measures, such as wrist splinting and activity modification?


What is the role of physical therapy?

Ultrasound for CTS

Short-wave diathermy treatment

Yoga-based intervention

Chiropractic or biobehavioral interventions

Magnet therapy

Low-level laser therapy,

Laser acupuncture


Which medications should clinicians prescribe first?

Non-steroidal anti-inflammatory drugs

Oral steroids

Lidocaine patch 5%

Diuretics


When should clinicians consider a corticosteroid injection?

Significant pain and mild to moderate CTS

Injection may provide relief

Effect less likely to last among women / patients with diabetes / those with nerve conduction abnormalities

Steroid injection contraindicated with

Thenar muscle weakness and atrophy

Advanced sensory loss indicating severe CTS

Acute CTS or wrist edema

Multiple injections not recommended


When should clinicians consider referral for surgical or nonsurgical specialist for treatment?

Failure to respond to conservative treatment for pain

Progressive sensory or motor deficits

Moderate-to-severe electrodiagnostic abnormalities

For consideration for surgery


How should clinicians follow patients?

Conservative treatment

Follow ≥6 months

Ensure clinical improvement and response to therapy

If conservative treatment fails

Consider surgical treatment

If patient has symptoms and progressive neurologic deficits

After surgery or injection

Return visits at 2- to 6-week intervals for up to 6 months

Attend to vascular status, wound healing, neurologic function


How should clinicians educate patients about CTS?

Education should address:

Known causes and risk factors

Exacerbating activities

Diagnostic methods

Therapeutic options


CLINICAL BOTTOM LINE: Treatment...

Tailor treatment to individual

Mild to moderate CTS

Splinting in neutral wrist position

Mobilization therapy, steroid injection

For secondary CTS, treat the associated systemic disease

Severe CTS

Surgical decompression

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.

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