Pietro Caliandro

Carpal Tunnel Syndrome: ultrasound, neurophysiology, clinical and patient-oriented assessment

OBJECTIVE The aim of this study is twofold. First, to assess the relationships between the cross-sectional area (CSA) of the median nerve (MN) calculated at ultrasound (US) and: (1) patients perception of his/her symptoms and hand function; (2) clinical severity of CTS; (3) neurophysiological classification; (4) hand distribution of symptoms. Second, to assess the sensitivity of ultrasonography (US) and neurophysiology in the diagnosis of CTS using clinical measures as gold standard. METHODS We performed a prospective study by using multidimensional assessment: clinical (Historic and Objective scale, Hi-Ob), neurophysiological, patient-oriented measures (Boston Carpal Tunnel Questionnaire, BCTQ) and high-resolution US. The dominant hands of 54 consecutive patients who were referred to our neurophysiologic laboratory with clinical signs of CTS (43 females, mean age 53.3, range 30-80, SD: 13.1) were examined. RESULTS A statistically significant correlation was found between the CSA of the MN at wrist and (1) hand function (according to BCTQ, r=0.35, p=0.01), (2) clinical scale (Hi-Ob scale, r=0.51, p<0.00007), (3) neurophysiologic classification (r=0.80, p<0.0000001), and (4) hand distribution of symptoms (p=0.017). Neurophysiology showed higher sensitivity than US but in one of 3 cases with normal neurophysiological results, US showed data suggestive of CTS. CONCLUSIONS A positive correlation exists between US findings and all the conventional measures of CTS severity. The sensitivity of the combination of US and neurophysiology is higher than the sensitivity of neurophysiology or US alone. US is a useful complementary tool for CTS assessment. SIGNIFICANCE Information on the contribution of US in CTS and the interpretation of severity measurements in CTS.

Contribution of ultrasound in a neurophysiological lab in diagnosing nerve impairment: A one-year systematic assessment

OBJECTIVE To evaluate the usefulness of a combination of electromyography (EMG) and ultrasound (US) assessments in diagnosing nerve trunk involvement. We hypothesised that in some cases, when the clinical or neurophysiological picture is unclear, the simultaneous study of the peripheral nervous system through both US and EMG may provide pathologic information not obtainable through EMG alone, and this may influence therapeutic decisions. METHODS In 2005, we performed a prospective study in 77 consecutive patients with involvement of a single nerve trunk, using a combination of EMG and US in the same session. We divided the diagnostic contribution of US into four categories: diagnostic, confirming, inconclusive and misdiagnostic. RESULTS In about a quarter of the patients, US provided results confirming the clinical neurophysiological diagnosis. In another quarter of the cases, US was very helpful in modifying diagnosis and therapy. In most of these cases, the contribution of US was important for the detection of tumors or cysts, thus showing the cause of nerve involvement. In half of the cases the US results were inconclusive, and in one case US was misdiagnostic. CONCLUSIONS The combination of EMG and US performed in the same session (or in collaboration with an ultrasound examiner) may be useful for diagnosis and determination of appropriate therapy. SIGNIFICANCE Diagnosis of mononeuropathies is improved through a combined functional and morphological evaluation of the nerve by using EMG and US.

Differential involvement of A-delta and A-beta fibres in neuropathic pain related to carpal tunnel syndrome

ABSTRACT Carpal tunnel syndrome (CTS), a common entrapment neuropathy involving the median nerve at the wrist, frequently manifests with neuropathic pain. We sought information on pain mechanisms in CTS. We studied 70 patients with a diagnosis of CTS (117 CTS hands). We used the DN4 questionnaire to select patients with neuropathic pain, and the Neuropathic Pain Symptom Inventory (NPSI) to assess the intensity of the various qualities of neuropathic pain. All patients underwent a standard nerve conduction study (NCS) to assess the function of non‐nociceptive A&bgr;‐fibres, and the cutaneous silent period (CSP) after stimulation of the IIIrd and Vth digits, to assess the function of nociceptive A&dgr;‐fibres. In 40 patients (75 CTS hands) we also recorded laser‐evoked potentials (LEPs) in response to stimuli delivered to the median nerve territory and mediated by nociceptive A&dgr;‐fibres. We sought possible correlations between neurophysiological data and the various qualities of neuropathic pain as assessed by the NPSI. We found that the median nerve sensory conduction velocity correlated with paroxysmal pain and abnormal sensations, whereas LEP amplitude correlated with spontaneous constant pain. Our findings suggest that whereas paroxysmal pain and abnormal sensations reflect demyelination of non‐nociceptive A&bgr;‐fibres, spontaneous constant pain arises from damage to nociceptive A&dgr;‐fibres.

Contribution of ultrasound in the assessment of nerve diseases.

Background and purpose:  Recently, ultrasound (US) has been used to assess the peripheral nervous system; however, there is no real study about its possible significant role in routine practice. Our study aims to assess the contribution of US as a routine tool in a neurophysiological laboratory.

Symptoms and neurophysiological picture of carpal tunnel syndrome in pregnancy

OBJECTIVE To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS. METHODS During 2000, the Italian CTS study group focussed on the occurrence of CTS in women during the final stages of pregnancy, enrolled in 7 Italian centers. In addition to the physician-centered and neurophysiologic traditional evaluations, we used a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment. RESULTS In our study, CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Our study provides evidence, reported here for the first time, of a correlation between edema and neurophysiological picture. Similarly, our study provides a correlation between validated patient-oriented measurement and edema. Moreover, a significant correlation between a negative trend (subjectively assessed) and smoking and alcohol consumption was observed. CONCLUSIONS Our observations confirm that the edema of the tissues in the carpal tunnel could induce a mechanical compression of the nerve. Moreover, our data suggest that smoking and alcohol consumption have a negative role in the evolution of the syndrome probably due to impairment of the microcirculation.

Predictive variables on disability and quality of life in stroke outpatients undergoing rehabilitation

The purposes of this study were: (1) to evaluate the relationship between disability and Quality of Life (QoL) in stroke outpatients undergoing rehabilitation and (2) to determine whether and how demographic and social features of the patient, duration of disease and concomitant diseases influence the disability and QoL of the stroke outpatients. We performed a prospective study using several conventional disability measurements (Barthel Index, Functional Independence Measure, Modified Rankin Scale and Deambulation Index) and a validated patient-oriented measurement of QoL (SF-36). Sixty-eight outpatients were evaluated consecutively. As expected, all disability measurements were related to Physical Function: patients with higher disability, according to the physician’s perspective, complained of higher deterioration of physical performance. Unexpectedly, patients with higher disability from the physician’s point of view perceive that they were not able to do some daily activities not only because of physical problems but also because of emotional problems, and complained of higher deterioration of mental health. Multivariate analysis showed that higher disability is associated with higher age, depression and lower educational level. Physical Composite Score appeared to be deteriorated in patients with lower educational level who lived with family; on the contrary, Mental Composite Score appeared deteriorated in patients with higher educational level who lived alone. The current study provides interesting data about the relationship, not always expected, between disability and QoL for stroke patients and about the influence of patients’ characteristics on disability and QoL. Our results showed that in a rehabilitation programme we should consider not only disability assessment but also QoL, which is more relevant for the patient.

Seronegative myasthenia gravis: comparison of neurophysiological picture in MuSK+ and MuSK− patients

The aim of this study was to compare the neurophysiological and clinical pictures of a large sample of seronegative myasthenia gravis (SNMG) patients with and without anti‐MuSK antibodies. Fifty‐two consecutive SNMG patients were retrospectively evaluated. They had undergone an extended neurophysiological evaluation: repetitive nerve stimulation (RNS), single fiber EMG (SFEMG), and electromyography (EMG) with nerve conduction study. A muscle biopsy was performed in 11 of 52 patients, the edrophonium test in 44 of 52 patients and anti‐AChR antibodies and anti‐MuSK antibodies were tested in all patients. Anti‐MuSK antibodies were detected in 25 SNMG patients (48.1%). The number of women in the MuSK+ group was significantly higher (P = 0.01) than in the MuSK− group. Seronegative MuSK+ patients are more severely affected and the deficit often involves the bulbar and the respiratory muscles. No statistically significant differences were observed in the edrophonium test between MuSK+ and MuSK− groups. The RNS test was abnormal in a significantly higher number of MUSK− patients than MUSK+ patients (P < 0.00001). With regard to SFEMG data, MuSK− patients were characterized to have more severe neurophysiological pattern. Our observations showed several differences between the clinical and neurophysiological pictures of MUSK+ and MUSK− patients.

Distribution of paresthesias in Carpal Tunnel Syndrome reflects the degree of nerve damage at wrist

OBJECTIVE To verify whether the distribution of paresthesias in patients with Carpal Tunnel Syndrome (CTS) is related to the degree of the neurophysiological involvement. METHODS We performed a cross-sectional study and retrospectively evaluated 163 patients who referred to our electromyography lab and to which a clinical and electrophysiological diagnosis of CTS was made. We divided the patients into two groups: (1) patients complaining of paresthesias at the hand as a whole and (2) patients with paresthesias in the territory of the median nerve. We referred to the distribution of paresthesias at the hand as GLOVE and to the distribution in the territory of the median nerve as MEDIAN. We compared the neurophysiological impairment in GLOVE and MEDIAN distributions. Moreover, we performed multiple regression analysis to evaluate which clinical-neurophysiological variables determined GLOVE and MEDIAN distribution. RESULTS In our sample, 70.4% of patients had GLOVE distribution and 29.6% of patients MEDIAN distribution. The risk of presenting MEDIAN distribution increases about twice (OR = 2.07; 95% IC: 1.51-2.83) for each unitary increment of neurophysiological class. CONCLUSIONS The distribution of paresthesias reflects the degree of nerve damage at wrist; patients suffering of SEV/EXT CTS present MEDIAN distribution. SIGNIFICANCE Our data have important clinical implications because they strongly suggest that we have to consider the possibility of a severe neurophysiological involvement of the median nerve at wrist in patients complaining of MEDIAN distribution.

Peroneal mononeuropathy: predisposing factors, and clinical and neurophysiological relationships.

Abstract The most common mononeuropathy in the lower extremity involves the nerve. We retrospectively evaluated the etiological predisposing factors and clinical-neurophysiological features of 36 patients affected by peroneal mononeuropathy (PM). In 30 patients, a clear predisposing factor was identified. PM was more frequently perioperative (11 cases), associated with axonal involvement. Unexpectedly, PM was not only due to surgery close to the peroneal region, but was mostly associated with hip surgery and, rarely, with thoracic-abdominal surgery. A postural predisposing factor of PM was also frequently observed, usually associated with a pure conduction block. Conversely, most patients with bedridden predisposing factor presented axonal involvement, which was rarely associated with conduction block. In 25 of 36 PM cases, a long-term follow-up lead to an improvement (12 cases) or to good recovery (13 cases) of PM. In conclusion, our study shows that: (1) in most PM cases it is possible to identify a predisposing factor; (2) there is a good correlation between predisposing factor and neurophysiological involvement, and (3) PM usually has usually a good prognosis.

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.