Assessment of the frequency of tarsal tunnel syndrome in rheumatoid arthritis

Objectives: In this study, we aimed to determine the frequency of tarsal tunnel syndrome (TTS) in rheumatoid arthritis (RA) patients. Patients and methods: Thirty RA patients (1 male, 29 females; mean age: 41.9±10.1 years; range, 26 to 65 years) who met the American College Rheumatology (ACR) classification criteria and 20 healthy volunteers (1 male, 19 females; mean age: 39.3±10.8 years; range, 26 to 60 years) without any complaints between August 2006 and October 2007 were included in the study. Demographic characteristics of the study group were assessed and neurological examinations were performed. The Tinel’s sign was checked to provoke the TTS symptoms. Disease severity was measured using Visual Analog Scale (VAS), Disease Activity Score-28 (DAS28), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The health-related quality of life and disability status were determined using the Health Assessment Questionnaire (HAQ), Short Form 36 (SF-36), Foot Function Index (FFI), and VAS (0-100 mm). The positional relationship of the foot pain was questioned with VAS. The 100-m walking distance of the patient and control groups were calculated. Results: Bilateral TTS was detected in 10 of the patients (33.3%) with rheumatoid arthritis. No relationship with the TTS disease duration, seropositivity, rheumatoid nodule, joint deformities, corticosteroid use, and DAS28 score were found. In correlation with TTS, foot and ankle joint were the first involved joints at the beginning of RA disease (p<0.005). The Tinel’s sign was found to be 45% positive in patients with TTS. The 100-m walking time was significantly longer in RA patients compared to the control group (p<0.0001). Conclusion: Tarsal tunnel syndrome is commonly seen in RA and its incidence increases in patients with primary foot involvement. Therefore, caution should be taken against the entrapment neuropathies in these patients, and they should be supported by electrophysiological practices, when the diagnosis is necessary.

Efficacy of 5% Dextrose Water Injection for Peripheral Entrapment Neuropathy: A Narrative Review

Current non-surgical treatment for peripheral entrapment neuropathy is considered insignificant and unsustainable; thus, it is essential to find an alternative novel treatment. The technique of perineural injection therapy using 5% dextrose water has been progressively used to treat many peripheral entrapment neuropathies and has been proven to have outstanding effects in a few high-quality studies. Currently, the twentieth edition of Harrison’s Principles of Internal Medicine textbook recommends this novel injection therapy as an alternative local treatment for carpal tunnel syndrome (CTS). Hence, this novel approach has become the mainstream method for treating CTS, and other studies have revealed its clinical benefit for other peripheral entrapment neuropathies. In this narrative review, we aimed to provide an insight into this treatment method and summarize the current studies on cases of peripheral entrapment neuropathy treated by this method.

Correlation of nerve conduction study parameters with thyroid hormone in newly diagnosed hypothyroid patients

Background: Thyroid hormones act on many organs including central and peripheral nervous system for maintaining metabolic homeostasis. Entrapment neuropathies are most common in hypothyroidism. Nerve conduction parameters are impaired even in newly diagnosed cases of hypothyroid. Aims and Objectives: This study aims to study the correlation between thyroid hormone and nerve conduction study (NCS) parameters in newly diagnosed hypothyroid patients. Materials and Methods: This cross-sectional, descriptive study included newly diagnosed hypothyroid patients (n=30; age: 31.96±9.12). In all subjects, NCS was performed in median, ulnar, tibial motor nerve and median, ulnar, sural sensory nerve using Nihon Kohden machine in Neurophysiology lab 2, B. P. Koirala Institute of Health Science. Thyroid function test (TFT) was analyzed by ELISA. The association between thyroid hormone and NCS parameters was done using Pearson’s correlation. Results: In NCS sensory parameters; SNAP amplitude of the left sural nerve showed significant positive correlation with t3 (lt; r=0.451, P=0.012). Among motor parameters, distal latency of left median nerve showed significant negative correlation with t3 whereas nerve conduction velocity of the left median nerve showed positive correlation with t3. In rest of the nerve, the association between NCS parameters and TFT (t3, t4, and TSH) parameters did not show any significant changes. Conclusion: Our study reveals that in newly diagnosed cases of hypothyroidism, nerve impairment occurs in which the left side is affected much earlier than right side and further its severity can be correlated with level of T3 rather than TSH.

1287 A Comparison of Surgical Decompression and Steroid Injections to Treat Carpal Tunnel Syndrome: A Meta-Analysis

Introduction Carpal tunnel syndrome (CTS) is caused by compression of the median nerve at the wrist. It accounts for 90% of all entrapment neuropathies, with a 7-16% in the UK. It has a significant impact on patients’ daily lives. Clinically, CTS results in paraesthesia, while extreme cases may involve muscular atrophy and weakness. There is currently a disparity between optimal treatments for CTS. Therefore, this paper aims to identify the optimal treatment for CTS with post-treatment BCTQ (Boston Carpal Tunnel Questionnaire) scores (including both functional and symptomatic severity) at 1, 3 and 6 months. Method The BCTQ scores for were sited from PubMed, Google Scholar and the University of Dundee Library search engine by entering key words such as “carpal tunnel syndrome”, “surgical decompression”, “surgical release” and “steroid injection”. Means and standard deviations for pre- and post-treatment after 1, 3 and 6 months were obtained. From this, forest plots were constructed using a software where steroid injection and surgical decompression were inputted separately, and effect sizes were then compared for 1, 3 and 6 months. Results The meta-analysis included reviewing 133 articles. The effect size was determined using the random effects model. Steroid injection was more effective than surgical decompression after 1 and 3 months. However, after 6 months, surgical decompression was more effective. Conclusions Identification of long-term relief of CTS through surgical decompression allows the reduction of symptom recurrence and thus costly follow-up appointments. This study provides robust clinical findings for the optimal treatment of CTS.

MRI Evaluation of Various Elbow, Forearm, and Wrist Neuropathies: A Pictorial Review

Upper extremity entrapment neuropathies are common and can cause pain, sensory loss, and muscle weakness leading to functional disability. We conducted a retrospective review from January 2007 until March 2020 of the magnetic resonance imaging (MRI) features of intrinsic and extrinsic causes of wrist, forearm, and elbow neuropathies of 637 patients who received a diagnosis of neuropathy by means of clinical and electrodiagnostic testing. We discuss cases with varying intrinsic and extrinsic nerve pathologies, including postoperative examples, affecting the median, radial, and ulnar nerve.Our collection of cases demonstrates a diversity of intrinsic and extrinsic causative factors. Intrinsic pathologies include neuritis as well as tumors arising from the nerve. Extrinsic causes resulting in nerve entrapment include masses, acute and chronic posttraumatic cases, anatomical variants, inflammatory and crystal deposition, calcium pyrophosphate deposition disease, and dialysis-related amyloidosis. Finally, we review postsurgical cases, such as carpal tunnel release and ulnar nerve transposition.Although upper extremity neuropathies tend to have a typical clinical presentation, imaging, particularly MRI, plays a vital role in evaluating the etiology and severity of each neuropathy and ultimately helps guide clinical management.

Important updates of finger fractures, entrapment neuropathies and wide-awake surgery of the upper extremity

Hand surgery is rapidly changing. The wide-awake approach, minimum dissection surgery and early protected movement have changed many things. This is an update of some of the important changes regarding early protected movement with K-wired finger fracture management, simplification of nerve decompression surgery, such as elbow median and ulnar nerve releases, and some new areas in performing surgery with wide-awake local anaesthesia without tourniquet.

Fascia and living tensegrity considerations in: lower extremity and pelvic entrapment neuropathies

Peripheral neuropathies can have a plethora of origins including physical insults resulting from connective tissue compression and entrapment. Observational investigations, using biotensegrity focused dissections, have identified site-specific fascial structures that are hypothesised to afford integrity to neurovascular structures by providing appropriate tension and compression. These myofascial structures act as site-specific fascia tuning pegs. While these ‘tuning pegs’ are capable of having a whole body impact, this paper will look specifically at the local influences on pelvis and lower limb. The analogy of a fascia ‘tuning peg’, similar to the tuning peg of a string instrument, is adopted to help explain this unfamiliar concept. An ‘out of tune’ fascial system would lead to hypertonic and inhibited tissues, dissonant notes, one could say. Hypertonic tissues increase tensional forces acting within local and global networks leading to inappropriate densification of fascial structures, fibrosis and neurovascular fascial adhesions. Inhibited tissues, unable to generate sufficient force to ensure appropriate fascial integrity, lead to excessive compression on neurovascular structures like a dissonant note striking a wrong cord. Site-specific fascia tuning pegs provide appropriate frequency and note specific tension and compression ensuring combined forces operate in an omnidirectional manner resulting in pain free physiology, neurology and motion. The role of muscles in metabolism, physiology, heat production and motion is well described within the scientific literature. Less understood is the local role of myofascial structures providing mechanotransductive forces resulting in fascial expansive responses ensuring appropriate gliding and decompression of neurovascular structures. It is proposed that failure of site-specific fascia tuning pegs results in excessive compression, friction, inflammation, pathology, pain and changes in sensations. KEY WORDS: Biotensegrity, Fascia, Site specific fascia tuning pegs, Tensegrity, Neuropathy, Dynamic ischemia.

Tarsal Tunnel Syndrome Caused by an Occult Schwannoma of the Posterior Tibial Nerve: Avoidance of Delay in Diagnosis

Tarsal tunnel syndrome (TTS), resulting from compression of the posterior tibial nerve (PTN) within the tarsal tunnel, is a relatively uncommon entrapment neuropathy. Many cases of tarsal tunnel syndrome are idiopathic; however, some causes, including space-occupying lesions, may lead to occurrence of TTS symptoms. Schwannoma, the most common tumor of the sheath of peripheral nerves, is among these space-occupying lesions, and may cause TTS when it arises within the tarsal tunnel, and it may mimic TTS even when it is located outside the tarsal tunnel and cause a significant delay in diagnosis. The possibility of an occult space-occupying lesion compressing the PTN should be kept in mind in the differential diagnosis of TTS, and imaging studies that are usually not used in entrapment neuropathies may be of importance in such patients. This case report presents a 65-year-old woman with TTS symptoms and neurophysiologic findings secondary to an occult schwannoma of the PTN proximal to the tarsal tunnel. Avoidance of delay in diagnosis in secondary cases is emphasized.

Ultrasound-guided injections in pelvic entrapment neuropathies

Pelvic entrapment neuropathies represent a group of chronic pain syndromes that significantly impede the quality of life. Peripheral nerve entrapment occurs at specific anatomic locations. There are several causes of pelvic entrapment neuropathies, such as intrinsic nerve abnormality or inflammation with scarring of surrounding tissues, and surgical interventions in the abdomen, pelvis and the lower limbs. Entrapment neuropathies in the pelvic region are not widely recognized, and still tend to be underdiagnosed due to numerous differential diagnoses with overlapping symptoms. However, it is important that entrapment neuropathies are correctly diagnosed, as they can be successfully treated. The lateral femoral cutaneous nerve, ischiadic nerve, genitofemoral nerve, pudendal nerve, ilioinguinal nerve and obturator nerve are the nerves most frequently causing entrapment neuropathies in the pelvic region. Understanding the anatomy as well as nerve motor and sensory functions is essential in recognizing and locating nerve entrapment. The cornerstone of the diagnostic work-up is careful physical examination. Different imaging modalities play an important role in the diagnostic process. Ultrasound is a key modality in the diagnostic work-up of pelvic entraptment neuropathies, and its use has become increasingly widespread in therapeutic procedures. In the article, the authors describe the background of pelvic entrapment neuropathies with special focus on ultrasound-guided injections.