Diagnostic Value of a Carpal Tunnel Corticosteroid Injection in Patients with Negative Electrodiagnostic Studies

Abstract Introduction There is a known false negative rate when using electrodiagnostic studies (EDS) to diagnose carpal tunnel syndrome (CTS). This can pose a management dilemma for patients with signs and symptoms that correlate with CTS but normal EDS. While corticosteroid injection into the carpal tunnel has been used in this setting for diagnostic purposes, there is little data in the literature supporting this practice. The purpose of this study is to evaluate the prognostic value of a carpal tunnel corticosteroid injection in patients with a normal electrodiagnostic study but exhibiting signs and symptoms suggestive of carpal tunnel, who proceed with a carpal tunnel release. Materials and Methods The group included 34 patients presenting to an academic orthopedic practice over the years 2010 to 2019 who had negative EDS, a carpal tunnel corticosteroid injection, and a carpal tunnel release. One patient (2.9%), where the response to the corticosteroid injection was not documented, was excluded from the study, yielding a study cohort of 33 patients. Three patients had bilateral disease, yielding 36 hands for evaluation. Statistical analysis was performed using Chi-square analysis for nonparametric data. Results Thirty-two hands (88.9%) demonstrated complete or partial relief of neuropathic symptoms after the corticosteroid injection, while four (11.1%) did not experience any improvement. Thirty-one hands (86.1%) had symptom improvement following surgery, compared with five (13.9%) which did not. Of the 32 hands that demonstrated relief following the injection, 29 hands (90.6%) improved after surgery. Of the four hands that did not demonstrate relief after the injection, two (50%) improved after surgery. This difference was statistically significant (p = 0.03). Conclusion Patients diagnosed with a high index of suspicion for CTS do well with operative intervention despite a normal electrodiagnostic test if they have had a positive response to a preoperative injection. The injection can provide reassurance to both the patient and surgeon before proceeding to surgery. Although patients with a normal electrodiagnostic test and no response to cortisone can still do well with surgical intervention, the surgeon should carefully review both the history and physical examination as surgical success may decrease when both diagnostic tests are negative. Performing a corticosteroid injection is an additional diagnostic tool to consider in the management of patients with CTS and normal electrodiagnostic testing.

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Diagnostic value of cytokeratin-1, survivin and TG expression in circulating tumor cells in the differentiation of benign and malignant thyroid nodules.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e17575 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e17575-e17575

Author(s):

Jie Liu ◽

Siyuan Xu ◽

Jinghua Luo ◽

Yan Wang ◽

Xia Liu ◽

...

Keyword(s):

Thyroid Cancer ◽

Real Time ◽

Quantitative Pcr ◽

Thyroid Nodules ◽

False Negative ◽

False Negative Rate ◽

Diagnostic Value ◽

Screening Methods ◽

Real Time Quantitative Pcr ◽

Minimal Trauma

e17575 Background: Fine needle aspiration cytology (FNAB) has the advantages of minimal trauma, speed and accuracy, and is currently considered to be the most predictive screening technique before thyroid nodule surgery. However, there are several drawbacks to this method, including certain complications, a relatively high false negative rate, a low acceptance of invasive surgery among patients, and the fact that about 20% of the lesions cannot be clearly defined as benign or malignant. Blood-based noninvasive testing can be used to analyze circulating cancer cells (CTCs) for clinical testing. Here, we investigated the performance of CTCs in thyroid cancer screening. Methods: We established a multi-marker real-time quantitative PCR (CK-19/surviving/Tg) to detect and quantify CTCs in peripheral blood samples. 100 subjects who were diagnosed by ultrasound imaging as having thyroid nodules were enrolled. FNAB or surgical specimens were subjected to pathological tests to differentiate between the benign nodules and thyroid cancer. Meanwhile the CTCs in the blood were isolated and quantified by multi-marker qPCR. Results: Among 100 patients, 50 were diagnosed as Papillary Thyroid Carcinoma (PTC) by pathological test. The sensitivity of each single marker of CK19, Survivin and Tg were only 48%, 44%, and 50% respectively, with the specificity of 94%, 100% and 94%. However, the combination of these three markers results in the highest sensitivity and specificity of 86% and 90%. Thus, the combined marker could achieve the best diagnostic value. Conclusions: Compared with FNAB, CTC is minimally invasive. The performance of the multi-marker real-time quantitative PCR showed that CTC could be used as an adjunctive test after ultrasound evaluation. Our results indicated that CTCs have potential clinical value in the identification of benign and malignant thyroid nodules.

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Cochrane corner: local corticosteroid injection for carpal tunnel syndrome

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193413490848 ◽

2013 ◽

Vol 38 (8) ◽

pp. 911-914 ◽

Cited By ~ 6

Author(s):

H. Stark ◽

R. Amirfeyz

Keyword(s):

Carpal Tunnel Syndrome ◽

Confidence Intervals ◽

Carpal Tunnel ◽

Corticosteroid Injection ◽

Signs And Symptoms ◽

Clinical Syndrome ◽

Surgical Interventions ◽

Relative Risks ◽

Tunnel Syndrome ◽

Local Corticosteroid Injection

Background: Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness is unknown. Objectives: To evaluate the effectiveness of local corticosteroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions. Search methods: We searched the Cochrane Neuromuscular Disease Group Trials register (searched May 2006), MEDLINE (searched January 1966 to May 2006), EMBASE (searched January 1980 to May 2006) and CINAHL (searched January 1982 to May 2006). Selection criteria: Randomized or quasi-randomized studies. Data collection and analysis: Three authors independently selected the trials and rated their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated.

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P104: Evaluating the use of the pulmonary embolism rule-out criteria in the emergency department

CJEM ◽

10.1017/cem.2018.302 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S93-S94

Author(s):

S. Sharif ◽

C. Kearon ◽

M. Eventov ◽

M. Li ◽

P. Sneath ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

False Negative ◽

False Negative Rate ◽

Signs And Symptoms ◽

Ct Scanning ◽

Pulmonary Angiogram ◽

Ct Angiogram ◽

D Dimer ◽

Rule Out

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. The pulmonary embolism rule-out criteria (PERC) can identify patients who can be safely discharged from the ED without further investigation for PE. The purpose of this study is to evaluate the use of the PERC rule in the ED and to compare the rates of testing for PE if the PERC rule was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the negative predictive value was calculated. Results: There were 1,163 patients that were tested for PE and 1,097 patients were eligible for our analysis. Of the total, 330/1,097 (30.1%; 95%CI 27.4-32.3%) had CT/VQ imaging for PE, and 48/1,097 (4.4%; 95%CI 3.3-5.8%) patients were diagnosed with PE. 806/1,097 (73.5%; 95%CI 70.8-76.0%) were PERC positive, and of these, 44 patients had a PE (5.5%; 95%CI 4.1-7.3%). Conversely, 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients were PERC negative, and of these, 4 patients had a PE (1.4%; 95%CI 0.5-3.5%). Of the PERC negative patients, 291/291 (100.0%; 95%CI 98.7-100.0%) had a D-dimer test done, and 33/291 (11.3%; 95%CI 8.2-15.5%) had a CT angiogram. If PERC was used, CT/VQ imaging would have been avoided in 33/1,097 (3%; 95%CI 2.2-4.2%) patients and the D-dimer would have been avoided in 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients. Conclusion: If the PERC rule was used in all patients with suspected PE, fewer patients would have further testing. The false negative rate for the PERC rule was low.

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An At-Risk Population Screening Program for Mucopolysaccharidoses by Measuring Urinary Glycosaminoglycans in Taiwan

Diagnostics ◽

10.3390/diagnostics9040140 ◽

2019 ◽

Vol 9 (4) ◽

pp. 140 ◽

Cited By ~ 4

Author(s):

Lin ◽

Lee ◽

Lo ◽

Tu ◽

Chang ◽

...

Keyword(s):

At Risk ◽

Screening Program ◽

False Negative ◽

False Negative Rate ◽

Signs And Symptoms ◽

Population Screening ◽

Risk Population ◽

Medical Specialists ◽

Mps Iva ◽

Mps I

Background: The mucopolysaccharidoses (MPSs) are a group of rare lysosomal storage disorders characterized by the accumulation of glycosaminoglycans (GAGs) and which eventually cause progressive damage to various tissues and organs. We developed a feasible MPS screening algorithm and established a cross-specialty collaboration platform between medical geneticists and other medical specialists based on at-risk criteria to allow for an earlier confirmative diagnosis of MPS. Methods: Children (<19 years of age) with clinical signs and symptoms compatible with MPS were prospectively enrolled from pediatric clinics between July 2013 and June 2018. Urine samples were collected for a non-specific total GAG analysis using the dimethylmethylene blue (DMB) spectrophotometric method, and the quantitation of three urinary GAGs (dermatan sulfate (DS), heparan sulfate (HS), and keratan sulfate (KS)) was performed by liquid chromatography/tandem mass spectrometry (LC-MS/MS). The subjects with elevated urinary GAG levels were recalled for leukocyte enzyme activity assay and genetic testing for confirmation. Results: Among 153 subjects enrolled in this study, 13 had a confirmative diagnosis of MPS (age range, 0.6 to 10.9 years—three with MPS I, four with MPS II, five with MPS IIIB, and one with MPS IVA). The major signs and symptoms with regards to different systems recorded by pediatricians at the time of the decision to test for MPS were the musculoskeletal system (55%), followed by the neurological system (45%) and coarse facial features (39%). For these 13 patients, the median age at the diagnosis of MPS was 2.9 years. The false negative rate of urinary DMB ratio using the dye-based method for these 13 patients was 31%, including one MPS I, two MPS IIIB, and one MPS IVA. However, there were no false negative results with urinary DS, HS and KS using the MS/MS-based method. Conclusions: We established an at-risk population screening program for MPS by measuring urinary GAG fractionation biomarkers using the LC-MS/MS method. The program included medical geneticists and other medical specialists to increase awareness and enable an early diagnosis by detecting MPS at the initial onset of clinical symptoms.

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Rates of and Risk Factors for Trigger Finger after Open Carpal Tunnel Release

Journal of Wrist Surgery ◽

10.1055/s-0041-1730343 ◽

2021 ◽

Author(s):

Jeremy E. Raducha ◽

Winston Jiang ◽

Lindsey Kahan ◽

James Houston Dove ◽

Christopher Cochran ◽

...

Keyword(s):

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Ring Finger ◽

Middle Finger ◽

Chi Square ◽

Level Of Evidence ◽

Patient Demographics ◽

History Of ◽

Chi Square Analysis ◽

Open Carpal Tunnel Release

Abstract Background We have anecdotally noticed a higher rate of trigger fingers (TFs) developing in patients who have undergone carpal tunnel release (CTR). Questions/Objective Is the rate of TFs after CTR greater compared to the nonoperative hand? Is the thumb more commonly involved postoperatively compared with spontaneous TFs? Do particular associated comorbidities increase this risk? Patients and Methods We queried our institutional database for patients who had undergone open CTR during a 2-year period and recorded the development of an ipsilateral TF after a CTR or a contralateral TF in the nonoperative hand. Patient demographics, comorbidities, concurrent initial procedures, time to diagnosis, and finger involvement were recorded. Results A total of 435 patients underwent 556 CTRs during this period. Furthermore, 46 ipsilateral TFs developed in 38 of 556 cases (6.83%) at an average of 228.1 ± 195.7 days after surgery. The thumb was most commonly involved (37.0%) followed by the ring finger (28.3%). The incidence rate of TF in the nonoperative hand during this period was 2.7%, with the ring finger and middle finger most commonly involved (33.3 and 28.6%, respectively). Only history of prior TF in either hand was found to be a significantly associated on Chi-square analysis and multivariable regression (p < 0.001). Conclusion In patients with carpal tunnel syndrome, ipsilateral TFs occurred after 6.83% of CTRs, compared with a rate of 2.7% in the nonoperative hand, making it an important possible outcome to discuss with patients. The thumb was more commonly involved in triggering in the surgical hand compared with the nonoperative hand. Patients with a history of prior TFs in either hand were more likely to develop an ipsilateral TF after CTR. Level of Evidence This is a Level III, retrospective study.

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Postoperative management following carpal tunnel release surgery: principles of rehabilitation

Neurosurgical FOCUS ◽

10.3171/foc.1997.3.1.12 ◽

1997 ◽

Vol 3 (1) ◽

pp. E11 ◽

Cited By ~ 6

Author(s):

Gregory G. Degnan

Keyword(s):

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Signs And Symptoms ◽

Postoperative Management ◽

Early Postoperative Period ◽

Management Problem ◽

Therapy Program ◽

Number Of Factors ◽

Patients At Risk ◽

Carpal Tunnel Release Surgery

The patient with an unsatisfactory result following carpal tunnel release is fortunately the exception rather than the rule. The vast majority of appropriately selected and treated patients will recover uneventfully without the need for extensive therapy. Although uncommon, the dissatisfied patient presents an extremely difficult management problem. Inasmuch as there are a number of factors that may potentially contribute to a poor result, failure to recognize and treat excessive edema and stiffness in the early postoperative period are responsible for a significant percentage of poor results. Patients with a poor result present with three basic signs or symptoms, which may occur in combination or alone. These signs and symptoms include excessive edema, stiffness, and hypersensitivity. If left untreated, these are the patients who will go on to develop persistent median nerve symptoms, stiffness, and possibly even reflex sympathetic dystrophy or sympathetically mediated pain. If identified early and placed in an appropriate therapy program, most of these patients will receive the proper treatment and will ultimately be satisfied with their result. The author presents here a protocol for the postoperative management of the patient who has undergone carpal tunnel release surgery, with emphasis on the recognition and treatment of those patients at risk for a poor result.

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Accuracy of Carpal Tunnel Injection: A Prospective Evaluation of 756 Patients

Hand ◽

10.1177/1558944718787330 ◽

2018 ◽

Vol 15 (1) ◽

pp. 54-58 ◽

Cited By ~ 3

Author(s):

David P. Green ◽

Brendan J. MacKay ◽

Steven J. Seiler ◽

Michael T. Fry

Keyword(s):

Median Nerve ◽

Carpal Tunnel ◽

Corticosteroid Injection ◽

Carpal Tunnel Release ◽

Therapeutic Modality ◽

Injection Technique ◽

Anatomic Landmarks ◽

Injection Techniques ◽

Open Carpal Tunnel Release ◽

Tunnel Injection

Background: Corticosteroid injection into the carpal tunnel is both a diagnostic test and a therapeutic modality in the treatment of carpal tunnel syndrome. Many injection techniques are described in the literature. Improper placement of injection may result in damage to neurovascular structures in the carpal canal or decrease efficacy of the test and/or therapy. The purpose of this study is to determine if carpal tunnel injection using anatomic landmarks is reproducible and safe. A review of the senior author’s injection technique is presented. Methods: Over 8 years, there were 756 attempted placements of a 25-gauge needle into the carpal tunnel in a simulated carpal tunnel injection prior to open carpal tunnel release. The needle was inserted at the wrist crease, just ulnar to palmaris longus. Open carpal tunnel release was subsequently performed, and position of the needle was recorded. Results: In 572 patients (75.7%), the needle was found to be in the carpal tunnel without penetration of contents. The needle was in the carpal tunnel but piercing the median nerve in 66 attempts (8.7%). The carpal tunnel was missed in 118 attempts (15.6%). Conclusions: This is the largest study looking at accuracy of carpal tunnel injection using anatomic landmarks. Our injection accuracy (75.7%) is less than reported in previous studies, which note 82% to 100% accuracy using the same injection technique. This may indicate that carpal tunnel injection is less reliable than previously thought. Safety of carpal tunnel injection remains an important concern. The median nerve was penetrated in 8.7% of attempts.

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False-Negative Rate of Gram-Stain Microscopy for Diagnosis of Septic Arthritis: Suggestions for Improvement

International Journal of Microbiology ◽

10.1155/2014/830857 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 15

Author(s):

Paul Stirling ◽

Radwane Faroug ◽

Suheil Amanat ◽

Abdulkhaled Ahmed ◽

Malcolm Armstrong ◽

...

Keyword(s):

Synovial Fluid ◽

Septic Arthritis ◽

False Negative ◽

False Negative Rate ◽

Diagnostic Value ◽

Royal Infirmary ◽

Gram Stain ◽

Data Set ◽

Ongoing Research ◽

Negative Rate

We quantify the false-negative diagnostic rate of septic arthritis using Gram-stain microscopy of synovial fluid and compare this to values reported in the peer-reviewed literature. We propose a method of improving the diagnostic value of Gram-stain microscopy using Lithium Heparin containers that prevent synovial fluid coagulation. Retrospective study of the Manchester Royal Infirmary microbiology database of patients undergoing synovial fluid Gram-stain and culture between December 2003 and March 2012 was undertaken. The initial cohort of 1896 synovial fluid analyses for suspected septic arthritis was reduced to 143 after exclusion criteria were applied. Analysis of our Gram-stain microscopy yielded 111 false-negative results from a cohort size of 143 positive synovial fluid cultures, giving a false-negative rate of 78%. We report a false-negative rate of Gram-stain microscopy for septic arthritis of 78%. Clinicians should therefore avoid the investigation until a statistically significant data set confirms its efficacy. The investigation's value could be improved by using Lithium Heparin containers to collect homogenous synovial fluid samples. Ongoing research aims to establish how much this could reduce the false-negative rate.

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Predicting Clinically Relevant Patient-Reported Symptom Improvement After Carpal Tunnel Release: A Machine Learning Approach

Neurosurgery ◽

10.1227/neu.0000000000001749 ◽

2021 ◽

Vol 90 (1) ◽

pp. 106-113 ◽

Cited By ~ 1

Author(s):

Lisa Hoogendam ◽

Jeanne A. C. Bakx ◽

J. Sebastiaan Souer ◽

Harm P. Slijper ◽

Eleni-Rosalina Andrinopoulou ◽

...

Keyword(s):

Machine Learning ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Symptom Improvement ◽

Learning Approach ◽

Patient Reported ◽

Machine Learning Approach

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Precollaborative Study of the GeneQuence® Salmonella Assay Using 24-Hour Enrichment Protocols for Detection of Salmonella spp. in Select Foods

Journal of AOAC International ◽

10.1093/jaoac/90.3.725 ◽

2007 ◽

Vol 90 (3) ◽

pp. 725-737 ◽

Cited By ~ 2

Author(s):

Susan Alles ◽

Xuan Peng ◽

Michael Wendorf ◽

Mark Mozola

Keyword(s):

Collaborative Study ◽

False Negative ◽

False Negative Rate ◽

Salmonella Spp ◽

Culture Methods ◽

Department Of Agriculture ◽

Chi Square ◽

Salmonella Assay ◽

Inspection Service ◽

Chi Square Analysis

Abstract New enrichment protocols are described for use with a DNA hybridization (DNAH) method for detection of Salmonella spp. in select foods. GeneQuence® Salmonella, in its original version, utilized a 3-stage enrichment of minimum 42 h duration. New 2-stage procedures of 2428 h duration are described for raw poultry, raw beef, pasteurized egg products, milk chocolate, and dry pet food. In the validation study described here, a total of 345 samples were tested by the abbreviated DNAH method in parallel with either the U.S. Food and Drug Administration's Bacteriological Analytical Manual (FDA/BAM) or U.S. Department of Agriculture-Food Safety and Inspection Service (USDA-FSIS) reference culture procedures. Results showed an overall sensitivity for the DNAH method of 97.1% (false-negative rate 2.9%). There were no false-positive results by the DNAH method; therefore the specificity was 100%. Overall agreement between the DNAH and reference culture methods was 98.5%. There were no significant differences in performance between the DNAH and reference methods for any of the foods tested as determined by Chi-square analysis. It is recommended that the DNAH method be subjected to AOAC collaborative study.

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