Thenar and Hypothenar Muscle Coverage on the Transverse Carpal Ligament

Background The purpose of the study was to examine the coverage of thenar and hypothenar muscles on the transverse carpal ligament (TCL) in the radioulnar direction through in vivo ultrasound imaging of the carpal tunnel. We hypothesized that the TCL distance covered by the thenar muscle would be greater than that by the hypothenar muscle, and that total muscle coverage on the TCL would be greater than the TCL-alone region. Methods Ultrasound videos of human wrist were collected on 20 healthy subjects. Automated algorithms were used to extract the distal cross-sectional image of the trapezium-hamate level. Manual tracing of the anatomical features was conducted. Results Thenar muscles covered a significantly larger distance (11.9 ± 1.8 mm) as compared with hypothenar muscles (1.7 ± 0.8 mm) (p < 0.001). The TCL covered by thenar and hypothenar muscles was greater than the TCL-alone length (p < 0.001). The thenar and hypothenar muscle coverage on the TCL, as normalized to the total TCL length, was 61.0 ± 7.5%. Conclusions More than 50% of the TCL at the distal carpal tunnel is covered by thenar and hypothenar muscles. Knowledge of muscular attachments to the TCL improves our understanding of carpal tunnel syndrome etiology and can guide carpal tunnel release surgery.

Sensory Nerve Conduction Velocity Predicts Improvement of Hand Function with Nerve Gliding Exercise Following Carpal Tunnel Release Surgery

This study aims to investigate the effects of nerve gliding exercise following carpal tunnel release surgery (NGE-CTRS) and the probing factors affecting the effect of NGE-CTRS on hand function. A total of 86 patients after CTRS participated. Grip strength (grip-s), pinch strength (pinch-s), Semmes-Weinstein monofilament test (SWMT), two-point discrimination (2PD), numbness, pain, and Phalen test (Phalen) were measured and compared between pre- and post-NGE-CTRS. The results showed that the combination of surgery and NGE significantly improved the postoperative grip-s, pinch-s, SWMT, 2PD, numbness, and Phalen; however, no improvement was observed in pain. Background factors that influenced the improved grip-s and pinch-s included gender and preoperative sensory nerve conduction velocity (SCV). Additionally, numbness and Phalen were not affected by age, gender, fault side, bilateral, trigger finger, dialysis, thenar eminence atrophy, motor nerve conduction velocity, SCV, the start of treatment, and occupational therapy intervention. In conclusion, the combination of surgical procedures and NGE showed a high improvement. SCV and time-to-start treatment of intervention for carpal tunnel syndrome may be useful in predicting the function after the intervention.

Use of conservative therapy before and after surgery for carpal tunnel syndrome

Background Conservative therapies are typically offered to individuals who experience mild or intermittent symptoms of carpal tunnel syndrome (CTS) or postoperatively to subjects who have undergone carpal tunnel release. Although long-term studies report mostly positive results for carpal tunnel release, knowledge on the need for conservative treatments following surgery is scarce. The aim of this retrospective cohort study was to examine the use of conservative therapies before and after carpal tunnel releasing surgery. Methods Of 528 patients who underwent carpal tunnel release surgery in the study hospital during the study period, 259 provided sufficiently completed questionnaires (response rate 49 %). The patients completed a questionnaire battery including a sociodemographic, medical history and symptom questionnaire, the Boston Carpal Tunnel Syndrome Questionnaire, 6-item CTS symptoms scale and EuroQoL 5D. Frequencies of conservative therapies pre- and postoperatively were calculated. Association between Pain VAS and satisfaction with treatment were examined in patient groups according to the use of conservative therapies. Results Of all patients, 41 (16 %) reported receiving only preoperative, 18 (7 %) reported receiving only postoperative, 157 (60 %) reported receiving both pre- and postoperative conservative therapies and 43 (17 %) did not receive any therapies. Preoperative use of conservative therapies was more common in females than males (82 % vs. 64 %; p = 0.002), but postoperatively no significant gender difference was observed. The patients who received conservative therapies were younger than non-users in both the preoperative (median age 59 vs. 66; p < 0.001) and postoperative (59 vs. 66; p = 0.04) phases. The patients reported high satisfaction with their treatment and simultaneous improvement in Pain VAS scores. Those receiving conservative therapies only preoperatively reported the highest satisfaction. Conclusions While the use of conservative therapies decreased after surgery, a large proportion of the patients received these adjunct interventions. Patients reported high satisfaction with their treatment one year post surgery. Pain outcome seems to be closely related to satisfaction with treatment. Level of Evidence Level III.

The frequency of cardiac amyloidosis in 182 patients receiving carpal tunnel release surgery

Introduction Retrospective studies have suggested that a significant proportion of patients with cardiac amyloidosis received surgical treatment for carpal tunnel syndrome (CTS) 5–10 years before diagnosis of their cardiac condition. So far, one cross-sectional study has investigated the presence of localized and systemic amyloidosis in 98 patients undergoing carpal tunnel release surgery (CTRS). Ten percent were shown to have amyloid deposits in the carpal tunnel while two had cardiac involvement caused by either AL amyloidosis or wild-type transthyretin amyloidosis (ATTR). Purpose To investigate the prevalence of cardiac amyloidosis among unselected and consecutive patients undergoing CTRS. Methods Tissue samples from the carpal tunnel of 182 CTRS patients were stained with Congo Red. Amyloid positive samples were subtyped by immunoelectron microscopy and mass spectrometry. Amyloid positive patients underwent investigations for cardiac amyloidosis including ECG-recording, echocardiography and strain imaging, cardiac magnetic resonance imaging and whole-body scintigraphy (99m-tc-DPD). Genetic investigation of the gene for TTR was performed in patients with ATTR amyloidosis or an undetermined subtype. Patients were also investigated by measurements of NT-proBNP, troponins, immunoglobulins, M-protein in serum and urine, and free light kappa and lambda chains in serum. Results In total, 16% (29/182) of the patients had amyloid positive biopsies. They were significantly older than amyloid negative patients (73 years vs 53 years, p&lt;0.001). The prevalence of males was significantly higher in the amyloid positive group (66% vs 25%, p&lt;0.001). The presence of bilateral CTS was not associated with amyloid deposits. The subtype of amyloid was shown to be (a) ATTR in 86% (n=25) of patients, (b) localized light-chain amyloidosis in 3% (n=1), and (c) fibrinogen alpha amyloidosis in 3% (n=1), while the amount of tissue did not allow subtyping in 7% (n=2). All ATTR patients had a normal genetic investigation. So far, 24 of the 29 amyloid positive patients have completed all clinical investigations and no one fulfilled diagnostic criteria of cardiac amyloidosis. Conclusion A significant number of CTRS patients, (14%), had wild-type ATTR amyloidosis confined to the carpal tunnel. None of these had cardiac involvement. These findings were different from the results in the previous prospective study and were likely to be explained by differences in the patient cohorts investigated. We investigated unselected patients in contrast to the highly selected cohort in the previous study. Based on the findings in the current study the proportion of CTRS patients with localized amyloidosis who may develop systemic disease is unknown. Therefore, it is necessary to perform long term follow-up of these patients before routine investigations for amyloidosis may be recommended. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Financial support was obtained by an unrestricted research grant from Alnylam Pharmaceuticals

Outcome of Single Dose Prophylactic Antibiotic in Carpal Tunnel Release Surgery

Background: It has been well documented that administering a prophylactic antibiotic brings down the rate of postoperative wound infection very strikingly in carpal tunnel release (CTR) surgery. Carpal tunnel syndrome (CTS) is definitely a compressive neuropathy of the upper limbs, which is both benign and frequent. The study objective was to determine the postoperative wound infection rate in carpal tunnel release surgery after having administered a single dose of a prophylactic antibiotic. Methods: This cross-sectional study was carried out at the department of Neurosurgery, Dammam Medical Complex-Saudi Arabia. The study was based on 122 patients who were operated for carpal tunnel release procedures at the centre. Pre-operatively all patients were subjected to nerve conduction studies (NCS) to document CTS as the definitive diagnosis. As a routine, every patient was administered intravenous loading dose of cefuroxime (1.5g) at least 1 hour prior to surgery. All patients were treated as day care cases and were discharged after a few hours of surgery. On discharge, no further antibiotics were administered. Their wounds were examined. Results: Superficial redness over the site of incision was noted in three of the patients and wound infection in two others. These two patients improved with oral antibiotics. Not a single patient needed re-exploration. Conclusion: The current study showed that this is an efficacious and a very safe protocol to follow. Assuming the fact that the incidence of surgical site infection (SSI) in CTR surgery is low, the results were not different when compared to the results from other centres.