carpal tunnel syndrome (median neuropathy)
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Introduction
Entrapment of the median nerve at the carpal tunnel (wrist).
Etiology
- idiopathic
- occupational
- pregnancy
- hypothyroidism
- rheumatoid arthritis
- injury (Colles fracture)
- amyloidosis
- acromegaly
- multiple myeloma
- T-cell lymphoma[17]
- diabetes mellitus[8]
- obesity
Epidemiology
- 3% of U.S. population
- more common in females[23]
Pathology
- nerve impingement syndrome due to compression of the median nerve as it passes through the carpal tunnel
- thickening from tendinitis or other swelling can narrow the carpal tunnel & causes the median nerve to be compressed
Genetics
- associated with defects in transthyretin (type 1)
Clinical manifestations
- pain & paresthesias, especially at night
- often relieved by shaking affected wrist/hand[23]
- wrist pain & numbness that worsens with repetitive activity
- sensory abnormalities on palmar surface of radial 3 & 1/2 fingers (includes thumb)[4]
- Tinel's sign (limited discrimination utility)[4]
- Phalen's sign (limited discrimination utility)[4]
- Durkan maneuver (64% sensitive, 83% specific)
- pain may refer to the forearm or shoulder
- thenar atrophy & muscle weakness occurs with more severe cases[13]
Laboratory
- thyroid function tests
- erythrocyte sedimentation rate
- complete blood count
- fasting serum glucose
- serum protein electrophoresis, urine protein electrophoresis if multiple myeloma suspected
Diagnostic procedures
- EMG, nerve conduction study if surgery contemplated
- slowed impulse conduction in the median nerve
- include entire upper extremity in study
- more proximal nerve entrapment may produce similar symptoms
- active denervation is an indication for surgical decompression
- ultrasound, neuromuscular
- measurement of median nerve cross-sectional area[9]
Radiology
- magnetic resonance imaging of unclear value[4]
Differential diagnosis
- C6, C7 radiculopathy
- tenosynovitis & osteoarthritis
- polyneuropathy
- proximal median nerve injury (at elbow)
- brachial plexus lesion Complication:
- increased risk of later amyloidosis (0.10% vs 0.006%)[20]
- increased risk of later heart failure (5.3% vs 3.2%)[20]
Management
- avoidance of repetitive motions
- wrist splint that holds wrist straight or extended not greater than 15 degrees (at night)
- occupational therapy[4]
- anti-inflammatory agents
- prednisone 20 mg PO QD for 1 week, then 10 mg QD for 1 week
- NSAIDs as needed
- glucocorticoid injection[5]
- more effective than oral glucocorticoid
- 0.25 mg of Kenalog (40 mg/mL) + 0.75 mL of 1% lidocaine
- injection into flexor retinaculum adjacent to median nerve or just proximal to the carpal tunnel[3]
- outcomes are better when carpal tunnel injection is performed under ultrasound guidance[16]
- relief of symptoms strongly supports diagnosis
- early improvement in symptoms, but most patients still opt for surgery[10]
- intermediate-term outcomes similar for glucorticoid injection vs slinting but glucorticoid injection resulted in fewer lost work days[19]
- ultrasound-guided perineural injection with D5W superior to glucocorticoid injection[18]
- ice pack to the palm side of the wrist
- splinting[19]
- surgical decompression[5]
- release of transverse carpal ligament[15]
- prevent irreversible muscle weakness[4]
- indications:
- active denervation on nerve conduction studies
- muscle weakness & muscle atrophy (thenar atrophy)[4]
- intolerable pain[4]
- not responsive to conservative measures[4]
- useful for patients without denervation[7]
- superior to medical management[21]
- improve control of comorbidities
- 50 mg of vitamin B6 BID may be of benefit
- indications for follow-up
- severe pain not relieved by rest, ice, & anti-inflammatory agents
- hand grip becomes weak
- numbness persisting more than one month
- prognosis
- thenar atrophy & weakness of pinch or opposition strength are late motor signs that may respond poorly to surgical or medical management
- better symptom relief with steroid injection than surgery in 1st few months; no difference at 6 months[5]
More general terms
- entrapment neuropathy; nerve entrapment syndrome; pinched nerve
- median neuropathy
- repetitive strain disorder
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 803-805, 1016-18
- ↑ DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 872
- ↑ 3.0 3.1 Journal Watch vol 19 #22, pg 177, Nov 15, 1999
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018.
- ↑ 5.0 5.1 5.2 5.3 Journal Watch 25(6):52, 2005 Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005 Feb;52(2):612-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15692981
- ↑ Jarvik JG et al Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial The Lancet 2009, 374:1074-1081 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19782873
Atroshi I and Gummesson C Non-surgical treatment in carpal tunnel syndrome The Lancet 2009, 74:1042-1044 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19782855 - ↑ 7.0 7.1 Jarvik JG et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: A randomised parallel-group trial. Lancet 2009 Sep 26; 374:1074. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19782873
- ↑ 8.0 8.1 Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
- ↑ 9.0 9.1 Cartwright MS et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve 2012 Aug;46(2):287-93 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22806381
- ↑ 10.0 10.1 Atroshi I et al Methylprednisolone Injections for the Carpal Tunnel Syndrome: A Randomized, Placebo-Controlled Trial. Ann Intern Med. 2013;159(5):309-317 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24026316 <Internet> http://annals.org/article.aspx?articleid=1733275
- ↑ D'Arcy CA, McGee S. Clinical diagnosis of carpal tunnel syndrome JAMA. 2000 Oct 18;284(15):1924-5. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11035885
D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA. 2000 Jun 21;283(23):3110-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10865306 - ↑ Huisstede BM, Hoogvliet P, Randsdorp MS et al Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):981-1004. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20599038
Huisstede BM, Randsdorp MS, Coert JH et al Carpal tunnel syndrome. Part II: effectiveness of surgical treatments--a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):1005-24 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20599039 - ↑ 13.0 13.1 The NNT: Carpal Tunnel Syndrome http://www.thennt.com/lr/carpal-tunnel-syndrome/
- ↑ Alfonso C, Jann S, Massa R, Torreggiani A. Diagnosis, treatment and follow-up of the carpal tunnel syndrome: a review. Neurol Sci. 2010 Jun;31(3):243-52 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20145967
- ↑ 15.0 15.1 15.2 Young K, Sofair A, Chavey WE Carpal Tunnel Syndrome Guidelines Published Physician's First Watch, March 4, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
Guideline on the Treatment of Carpal Tunnel Syndrome American Association of Orthopedic Surgeons (AAOS) http://www.aaos.org/Research/guidelines/CTStreatmentguide.asp
Carpal tunnel syndrome appropriate use criteria American Academy of Orthopaedic Surgeons (AAOS) http://www.orthoguidelines.org/go/auc/default.cfm?auc_id=224989&actionxm=Terms - ↑ 16.0 16.1 Evers S, Bryan AJ, Sanders TL, Selles RW, Gelfman R, Amadio PC. Effectiveness of ultrasound-guided compared to blind steroid injections in the treatment of carpal tunnel syndrome. Arthritis Care Res (Hoboken) 2017 Jul; 69:1060 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27696773
- ↑ 17.0 17.1 Chevalier X, Hermine O, Authier FJ, Gaulard P, Gherardi RK. Carpal tunnel syndrome due to T cell lymphoma. Arthritis Rheum. 1995 Nov;38(11):1707-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/7488294
- ↑ 18.0 18.1 Wu YT, Ke MJ, Li TY. Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol 2018 Sep 5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30187524 https://onlinelibrary.wiley.com/doi/abs/10.1002/ana.25332
- ↑ 19.0 19.1 19.2 Chesterton LS et al. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): An open-label, parallel group, randomised controlled trial. Lancet 2018 Oct 20; 392:1423. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30343858 Free PMC Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31572-1/fulltext
- ↑ 20.0 20.1 20.2 Fosbol EL, Rorth R, Leicht BP et al Association of Carpal Tunnel Syndrome With Amyloidosis, Heart Failure, and Adverse Cardiovascular Outcomes. J Am Coll Cardiol. Volume 74, Issue 1, July 2019 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/31272537 <Internet> http://www.onlinejacc.org/content/74/1/15
Ton VK, Patel S, Gottlieb SS Carpal Tunnel Syndrome and Future Amyloidosis. Time to Heed the Warning Sign. J Am Coll Cardiol. Volume 74, Issue 1, July 2019 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/31272547 <Internet> http://www.onlinejacc.org/content/74/1/24 - ↑ 21.0 21.1 Blom AW, Donovan RL, Beswick AD et al. Common elective orthopaedic procedures and their clinical effectiveness: Umbrella review of level 1 evidence. BMJ 2021 Jul 7; 374:n1511 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34233885 PMCID: PMC8262448 Free PMC article https://www.bmj.com/content/374/bmj.n1511
- ↑ Currie KB, Tadisina KK, Mackinnon SE Common Hand Conditions. A Review. JAMA. 2022;327(24):2434-2445. June 28 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35762992 https://jamanetwork.com/journals/jama/fullarticle/2793654
- ↑ 23.0 23.1 23.2 23.3 NEJM Knowledge+ Neurology
- ↑ NINDS Carpal Tunnel Syndrome Information Page https://www.ninds.nih.gov/disorders/all-disorders/carpal-tunnel-syndrome-information-page
Carpal Tunnel Syndrome Fact Sheet https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Carpal-Tunnel-Syndrome-Fact-Sheet
Patient information
carpal tunnel syndrome (median neuropathy) patient information