Carpal tunnel syndrome

Screening for Cardiac Amyloidosis 5 to 15 Years After Surgery for Bilateral Carpal Tunnel Syndrome

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Abstract

Background

Bilateral carpal tunnel syndrome (CTS) is a common extracardiac manifestation of amyloidosis and usually predates overt cardiac amyloidosis (CA) by several years. Screening studies on patients undergoing CTS surgery have shown a low yield of CA (2.0%), but high prevalence of amyloid in the carpal ligament. The proportion of patients with amyloid in the carpal ligament who later develop CA is unknown.

Objectives

The authors sought to investigate the prevalence of undiagnosed CA 5 to 15 years after surgery for bilateral CTS.

Methods

Using national registries, the authors identified subjects aged 60 to 85 years with prior CTS surgery, where the first procedure on the second wrist was performed 5 to 15 years earlier. Invitations to participate in the study were sent by mail. Per international recommendations, the initial cardiac evaluation included echocardiography, 99mtechnetium-pyrophosphate scintigraphy, and assessment of monoclonal proteins in serum and urine.

Results

A total of 250 subjects (35.7% of those invited) participated in the study. The median age was 70.4 years, and 50% were female. CA was diagnosed in 12 patients (4.8%; 95% CI: 2.5%-8.2%), and all cases were wild-type transthyretin amyloidosis (ATTRwt). The prevalence of ATTRwt in men was 8.8% (95% CI: 4.5%-15.2%; n = 11), and 21.2% (95% CI: 11.1%-34.7%) in male subjects ≥70 years with a BMI <30 kg/m2. All but 2 patients diagnosed with ATTRwt were in the lowest disease severity score (Mayo score).

Conclusions

Screening for CA in patients with prior surgery for bilateral CTS finds approximately 5% with early-stage transthyretin CA. The clinical yield was higher (>1 in 5) when focusing on nonobese men ≥70 years, showing potential for systematic screening.

9 Things You Need to Know About Carpal Tunnel Syndrome

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No, you don’t have to stop typing forever.
carpal-tunnel

Think of carpal tunnel syndrome as pins and needles on steroids. This health condition can cause persistent numbness, tingling, and burning in your fingers, wrists, and even your arms. Luckily, carpal tunnel treatment is precise enough that it has the potential to completely resolve the problem that fuels this syndrome in the first place. So here’s everything you need to know about carpal tunnel syndrome, including how to treat it if you’re experiencing symptoms.

1. Carpal tunnel syndrome all comes down to a single nerve.

The median nerve, which runs from your forearm into your thumb, index, and middle fingers, along with part of your ring finger, is nestled inside a canal known as the carpal tunnel. “When the median nerve doesn’t get enough blood flow, it makes your hand hurt and feel like it’s tingling and numb,” Leon S. Benson, M.D., an orthopedic surgeon with the Illinois Bone and Joint Institute who specializes in elbow, hand, and shoulder issues, tells SELF.

These symptoms are especially likely to strike when you’re using your hands for things like driving and talking on the phone, and they can make you instinctively shake your hand to get rid of the sensations. And, since apparently nothing is sacred, your symptoms might be particularly bothersome at night and wake you up.

2. Your constant typing actually isn’t the main carpal-tunnel culprit.

Thought experts haven’t yet pinpointed one single cause behind carpal tunnel, there are various risk factors. One is being born with a tight carpal tunnel, potentially due to genetics, Dr. Benson says. Because they cause swelling that puts pressure on the carpal tunnel—whether through weight gain, fluid retention, inflammation, or another mechanism—health conditions like pregnancy, menopause, diabetes, obesity, and rheumatoid arthritis can contribute as well.

Doing repetitive work like typing doesn’t seem to explicitly cause this condition, but it may bring it about if you’re predisposed, David Hay, M.D., an orthopedic surgeon at Kerlan-Jobe Orthopaedic Clinic in Los Angeles, tells SELF.

3. If carpal tunnel is allowed to progress unchecked, it can lead to permanent nerve damage. But when caught soon enough, it can be cured.

Carpal tunnel symptoms may come and go, or bother you more at certain times than others, but this condition will usually worsen over time without treatment. The exception is if one specific thing caused your carpal tunnel syndrome, then you completely remove it from the equation—like if you got carpal tunnel due to weight gain during pregnancy, then you give birth, Dr. Benson says.

If you think you have carpal tunnel syndrome, see a doctor, who can diagnose you based on your symptoms, a physical examination, an X-ray, or tests like an electromyogram to see how your hands are functioning, according to the Mayo Clinic. Once you’re diagnosed, they’ll help you come up with an action plan based on the severity of your symptoms.

4. The first line of defense is typically pain medication like NSAIDs.

There are essentially two options for carpal tunnel treatment, Dr. Benson says: You can reduce swelling around the median nerve, or you can make the canal surrounding it bigger. Non-steroidal anti-inflammatory medications can ease the swelling that aggravates your median nerve, Dr. Benson says. This can help in the moment, but it’s not a long-term solution.

5. You can also try a cold compress for sweet, sweet relief.

The cold temperature can help decrease inflammation around the median nerve and ease carpal tunnel-related pain. Dr. Hay typically advises people to ice the area for 10-15 minutes, remove the ice for 30-40, then ice again for 10-15. “Don’t over-ice it,” he says. Doing so can harm your skin and reduce blood flow.

6. The next level of treatment involves using a nighttime wrist splint.

A splint helps make sure you’re not keeping your wrists bent for hours while you sleep. “You don’t need to immobilize your wrists during the day when you’re aware of them, but a lot of times when people are asleep, they curl up like a fetus and naturally bend their wrists,” Dr. Benson says. This can lead to a carpal tunnel flare and very rudely rouse you from your sleep.

If you have carpal tunnel, talk to your doctor about whether a wrist splint makes sense for you. If a splint still hasn’t assuaged your symptoms after six to eight weeks, it’s time to get more aggressive.

7. Your doctor may recommend corticosteroid treatment, which can do a brilliant job of relieving inflammation.

“With a thin needle, we inject a small amount of an anti-inflammatory corticosteroid around the carpal tunnel,” Dr. Benson says. “It delivers medication right around the nerve and is incredibly effective.”

Corticosteroid injections can often completely eradicate less advanced cases of carpal tunnel syndrome, Dr. Hay says. They can even be helpful if your case is more advanced, because the relief may still last for months. This can be useful if surgery isn’t convenient for you right now or you can’t afford it, but your symptoms aren’t responding to treatment methods like a splint, Dr. Hay says.

8. Surgery is the final option for carpal tunnel treatment, and it can be quite successful.

The point is to make the canal around the median nerve roomier by cutting the ligament pressing down on the nerve. “It’s like loosening a belt one notch,” Dr. Benson says.

The surgery can either be endoscopic, when your surgeon makes smaller incisions and uses an tool called an endoscope to perform the surgery, or open, which involves a larger incision of around two inches, according to the National Institute of Neurological Disorders and Stroke. It’s typically done under a light level of anesthesia or sedation and takes around 20 minutes, Dr. Benson says.

Your symptoms can completely disappear after surgery, but you might experience some mild soreness for a few months, Dr. Hay says. You may also experience a weak grip, though that usually improves over time, according to National Institute of Neurological Disorders and Stroke. Most people are back to driving after a day or two, Dr. Hay says, though you may have to modify your work and lifestyle routines for a few weeks depending on your healing. And for some people, surgery really is able to resolve their carpal tunnel.

9. There are a few strategies for preventing carpal tunnel—none of which involve throwing out your keyboard.

If you do any sort of repetitive work involving your hands for hours on end (like typing or assembly work), taking frequent breaks can help ward off wrist and hand pain. “Take a 5- or 10-minute break every hour or two,” Dr. Benson says. “Like anything else in your body, give your hands and wrists a rest if you’re using them constantly.”

During this time you can also do a few stretches to prevent straining your fingers, hands, and wrists. Here are a few you can cycle through on each hand during your breaks, courtesy of Dr. Benson, although it’s always a good idea to check in with your own doctor before introducing new exercises into your routine. (Especially if you already have carpal tunnel—definitely check in with your doctor before trying these in that case.)

  • Hold your hand up like you’re stopping traffic. Flex and extend your wrist.
  • Make a fist, then extend your fingers all the way out.
  • Use one hand to gently press the extended fingers of the other hand back.

Having an ergonomic work set-up can also help ward off all sorts of aches and pains, not just ones in your wrists and hands. Check out the Mayo Clinic’s guides for an ergonomic workspace, whether you’re sitting or standing.

Keep in mind that if you already have carpal tunnel syndrome, prevention isn’t enough to keep your symptoms from getting worse. So if you’re suffering, discuss carpal tunnel treatment with your doctor. That’s the best way to stop looking like a 2003 throwback who’s constantly shaking it like a polaroid picture.

Migraine Linked to Carpal Tunnel Syndrome

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A study for the first time has revealed a possible association between migraines and carpal tunnel syndrome (CTS), with migraines more than twice as prevalent in patients with CTS as in those without.

“The association of these two distinct disease processes is a fascinating connection that needs to be explored further,” study investigator Douglas M. Sammer, MD, chief of the Hand and Upper Extremities Division, Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, said in a statement.

“This association suggests the possibility, although not demonstrated in this study, of a common systemic or neurologic risk factor,” the authors write. In addition, migraine headache may be an early warning sign of increased risk for future CTS, they say.

The study was published online in Plastic and Reconstructive Surgery.

In a cross-sectional analysis of 25,880 adults who responded to the 2010 National Health Interview Survey, 952 (3.7%) had CTS and 4212 (16.3%) had migraine headache.

A case of CTS was defined as a respondent who answered “yes” to two questions: “Have you ever been told by a doctor or other health professional that you have a condition affecting the wrist and hand called carpal tunnel syndrome?” and “During the past 12 months have you had carpal tunnel syndrome?”

A case of migraine was defined as a respondent who answered “yes” to the question, “During the past 3 months, did you have severe headache or migraine?”
The study team found that migraine prevalence was higher in those with than without CTS (34% vs 16%; adjusted odds ratio [aOR], 2.60; 95% confidence interval [CI], 2.16 – 3.13).

CTS prevalence was also higher in persons with than without migraine headache (8% vs 3%; aOR, 2.67; 95% CI, 2.22 – 3.22).

CTS was associated with older age, female sex, obesity, diabetes, and smoking. Migraine headache was associated with younger age, female sex, obesity, diabetes, and smoking.

“Although we have theories, at this time we simply don’t know why people with carpal tunnel syndrome are more likely to have migraines, and vice versa,” Dr Sammer said. “A deeper understanding of how and why this connection exists may lead to earlier diagnosis or even the ability to implement preventive measures,” he added.

Unlike CTS, migraine has not historically been considered a compression neuropathy, the researchers note in their article. However, some recent evidence suggests that some migraine headaches may be associated with nerve compression around the head and neck and that some migraines may be successfully treated by targeted peripheral nerve decompression, they note.

“Based on the findings of this study and prior studies, it may be worthwhile in patients with migraine to perform an examination for peripheral nerve compression in the head and neck,” the authors suggest.

A key limitation of the study, say the researchers, is that the survey question for migraine headache was worded “migraine or severe headache.” This lack of specificity may have led to a number of false-positive respondents without true migraine headaches, they point out.

Another limitation is the fact that this was a survey-based study and did not consist of patients with CTS or migraine headache diagnoses confirmed by a medical professional.

Experts Weigh In, Urge Caution

Reached for comment, Matthew S. Robbins, MD, director, Inpatient Services, Montefiore Headache Center, chief of neurology, Einstein Division, Montefiore Medical Center, Bronx, New York, told Medscape Medical News that the study is “interesting and does address this connection for the first time.”

“From my own clinical practice, I do believe in the study results reported,” Dr Robbins said. “However, the emphasis on peripheral nerve compression as a cause or major factor for migraine is highly disputed, and most of us who diagnose, treat, and study patients with migraine regularly know that migraine is a problem of the brain.”

He added, “The labeling of the disorder as ‘migraine headache’ rather than ‘migraine’ also reflects a lack of emphasis on this point, as migraine features so many other symptoms aside from headache, as any patient would describe. Migraine is a disorder where there is an inherited sensitivity of the nervous system, and with time there is sensitization of broader pain pathways that elevate the risk of experiencing other pain conditions. That is why migraine is associated not just with carpal tunnel syndrome but low back pain, fibromyalgia, temporomandibular dysfunction, and other pain conditions — the list is long.”

Dr Robbins agrees that the methods for defining migraine in this study were “not ideal, [but] the authors took advantage of a large, established national database with immense power, so within the study mechanism this is a limitation to concede. However, it is likely that the question does capture many of those with active migraine.”

But Stephen Silberstein, MD, director of the Headache Center at Thomas Jefferson University, Philadelphia, Pennsylvania, has major concerns about the methods. The “crucial fundamental flaw” is defining migraine as having severe headache or migraine in the last 3 months.

“The only way to show an association is lifetime prevalence of migraine as opposed to any headache in the last 3 months, so the criteria questions they used are not adequate,” he told Medscape Medical News.

Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial

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Abstract

Background: The effectiveness of acupuncture for managing carpal tunnel syndrome is uncertain, particularly in patients already receiving conventional treatments (e.g., splinting). We aimed to assess the effects of electroacupuncture combined with splinting.

Methods: We conducted a randomized parallel-group assessor-blinded 2-arm trial on patients with clinically diagnosed primary carpal tunnel syndrome. The treatment group was offered 13 sessions of electroacupuncture over 17 weeks. The treatment and control groups both received continuous nocturnal wrist splinting.

Results: Of 181 participants randomly assigned to electroacupuncture combined with splinting (n = 90) or splinting alone (n = 91), 174 (96.1%) completed all follow-up. The electroacupuncture group showed greater improvements at 17 weeks in symptoms (primary outcome of Symptom Severity Scale score mean difference [MD] -0.20, 95% confidence interval [CI] -0.36 to -0.03), disability (Disability of Arm, Shoulder and Hand Questionnaire score MD -6.72, 95% CI -10.9 to -2.57), function (Functional Status Scale score MD -0.22, 95% CI -0.38 to -0.05), dexterity (time to complete blinded pick-up test MD -6.13 seconds, 95% CI -10.6 to -1.63) and maximal tip pinch strength (MD 1.17 lb, 95% CI 0.48 to 1.86). Differences between groups were small and clinically unimportant for reduction in pain (numerical rating scale -0.70, 95% CI -1.34 to -0.06), and not significant for sensation (first finger monofilament test -0.08 mm, 95% CI -0.22 to 0.06).

Interpretation: For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting.

Therapeutic ultrasound for carpal tunnel syndrome..

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Therapeutic ultrasound may be offered to people experiencing mild to moderate symptoms of carpal tunnel syndrome (CTS). The effectiveness and duration of benefit of this non-surgical intervention remain unclear.

OBJECTIVES: To review the effects of therapeutic ultrasound compared with no treatment, placebo or another non-surgical intervention in people with CTS. SEARCH
METHODS: On 27 November 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2012, Issue 11 in The Cochrane Library), MEDLINE (January 1966 to November 2012), EMBASE (January 1980 to November 2012), CINAHL Plus (January 1937 to November 2012), and AMED (January 1985 to November 2012).
SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any regimen of therapeutic ultrasound with no treatment, a placebo or another non-surgical intervention in people with CTS.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias in the included studies. We calculated risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CIs) for primary and secondary outcomes. We pooled results of clinically homogenous trials in a meta-analysis using a random-effects model, where possible, to provide estimates of the effect.
MAIN RESULTS: We included 11 studies including 414 participants in the review. Two trials compared therapeutic ultrasound with placebo, two compared one ultrasound regimen with another, two compared ultrasound with another non-surgical intervention, and six compared ultrasound as part of a multi-component intervention with another non-surgical intervention (for example, exercises and splint). The risk of bias was low in some studies and unclear or high in other studies, with only two reporting that the allocation sequence was concealed and six reporting that participants were blinded. Overall, there is insufficient evidence that one therapeutic ultrasound regimen is more efficacious than another. Only two studies reported the primary outcome of interest, short-term overall improvement (any measure in which patients indicate the intensity of their complaints compared with baseline, for example, global rating of improvement, satisfaction with treatment, within three months post-treatment). One low quality trial with 68 participants found that when compared with placebo, therapeutic ultrasound may increase the chance of experiencing short-term overall improvement at the end of seven weeks treatment (RR 2.36; 95% CI 1.40 to 3.98), although losses to follow-up and failure to adjust for the correlation between wrists in participants with bilateral CTS in this study suggest that this data should be interpreted with caution. Another low quality trial with 60 participants found that at three months post-treatment therapeutic ultrasound plus splint increased the chance of short-term overall improvement (patient satisfaction) when compared with splint alone (RR 3.02; 95% CI 1.36 to 6.72), but decreased the chance of short-term overall improvement when compared with low-level laser therapy plus splint (RR 0.87; 95% CI 0.57 to 1.33), though participants were not blinded to treatment, it was unclear if the random allocation sequence was adequately concealed, and there was a potential unit of analysis error. Differences between groups receiving different frequencies and intensities of ultrasound, and between ultrasound as part of a multi-component intervention versus other non-surgical interventions, were generally small and not statistically significant for symptoms, function, and neurophysiologic parameters. No studies reported any adverse effects of therapeutic ultrasound, but this outcome was only measured in three studies. More adverse effects data are required before any firm conclusions on the safety of therapeutic ultrasound can be made.
AUTHORS’ CONCLUSIONS: There is only poor quality evidence from very limited data to suggest that therapeutic ultrasound may be more effective than placebo for either short- or long-term symptom improvement in people with CTS. There is insufficient evidence to support the greater benefit of one type of therapeutic ultrasound regimen over another or to support the use of therapeutic ultrasound as a treatment with greater efficacy compared to other non-surgical interventions for CTS, such as splinting, exercises, and oral drugs. More methodologically rigorous studies are needed to determine the effectiveness and safety of therapeutic ultrasound for CTS.

Source: cochrane