Mauro Mondelli

Carpal tunnel syndrome incidence in a general population

Objective: To determine the incidence of carpal tunnel syndrome (CTS) in a general population of a restricted area in the middle part of Italy. Methods: Prospective study to identify cases of CTS, newly diagnosed on the basis of clinical symptoms and delay in distal conduction velocity of the median nerve. In the 8-year period from 1991 to 1998, cases were identified by electromyographic services in the Siena area of Local Health District No. 7 of Tuscany (Italy). This area has a population of 120,000. Results: In the 8-year period, 3,142 cases (79.7% women and 20.3% men; mean age, 55 years; range, 13 to 97 years) were identified. The mean annual crude incidence was 329 cases per 100,000 person-years, and the standardized incidence was 276. The sex-specific incidences were 139 for men and 506 for women. The mean annual incidence for men increased moderately but significantly during the study period, whereas that for women remained constant. The age-specific incidence for women increased gradually with age, reaching a peak between 50 and 59 years, after which it declined. In men, there was a bimodal distribution with peaks between 50 and 59 years and between 70 and 79 years. Rural and industrial areas had higher crude and age- and sex-specific incidences than did urban areas. Conclusions: The incidence in the Siena area is about threefold that reported in the Rochester area (Minnesota) and is similar to that of Marshfield (Wisconsin). The different results with respect to US reports may depend on case inclusion criteria and occupational activities of the population at risk.

Traumatic peripheral nerve injuries: epidemiological findings, neuropathic pain and quality of life in 158 patients

The objectives of this study were (1) epidemiological analysis of traumatic peripheral nerve injuries; (2) assessment of neuropathic pain and quality of life in patients affected by traumatic neuropathies. All consecutive patients with a diagnosis of traumatic neuropathies from four Italian centres were enrolled. Electromyography confirmed clinical level and site diagnosis of peripheral nerve injury. All patients were evaluated by disability scales, pain screening tools, and quality of life tests. 158 consecutive patients for a total of 211 traumatic neuropathies were analysed. The brachial plexus was a frequent site of traumatic injury (36%) and the radial, ulnar, and peroneal were the most commonly involved nerves with 15% of iatrogenic injuries. Seventy‐two percent of the traumatic neuropathies were painful. Pain was present in 66% and neuropathic pain in 50% of all patients. Patients had worse quality of life scores than did the healthy Italian population. Moreover, there was a strong correlation between the quality of life and the severity of the pain, particularly neuropathic pain (Short Form‐36 [SF‐36] p < 0.005; Beck Depression Inventory [BDI] p < 0.0001). Traumatic neuropathies were more frequent in young males after road accidents, mainly in the upper limbs. Severe neuropathic pain and not only disability contributed to worsening the quality of life in patients with traumatic neuropathies.

Diagnostic utility of ultrasonography versus nerve conduction studies in mild carpal tunnel syndrome

OBJECTIVE To prospectively compare high-resolution ultrasonography (US) and nerve conduction velocity (NCV) in clinically diagnosed mild carpal tunnel syndrome (CTS). METHODS Eighty-five patients (70 women and 15 men, mean age 46.8 years) reported symptoms compatible with classic/probable CTS. The protocol included NCV of the median and ulnar nerves (distal motor latency [DML], sensory conduction velocity [SCV] from the third [M3 SCV] and fourth fingers [M4 SCV] to the wrist for the median nerve); electrophysiologic severity scale; self-administered Levine/Boston questionnaire (BQ); and cross-sectional area (CSA) measurement of the nerve at the tunnel inlet (CSA-I), at the middle (CSA-M), and at the outlet (CSA-O). Relationship between age, body mass index, duration of symptoms, CSAs, NCV, electrophysiologic severity scale, and BQ scores was calculated. Concordance between CSAs and NCV, sensitivity of NCV and US was also evaluated. RESULTS The mean values of CSA-I, CSA-M, and CSA-O were 10.3, 9.8, and 8.7 mm2, respectively. Relationships were found between CSA-I and M3 SCV (r = -0.45), M4 SCV (r = -0.56), and median nerve DML (r = 0.29). Anomalous CSA-I, CSA-M, and CSA-O were found in 48, 25, and 26 patients, respectively; 55 (64.7%) had > or =1 abnormal CSA. NCV abnormalities were found in 67%. The sensitivity increased to 76.5% if US and NCV were considered together. The highest concordance to detect absence/presence of abnormalities was between CSA-I and NCV (77.6%; kappa = 0.52). CONCLUSION In mild cases of CTS, US did not detect more anomalies than NCV and vice versa, and no anomalies were detected with either diagnostic instrument in 23.5% of mild cases.

Outcome of surgical release among diabetics with carpal tunnel syndrome.

OBJECTIVE To compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes with those of patients with idiopathic CTS. DESIGN Prospective case series. SETTING Ambulatory care in Italy. PARTICIPANTS Twenty-four consecutive patients with diabetes type 1 or 2 and CTS (mean age, 66.7 y) were matched for age and sex with 72 patients (mean age, 66.2 y) with idiopathic CTS. INTERVENTIONS All patients underwent surgical release of CTS by the mini-incision of palm technique. MAIN OUTCOME MEASURES Clinical and electrophysiologic evaluation and patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status before and 1 and 6 months after surgery. RESULTS After surgical release, almost all patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. One month after surgery, there was a significant improvement in clinical status, BQ scores, and distal conduction velocities of the median nerve. A further improvement was evident at 6-month follow-up. There were no differences between the 2 groups in the number of surgical complications, in clinical and electrophysiologic status, or in BQ scores before and after surgery. The improvement in distal conduction velocities of the median nerve, BQ scores, and clinical and electrophysiologic status were similar in the 2 groups after surgery. CONCLUSION Diabetes is not a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes have the same probability of positive surgical outcome as patients with idiopathic CTS.

Systematic review of pregnancy-related carpal tunnel syndrome

The reported incidence of pregnancy‐related carpal tunnel syndrome (PRCTS) ranges from 0.8% to 70%, and little is known of its natural history. We systematically reviewed the reported incidence of PRCTS and evaluated its natural history. We identified 214 studies that fulfilled our selection criteria. Six publications fulfilled the inclusion criteria. Five fulfilled the incidence criteria, 3 fulfilled the natural history criteria, and 2 of the 6 publications satisfied both. The reported incidence of neurophysiologically confirmed PRCTS ranged from 7% to 43%, whereas the incidence of clinically diagnosed PRCTS ranged from 31% to 62%. Symptoms persisted in more than 50% of the patients after 1 year and in about 30% after 3 years. Our review suggests that variations in the reported incidence of PRCTS largely depend on the methods used to detect this syndrome. Our data also suggest that symptoms persist in a substantial number of patients 1 or more years after delivery. Muscle Nerve 42: 697–702, 2010

Carpal tunnel syndrome in pregnancy Multiperspective follow-up of untreated cases

In a follow-up of carpal tunnel syndrome (CTS) after pregnancy, the Italian CTS Study Group prospectively studied 63 pregnant women with multiple measurements of CTS symptoms. Fifty-four percent of women with CTS symptoms during pregnancy had symptoms 1 year later. Patients with onset of CTS symptoms early during pregnancy are less likely to improve after delivery.

Ultrasonography in ulnar neuropathy at the elbow : Relationships to clinical and electrophysiological findings

INTRODUCTION Though ultrasonography (US) is commonly used in the diagnosis of carpal tunnel syndrome (CTS), there are only few studies on the utility of US in ulnar neuropathy at the elbow (UNE). The aims of this study were to measure the cross-sectional area (CSA) of the ulnar nerve at the elbow and to correlate CSA values with clinical and electrophysiological findings. PATIENTS AND METHODS Thirty-three UNE patients (mean age 50.1 years) were consecutively enrolled. Diagnosis was based on clinical findings and slowing of the motor conduction velocity (MCV) of the ulnar nerve across the elbow. CSAs of the ulnar nerve were measured within the cubital tunnel at the level of the medial epicondyle (CSA-M) and approximately 2cm proximal to this point (CSA-I). Correlations between CSA and demographic, clinical (ordinal severity scale and self-administered symptom questionnaire), and electrophysiological findings (neurographic results and ordinal electrophysiological severity scale) were calculated using Spearmans correlation coefficient. RESULTS The mean CSA-M and CSA-I were 9.6+/-8.5 and 9.3+/-5.6mm2, respectively. Fifteen (45.5%) and eight (24.5%) cases showed abnormal CSA-M and CSA-I values, respectively (mean+2S.D. compared to a control group of the same age). All cases with abnormal CSA-I had abnormal CSA-M except one. Significant relationships were only found between CSA-M and CSA-I with across elbow MCV, sensory action potential amplitude, and the electrophysiological severity scale score. DISCUSSION Our study showed anomalous CSA values in less than 50% of the UNE cases. This is less than the reported percentages in the few literature reports. This difference may be due to our enrolment criteria or to the electrophysiological and US techniques. It is likely that the CSAs measured by axial scan at a fixed level of the cubital tunnel may have lower diagnostic sensitivity than the same technique used in CTS.

Multicenter study of peroneal mononeuropathy: clinical, neurophysiologic, and quality of life assessment.

Abstract  This is a multicenter study on peroneal mononeuropathy (PM), in which a multidimensional protocol was performed to evaluate (1) the predisposing factors and their occurrence; (2) the relationships between the etiological, clinical, and neurophysiologic findings; and (3) disability and quality of life (QoL) in a wide sample with PM. Clinical and neurophysiologic evaluation was performed in all patients; moreover, the group adopted validated disability and QoL measurements to obtain more comprehensive and reliable data on PM. From November 2002 to January 2004, 69 patients were enrolled consecutively in 11 Italian centers. Our data showed that PM involves men more frequently than women (male : female = 4.1:1). PM was idiopathic (16%) or due to prolonged posture (23.1%), surgery (20.3%), weight loss (14.5%), trauma (11.6%), bedridden condition (7.3%), external compression from cast (5.8%), and arthrogenic cyst at the fibula (1.4%). Unexpectedly, peroneal nerve lesions were not only due to surgical operation close to the peroneal region but were also associated with thoracic‐abdominal surgery. We observed conduction block in about 50–70% of postural and weight loss PM; in perioperative and idiopathic PM, conduction block or mixed damage was equally present; in PM due to trauma, we observed an exclusive axonal damage in about 60% of cases. Only in three cases (one postural PM, one idiopathic PM, and one weight loss PM), we observed a slowing of conduction velocity in the popliteal fossa‐fibular head segment without conduction block. The comparison between QoL in patients with PM and in healthy subjects showed a significant involvement of physical and mental aspects. With regard to disability, 68% of patients walked with difficulty. Our data show that (1) most of the cases of PM are due to an identifiable predisposing factor; (2) there is a good correlation between predisposing factors and clinical‐neurophysiologic findings; and (3) PM causes disability and deterioration of the physical and emotional aspects of QoL.

Axonal motor and sensory neuropathy in myotonic dystrophy

We report the neurophysiological findings from 24 subjects with myotonic dystrophy of Steinert and the histological findings in two of them. The conduction data is compared with that of a group of subjects with Landouzy‐Déjérine muscular dystrophy. In 46% of cases, the electrophysiological data revealed slight and generalized axonal neuropathy. Histological results of sural nerve confirmed axonal damage of sensory fibres. The neuropathy was not correlated with age of patients, duration or onset of the disease, nor with the state of the deep reflexes; it did not show signs of progressing and is probably one of the multisystemic manifestations of gene pleiotropism.

Cerebrotendinous xanthomatosis: 11-year treatment with chenodeoxycholic acid in five patients. An electrophysiological study

We report the electrophysiological follow-up of five cerebrotendinous xanthomatosis patients treated for 11 years with chenodeoxycholic acid (CDCA). Nerve conduction velocity (NCV) was reduced in three cases. P100 latency of visual evoked potentials was delayed in four cases, interpeaks I-III and I-V of brainstem auditory evoked potentials (BAEPs) was increased in two and interpeak N13-20 of upper limb somatosensory evoked potentials (SEPs) was slowed in one. After 4 months of therapy with CDCA, NCV was normal and did not show any significant change during the 11 years of observation. Central motor conduction time of motor evoked potentials (MEPs) and N24-P40 interpeak latency of lower limb SEPs were increased in five and four cases, respectively, in spite of 2/3-year treatment with CDCA. Improvement of evoked potentials, especially of MEPs and SEPs, was slower and continued over the whole 11-year period. The size of xanthomas slightly decreased in some patients during treatment and the clinical manifestations stabilized, avoiding progressive worsening, but there was no significant improvement in neurological deficit. Two sisters of patients who never took CDCA showed progressive worsening of clinical manifestations, upper limb SEPs and BAEPs.