Claudia Loreti

Carpal tunnel syndrome: clinical features, diagnosis, and management

Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome worldwide. The clinical symptoms and physical examination findings in patients with this syndrome are recognised widely and various treatments exist, including non-surgical and surgical options. Despite these advantages, there is a paucity of evidence about the best approaches for assessment of carpal tunnel syndrome and to guide treatment decisions. More objective methods for assessment, including electrodiagnostic testing and nerve imaging, provide additional information about the extent of axonal involvement and structural change, but their exact benefit to patients is unknown. Although the best means of integrating clinical, functional, and anatomical information for selecting treatment choices has not yet been identified, patients can be diagnosed quickly and respond well to treatment. The high prevalence of carpal tunnel syndrome, its effects on quality of life, and the cost that disease burden generates to health systems make it important to identify the research priorities that will be resolved in clinical trials.

Tarsal tunnel syndrome: still more opinions than evidence. Status of the art.

Tarsal tunnel syndrome is an entrapment neuropathy of the posterior tibial nerve or its terminal branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. The condition is frequently underdiagnosed leading to controversies regarding its epidemiology and to an intense debate in the literature. With the advent of nerve imaging techniques, the diagnostic confirmation and the etiological identification have become more accurate. However, management of this entrapment neuropathy remains challenging because of many intervention strategies but limited robust evidence. Uncertainties still exist about the best conservative treatment, timing of surgical intervention, and best surgical approach. In the attempt to clarify these aspects and to provide the reader some understanding of the status of the art, we have reviewed the published literature on this controversial condition.

Diagnosis and treatment of carpal tunnel syndrome – Authors' response

While I believe that the Review by Luca Padua and colleagues can be useful for many health-care professionals, an excellent analysis of the available evidence regarding carpal tunnel syndrome was not included. Hand surgeons will approach this disease in a slightly different manner than Padua and colleagues do. From a surgeon’s perspective, each of the non-surgical management strategies described by the authors can be considered a low risk, but also a low benefit approach, with any improvement in symptoms likely transient in nature, and possibly related to placebo effect. Non-surgical management should be considered in mild cases, and if symptoms can reverse spontaneously (eg, during pregnancy). The risks associated with surgical treatment are low, especially if endoscopic surgery is performed under local anaesthesia. Surgery is usually a cure of the disease, as it is the only treatment that addresses the root cause of carpal tunnel syndrome— namely that the volume of the carpal tunnel is too small for its contents. Surgery should be considered in any patients with symptoms that cause substantial sleep disruption or interference with activities of daily living, or if there are symptoms or signs of advanced disease, such as constant numbness, thenar weakness or atrophy, or denervation observed on EMG testing. But surgery can also be considered in mild cases— why should anyone suffer if a cure is available? Instead of a universal hierarchy of treatment (eg, all patients should undergo at least 1 month of splinting, or all patients should have a steroid injection before considering surgery), better to choose the best treatment for each individual patient. The authors believe “that a comprehensive diagnostic workup is needed.” However, roughly half of hand surgeons surveyed think that no electrophysiological or other diagnostic testing is necessary in patients with a typical history of carpal tunnel syndrome. Electrophysiological testing can be useful (eg, in atypical presentations, when looking for other potential nerve compression sites, or for medicolegal reasons), but routine use of diagnostic testing and trials of non-surgical management, such as steroid injection, increase costs, delay definitive treatment, and offer no improvement in outcome. I agree with the authors on the importance of history-taking in diagnosis. Patients are often referred to surgeons like me after a diagnosis of carpal tunnel syndrome, but without the typical features in their clinical history. Convincing a patient that the diagnosis was wrong, or that they need a different work-up or treatment can lead to frustration. In the words of Sir William Osler, one of the founding fathers of modern medicine, “Listen to your patient; he is telling you the diagnosis.”

Letter: Cubital Tunnel Syndrome: Incidence and Demographics in a National Administrative Database

To the Editor: Osei and colleagues recently published a very interesting paper entitled “Cubital Tunnel Syndrome: Incidence and Demographics in a National Administrative Database”.1 We would like to sincerely praise the authors for this brilliant publication about ulnar neuropathy at elbow; cubital tunnel syndrome is a common disease and it represents the second most frequent nerve entrapment.2 Osei and colleagues investigated the incidence of this neuropathy in United States, using a very large database. The authors started from the consideration that knowing the epidemiological impact of this disease in the general population should be desirable for a better management. They found an incidence of about 30 persons per 100 000 per year and an increasing incidence and major frequency of surgically treated cases in older populations.1 The paper is very important for different reasons. First, the authors underlined the significance of an extensive knowledge of a very common disease. In fact, a well-known syndrome may show meaningful features that only large studies and big data collection can reveal. Furthermore, they explored epidemiological aspects of cubital tunnel. This issue is significant because it provides very useful information for the physicians dealing with this neuropathy. In particular, the importance of the paper is due to the analysis of the general population of a whole country. This could stimulate other groups to consider similar studies in order to obtain other country-specific data. Finally, Osei and colleagues presented the findings about the age-related growing incidence, useful information for prognosis. The authors presented the limitations of their study considering the possible bias of misclassification. They wrote that neurophysiological examination could reduce these mistakes, even if its use was not possible because of the study design.1 We agree with authors about the importance of neurophysiology for ulnar neuropathy assessment, but we would like to add the diagnostic importance of imaging tool in this syndrome. In particular, ultrasound (US) is very effective for neuropathy management. We would like to present a case of ulnar nerve dislocation, in which US allowed definition of the diagnosis, in order to show the potential powerful association between clinical evaluation, neurophysiology, and imaging tool. A 41-year-old woman came to our lab for clinical symptoms of left ulnar nerve suffering at elbow (paresthesia at the last 2 fingers during elbow flexion). Clinical examination revealed mild hypoesthesia at the left ring and little fingers and no muscle strength deficit. Electrophysiological examination confirmed the suffering, showing a mild slowing of motor nerve conduction velocity at elbow. US evaluation found enlargement of the left ulnar nerve at elbow, with a cross sectional area of 12 mm2 and a dislocation during the dynamic assessment, ie maximal flexion of the forearm. At the end of this movement, ulnar nerve subluxation was visible (Figure). The subject involved in the study gave informed consent. Our case shows the relevance of US for the assessment of ulnar neuropathy at elbow. The tool is able to see the nerve and allows a dynamic evaluation, providing information about the nerve and the surrounding anatomical structures, essential for eventual surgical palnning.3,4 Obviously, clinical examination is fundamental for diagnosis of peripheral nervous system diseases. The association with specific and efficient instruments, able to provide objective data about patient condition, should be considered in supporting diagnosis, prognosis, therapeutic decision, and rehabilitation programs for neuropathies.

Carpal tunnel syndrome treatment with palmitoylethanolamide: neurophysiology and ultrasound show small changes in the median nerve

We have read with attention the paper by Güner et al. about the use of lower-power laser and kinesio taping in carpal tunnel syndrome (CTS) [1]. The authors enrolled 37 patients presenting mild or moderate CTS, diagnosed by neurophysiology [1]. The patients were divided into three groups, to compare the effects of low-power laser therapy, kinesio taping associated with the same type of laser and sham laser. This specific treatment was applied for 3 weeks. The authors considered different outcome measures: visual numeric pain scale, hand grip strength, finger pinch strength, Boston Carpal Tunnel Questionnaire. The evaluations were performed before the therapy, after the treatment and three months later. Güner et al. found the patients managed with the two real treatments showed significant improvements in comparison with the sham one [1]. This work sheds light on specific conservative treatments of CTS, not only throughout questionnaires, but also with more objective measurements (like hand grip strength). The authors explored the effects of the mentioned treatments in a relative small amount of patients and in a relative short-term evaluation. The paper is extremely important for clinic and research activity. It shows the potential effectiveness of conservative approaches in treating CTS. Güner et al. evaluated the effects of an instrumental therapy and a particular device, but some drugs may be considered, in particular for pain relief in CTS. A possible and safe painkilling approach could be based on specific nutraceuticals able to treat pain with limited side effects. Among these, palmitoylethanolamide (PEA) may be a choice, because of its anti-inflammatory properties. However, besides promising data about its effectiveness for pain relief, evidence about its interactions with nerve function is scarce [2]. We have investigated PEA effects in CTS, through a double-blind study, comparing it with a placebo. We enrolled 56 patients presenting minimum and mild idiopathic CTS, diagnosed by clinical, neurophysiological and ultrasonographic (US) examination, following Padua’s classification [3]. We excluded patients with other neuropathies and orthopedic, endocrinological and rheumatological diseases. The patients were directly involved in the study and each one signed a written informed consent. The study was approved by the Local Ethical Committee of Fondazione Don Carlo Gnocchi (number 4_17/6/2009, date June 17, 2009). The patients were randomly assigned to group A (treated with PEA 600 mg/die) and group B (placebo treated). The treatment was one-month long. PEA and the placebo were administered as tablets with the same aspect, thus they were undistinguishable. During the treatment period, the patients were asked to avoid wrist overuse and no other drugs or specific therapy were administered. From the affected hand, we collected: (1) sensory nerve conduction velocity and amplitude of the first and the third digits; (2) distal motor latency and Rheumatology INTERNATIONAL

Ulnar neuropathy at wrist: entrapment at a very “congested” site

Ulnar tunnel syndrome indicates ulnar neuropathy at different sites within the wrist. Several classifications of ulnar tunnel syndrome are present in literature, based upon typical nerve anatomy. However, anatomical variations are not uncommon and can complicate assessment. The etiology is also complex, due to the numerous potential causes of entrapment. Clinical examination, neurophysiological testing, and imaging are all used to support the diagnosis. At present, many therapeutic approaches are available, ranging from observation to surgical management. Although ulnar neuropathy at the wrist has undergone extensive prior study, unresolved questions on diagnosis and treatment remain. In the current paper, we review relevant literature and present the current knowledge on ulnar tunnel syndrome.

Ulnar neuropathy after glatiramer acetate subcutaneous injection: Ultrasound findings

We have read the paper by Villaverde Piñeiro and colleagues, enti‐ tled “Paralysis of the external popliteal sciatic nerve associated with daptomycin administration.”1 The authors present a very interesting case of a 62‐year‐old man showing a toxic neuropathy, 22 days after daptomycin therapy. The patient developed a foot drop, and iatro‐ genic fibular neuropathy was suspected. The paper is informative, because it sheds light on possible side effects of some drugs, involv‐ ing the nervous system. Furthermore, the genetic evaluation and the suggested association between metabolism and the side effects are very interesting. The authors also used neurophysiological exam‐ ination in their evaluation.1 This approach is valuable, but we would like to suggest to the authors that imaging may be profitable in peripheral nerve assessment. Furthermore, we would like to report a likely drug‐related neuropathy from a local drug administration. Indeed, in the case by Villaverde Piñeiro and colleagues, the drug might have caused the neuropathy by a toxic mechanism possibly linked to a metabolic alteration, but other type of damage could be associated with drug administration procedures.1 We present a case of 30‐year‐old woman, with multiple sclero‐ sis, who complained of left ulnar nerve pain immediately after glati‐ ramer acetate (GA) subcutaneous injection in the posterior side of the left arm. The patient reported an “electrical shock” sensation during the injection. Our clinical evaluation showed weakness of the intrinsic muscles of the left hand and sensory deficit in the ulnar

The Role of Cognitive Reserve in the Choice of Upper Limb Rehabilitation Treatment After Stroke. Robotic or Conventional? A Multicenter Study of the Don Carlo Gnocchi Foundation

Rehabilitation is essential after stroke and, besides conventional rehabilitation, technological one has had big growth in clinical practice. There is a growing interest in cognitive reserve (CR) that summarizes pre-morbid life of each patient and has a key role in a sudden change of individual lifestyle (for example, after a stroke). Our preliminary data suggested that CR impacts on motor rehabilitation outcome. We hypothesized that CR may help in the complex choice between technological or conventional rehabilitation. The aim of this study is to evaluate whether the CR influences the motor outcome in patients after stroke treated with conventional or robotic therapy and if CR may address towards one treatment rather than another.

Limb hypotrophy in a child with history of umbilical cord knots. Nerve ultrasound findings

We have read with appreciation the paper by Okechi and coworkers about three cases of pediatric fibrolipomatous hamartomas of the median nerve [4]. The authors completed the diagnosis throughout magnetic resonance and ultrasound (US), showing the features of the lesions. These morphological data were used to support surgical intervention. Imaging is very useful for diagnosis. In particular, US is able to quickly show patient’s anatomy and morphological alterations, even in peripheral nerve diseases. Its use in children is recommendable for the high tolerability and the absence of side effects [1, 3]. We present a five-year-old boy with fetal history of umbilical cord knots, around the left arm. The child presented hypoplasia of the whole left upper limb and strength deficit in hand extension. The left arm showed two sulci along its circumference, due to the umbilical cord knots. US examination found reduction in dimensions of radial and ulnar nerves. In particular, these nerves presented a cross-sectional area reduction up to 30%, in comparison with the contralateral side (Fig. 1). The nerves presented a normal course with no focal changes and extrinsic compressions. Hypotrophy with no echogenicity alteration was found in the left forearm muscles. A rehabilitation protocol aimed to the left upper limb muscle reinforcement and movement reeducation was planned. Probably, the vascular supplying in the upper limb, during fetal life, was decreased, due to the umbilical cord knots [5]. This condition caused a general hypoplasia of the limb with reduced development of the nerves [2]. The case confirms the US ability to provide morphological information about the nerves and the surrounding tissues, with the possibility to calculate nerve dimension and, especially, to exclude other causes of strength deficit, like compression or nerve lesions. As Okechi and colleagues concluded, we recommend the completion of clinical and neurophysiological examination with imaging, in diagnosis of neuropathies [4].