Postoperative Electrophysiological Studies in Carpal Tunnel Syndrome

Ali Abbas Hashim Almusawi,Asr Faeq Abdulrasool Alattar
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Keywords : CTS, NCV,MRI,CT SCAN, EMG
Medical Journal of Babylon  13:1 , 2016 doi:1812-156X-13-1
Published :12 April 2016

Abstract

Carpal Tunnel Syndrome (CTS) is the most common entrapment neuropathy in the upper extremity.The median nerve is compressed within its course through the carpal Tunnel just distal to the wrist crease. Usually Occur in middle aged patients Ratio of female to male = 4: 1. It is bilateral in over 50 % of cases, but is usually worse in the dominant hand. Early diagnosis and treatment are important and result in complete cure, delay can result in irreversible median nerve damage Every patient with carpal tunnel syndrome should be care¬fully and individually evaluated clinically for proper diagnosis before surgery and thorough search for any associated condition that mimic carpal tunnel syndrome and may be responsible for postoperative complaints.Frequently use postoperative nerve conduction studies for prognostic purposes and to serve as a baseline in determine the postoperative state of median nerve. A patient with any numbness or tingling in the fingers or with any weakness or atrophy of the thenar muscles must be considered as having carpal tunnel syndrome, unless proves otherwise.

Introduction

Aetiology Carpal Tunnel is a closed space, and in this space any swelling may cause median nerve compression. In most cases, no specific etiology can be identified. The following etiologies tend to be more common in younger patients: A. Classic CTS: chronic time course, usually over aperiod of months to years 1. Truma : often job – related. a. Repetitive movements of hand or wrist: carpenters. b. Repeated forceful grasping or pinching of tools or other objects. c. Awkward positions of hand and or wrist, including wrist extension, ulnar deviation, or especially forced wrist flexion. d . Direct pressure over carpal tunnel. e. Use of vibrating hand tools. 2. Systemic conditions: a. Obesity. b. Local truma. c. Pregnancy and lactation. d. D.M. e. Rheumatiod arthritis . f . Mucopolysaccharidosis v . g. Menstural cycle . h. Contraceptive pills. I . Menopause. J. Pyridoxine deficiency. K. Amyloidosis. L. Chondrocalcinosis. M. Myxedema. W. Acromegaly. O. Athetoid – dystonic cerebral palsy . 3. Patients with A – V dialysis shunts in the forearm have an increased incidence of CTS , possibly on an ischemic basis or possibly from the underlying renal disorder[9,10]. B. Acute CTS : symptoms appear suddenly and severely following exertion or truma. 1. Median artery thrombosis; a persistent median artery 10% of the population. 2. Hemorrhage or hematoma in the transverse carpal ligament. 3. Tenosynovitis . 4. Acute palmar space in fection . 5. Masses: neurofibroma , hemangioma , lipoma , gouty tophus . C. Miscellaneous 1. Burns at the wrist due to oedema in carpal tunnel with compression of the median nerve. 2. Reduction in the capacity of carpal tunnel: A. Ideopathic or familial thickening of transverse carpal ligament. B. Malunion or callus following colles’ fracture or fracture of the carpal bones . C. Unreduced dislocation of the wrist or intercarpal joints D. Compression by cast. 3. Paraplegic patients that result from increase in pressure in the canal and repetitive truma from the use of a wheel chair[11,12,13].

Materials and methods

Between January  2012 to December 2014, we studied eighty - four patients (102 involved hands)  (54 from orthopedic department, Baghdad Teaching Hospital)  and (30 from neurosurgical department, Specialized Surgical Hospital).
There were sixty-two women (eighty hands) and twenty two men (twenty two hands). The age incidence of our group patients ranged between twenty to sixty-five
years (mean, 42.5 years( There were seventy-seven right hands dominant and seven left hands dominant . There were sixty-five right hands affected and thirty-seven left hands affected. There were sixty-six patients (Unilateral) and eighteen patients (Bilateral). 15 patients  had previous operation for CTS. the duration of the patients symptoms ranged from three months to five years (mean, 31 month).
In each patient, carpal tunnel syndrome was diagnosed by historical review, clinically and by preoperative electrophysiological study .




Results

In our study, patients were divided into three groups according to historical and clinical examination data. Group one: twenty patient (23.8 percent) characterized by intermittent pain and numbness, normal sensory and motor function and negative provocative testy. Group two: fifty five patient (65.4 percent) characterized by persistent pain and numbness with proximal radiat¬ion of pain, Sensory examination reveal (normal, paresthesia, hypesthesia) motor examination reveal (normal, weak, waste) thenarmuscles. Group three: nine patients (10.8 percent) characterized by persistent pain and numbness with proximal radiation of pain, marked sensory Loss, with marked weak and waste of thenar muscles. In both groups, two and three patients were evaluated with sensibility tests, results were recorded in (Table -3).

Discussions

Nerve conduction study are commonly performed in the evaluation of the syndrome and provide an objective measure of electrophysiologic changes with attention to the technical detail which is critical in arriving at reliable findings[14]. The information obtained narrow differential diagnosis and help plan treatment and determine prognosis. In the diagnostic evaluation of patients suspected of having the carpal tunnel syndrome, clinical electromyography had been proven to be an extremely valuable laboratory procedures, in recent years several electrodiagnostic criteria have been described for early diagnosis, but diagnosis can be made on the basis of prolonged duration of sensory nerve action potential response [15,16]. The estimation of the ratio of the median to ulnar sensory potential amplitude is a sensitive test and it is particularly useful in those patients who show abnormal latency of median nerve [17]. In our series distal sensory latencies were (62.7%) and only (28.4 %) hands, had normal both latencies but with decrease in nerve velocities.In our series pain and paresthesia disappear immediate in most of them with small number will disappear over a period of seven days, with normal thenar muscles power . In our series most of patients gets immediate benefit from surgery with few numbers gets benefit over several days, Only three patients out of thirty five on whom follow up have been done still were complained of weak thenar muscles function. The complications from surgical treatment of the syndrome for the most part must be attributed to poor technique, the greatest number of patients with complication were those whose entire ligament had not been completely released [9]. In our series , no complications were recorded and 15 patients who had previous operation for CTS has reported again and intraoperatively we found incomplete resected flexor retinaculum, so complete section is mandatory because recurrence of CTS occur with incomplete section . reassessment had been done clinically and with electrophysiological study postoperative nerve conduction studies were used for prognostic purposes and to serve as a baseline in determine the postoperative state of median nerve

Conclusions

1. Every patient with carpal tunnel syndrome should be care¬fully and individually evaluated clinically for proper diagnosis before surgery and thorough search for any associated condition that mimic carpal tunnel syndrome and may be responsible for postoperative complaints. 2. Electrophyiologica1 studies is mandatory in every patients whether the diagnosis is certain or uncertain , to detect or exclude coexisting condition prior to surgery to confirm the diagnosis in correlation to clinical findings. 3. Interthenar incision, is small incision, yield complete exposure of carpal ligament allowing safe sectioning. 4. Sufficient decompression of the median nerve in carpal tunnel syndrome is usually obtained by simple sectioning of the entire ligament and give dramatic relief . 5. At time of surgery. one must be careful and gentle to look for any pathological condition which may cause carpal tunnel syndrome. 6. It is unnecessary to perform internal neurolysis even in cases with sever compression proved clinically and with electrophysiological study . 7. Patients usually not need hospitalized postoperatively more than 24 hr. 8. Wefrequently use postoperative nerve conduction studies for prognostic purposes and to serve as a baseline in determine the postoperative state of median nerve

References

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