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ADDITIONALREADING

Go C, Avgerinos ED, Chaer RA, et al. Long-term clinical outcomes and cardiovascular events after carotid endarterectomy. Ann Vasc Surg. 2015;29(6):1265–1271.

Jonas DE, Feltner C, Amick HR, et al. Screening for asymptomatic carotid artery stenosis: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2014;161(5):336–346.

Paraskevas KI, Mikhailidis DP, Veith FJ. Comparison of the five 2011 guidelines for the treatment of carotid stenosis. J Vasc Surg. 2012;55(5):1504– 1508.

Rundek T, Sacco R. Risk factor management to prevent first stroke. Neurol Clin. 2008;26(4):1007–1045.

SEE ALSO

Algorithms: Stroke; Transient Ischemic Attack and Transient Neurologic Defects

CODES

ICD10

I65.29 Occlusion and stenosis of unspecified carotid artery

I65.21 Occlusion and stenosis of right carotid artery I65.22 Occlusion and stenosis of left carotid artery

CLINICALPEARLS

Atherosclerosis is responsible for 90% of all cases of carotid artery stenosis.

Duplex US is the best initial imaging modality.

Antiplatelet therapy and aggressive treatment of vascular risk factors are the mainstays of medical therapy.

Compared with CEA, CAS increases the risk of any stroke and decreases the risk of MI. For every 1,000 patients opting for stenting rather than endarterectomy, 19 more patients would have strokes and 10 fewer would have MIs.

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CARPALTUNNELSYNDROME

Philip H. Aurigemma, MD Marci D. Jones, MD

BASICS

DESCRIPTION

Symptomatic compression neuropathy of the median nerve

Increased pressure within the carpal tunnel leads to compression of the median nerve and characteristic motor-sensory findings.

The dorsal aspect of the carpal tunnel is composed of the carpal bones. The transverse carpal ligament defines the palmar boundary:

– The carpal tunnel contains nine flexor tendons and the median nerve.

Symptoms most commonly affect the dominant hand; >50% of patients will experience bilateral symptoms.

System(s) affected: musculoskeletal, nervous

ALERT

Increased incidence during pregnancy (up to 20–45%)

EPIDEMIOLOGY

Predominant age: 40 to 60 years

Predominant sex: female > male (3:1 to 10:1)

Incidence

Two peaks: late 50s (women), late 70s (both genders)

Incidence up to 276/100,000 has been reported.

Incidence increases with age.

Prevalence

9% in women and 6% in men; 50 cases per 1,000 individuals per year in United States

14% in diabetics without neuropathy and 30% in patients with diabetic neuropathy

Rising prevalence may be the result of increasing lifespan and increasing prevalence of diabetes.

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ETIOLOGYAND PATHOPHYSIOLOGY

Combination of mechanical trauma, inflammation, increased pressure, and ischemic injury to the median nerve within the carpal tunnel

Acute CTS caused by rapid and sustained pressure in carpal tunnel, usually secondary to trauma, may require urgent surgical decompression. Chronic CTS divided into four categories:

–Idiopathic: combination of edema and fibrous hypertrophy without inflammation

–Anatomic: persistent median artery, ganglion cyst, infection, spaceoccupying lesion in carpal tunnel

–Systemic: associated with conditions such as obesity, diabetes, hypothyroidism, rheumatoid arthritis, amyloidosis, scleroderma, renal failure, and drug toxicity

–Exertional: repetitive use of hands and wrists, repeated palmar impact, use of vibratory tools. Repetitive use is an objective cause of CTS.

Genetics

Unknown; however, a familial type has been reported.

RISK FACTORS

Prolonged postures in extremes of wrist flexion and extension; repetitive exposure to vibration

Alterations of fluid balance: pregnancy, arthritis, menopause, obesity, renal failure, hypothyroidism, congestive heart failure and oral contraceptive use Neuropathic factors (diabetes, alcoholism, vitamin deficiency, or exposure to

toxins) can elicit symptoms.

GENERALPREVENTION

There is no known prevention for CTS. It is recommended to take occasional (e.g., hourly) breaks when doing repetitive work involving hands or if prolonged occupational exposure to vibratory tools.

COMMONLYASSOCIATED CONDITIONS

Diabetes, obesity; pregnancy; hypothyroidism

Osteoarthritis of small joints of hand and wrist

Hyperparathyroidism, hypocalcemia

Miscellaneous associations include the following:

– Acromegaly; lupus erythematosus; leukemia

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–Pyogenic infections; sarcoidosis

–Primary amyloidosis; Paget disease

–Hormone replacement therapy

DIAGNOSIS

HISTORY

Nocturnal pain, numbness, and tingling of the thumb, index, long, and radial portion of the ring fingers; patients may not localize and alternatively describe the entire hand as being affected.

Hand weakness during tasks as opening jars is often noted early in the disorder.

Atypical presentation involves paresthesias in radial digits, with pain radiating proximally along median nerve to elbow and sometimes the shoulder.

Symptoms characteristically are relieved by shaking or rubbing the hands.

During waking hours, symptoms occur when driving, talking on the phone, and occasionally when using the hands for repetitive maneuvers.

Presence of predisposing factors, such as diabetes, obesity, acromegaly, pregnancy, or occupational exposure

PHYSICALEXAM

Positive Tinel sign: Tapping over the palmar surface of the wrist proximal to the carpal tunnel may produce an electric sensation along the distribution of the median nerve (50% sensitivity; 77% specificity).

Positive Phalen sign: Holding the wrist in fully flexed position for 60 seconds precipitates paresthesias (68% sensitivity; 73% specificity).

Durkan compression test: Direct compression of median nerve at carpal tunnel for 30 seconds elicits symptoms (87% sensitivity; 90% specificity).

Wasting of thenar musculature is a late sign.

Loss of 2-point discrimination

Ulceration of fingertips is associated with loss of protective sensation.

DIFFERENTIALDIAGNOSIS

Cervical spondylosis (carpal tunnel may also occur with cervical spine disease; “double crush”)

Generalized peripheral neuropathy

Brachial plexopathy, in particular upper trunk

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CNS disorders (multiple sclerosis, cerebral infarction)

Thoracic outlet syndrome

Pronator syndrome

Anterior interosseous syndrome

Musculoskeletal disorders of the wrist:

–Trauma or distal radius fracture

–Degenerative joint disease

–Rheumatoid arthritis

–Ganglion cyst

Scleroderma

DIAGNOSTIC TESTS & INTERPRETATION

No laboratory test is diagnostic.

Normal serum thyrotropin (thyroid-stimulating hormone [TSH]) and normal serum chemistries help exclude secondary conditions associated with CTS.

Initial Tests (lab, imaging)

Special tests

–Electrodiagnostic studies

Sensitivity 85%; specificity 95%

Nerve conduction studies compare latency and amplitude of median nerve signals across the carpal tunnel.

Prolonged distal latency of the median motor and/or sensory fibers may be seen. Decreased amplitudes suggest axon loss.

The most sensitive indicator is median sensory distal latency, which is prolonged in CTS. Sensory nerve action potentials may be reduced or unobtainable.

Electromyographic changes are indicative of long-standing or severe

nerve dysfunction.

Perform ulnar nerve stimulation to exclude generalized polyneuropathy.

Standard radiographs of the wrist evaluate bony anatomy and degenerative joint disease.

Special radiographic views of the carpal tunnel are of limited use.

Magnetic resonance imaging and ultrasound are of limited benefit in diagnosis of CTS.

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TREATMENT

GENERALMEASURES

Splinting the wrist in a neutral position while sleeping may provide significant symptom relief:

–Limited evidence indicates that night splints are more effective than no treatment in the short term; insufficient evidence to recommend a specific splint design or wearing schedule (1)[A]

–American Academy of Orthopaedic Surgeons (AAOS) guidelines indicate immobilization improves outcomes.

Splinting (sometimes prolonged) typically promotes symptom resolution.

Corticosteroid injections are effective for up to 3 months compared with placebo (2)[A]. Outcomes at 1 year show no benefit for local steroid injections compared to placebo (3)[A].

MEDICATION

First Line

NSAIDs, such as ibuprofen or naproxen sodium, are commonly used. There is insufficient evidence to determine their routine efficacy:

Contraindications: GI intolerance

Precautions: GI side effects of NSAIDs may preclude their use in selected patients.

Second Line

Local steroid injection: Methylprednisolone injections are more effective than systemic steroids or placebo at 1 and 3 months and more effective than splinting at 6 months.

Response to injections helps confirm diagnosis of CTS and predicts a better response to surgery.

Side effects include reduction of collagen and proteoglycan synthesis, limiting tenocytes, and reducing mechanical strength of tendon, leading to further degeneration and risk for rupture.

Oral steroids may provide a short-term improvement (2 to 8 weeks) in symptoms.

The long-term risks of even a short course of steroids should be balanced with the limited potential benefit of symptom improvement.

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ISSUES FOR REFERRAL

Preoperative electrodiagnostic studies are generally obtained prior to any surgical intervention.

SURGERY/OTHER PROCEDURES

Completely dividing the transverse carpal ligament provides symptom relief in >95% of patients.

Surgical decompression is an outpatient procedure performed under local or regional anesthesia.

Incisional healing generally takes 2 weeks; an additional 2 weeks may be required before using the affected hand for tasks requiring strength.

Long-term results of open carpal tunnel release are excellent. Patients experience consistent pain relief for 10 to 15 years (3)[B].

Recent randomized, controlled studies indicate that surgery leads to better functional improvements at 1 year compared with nonoperative management.

Open versus endoscopic surgical procedures produce similar outcomes at 6 months. The approach should be based on surgeon and patient preference.

Risk of transient nerve injuries is higher with endoscopic release (4)[A].

Therapeutic ultrasound, exercise, and mobilization techniques have limited benefit compared with other nonsurgical interventions. Poor quality evidence shows ultrasound may be more effective than placebo (5,6)[A].

COMPLEMENTARY& ALTERNATIVE MEDICINE

No trial data support the use of vitamin B6 in the prevention or treatment of CTS.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Outpatient

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

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Patients treated nonoperatively (splinting, injections) require follow-up over 4 to 12 weeks to ensure adequate progress.

There is only limited, low-quality evidence to suggest that rehabilitation exercises such as wrist immobilization, ice therapy, and multimodal hand rehabilitation are beneficial.

7–20% of patients treated surgically may experience recurrence.

PATIENT EDUCATION

American Society for Surgery of the Hand: http://www.assh.org/Public/HandConditions/Pages/CarpalTunnelSyndrome.aspx

PROGNOSIS

Patients with severe CTS may not recover completely after surgical release. Paresthesias and weakness may persist, but night symptoms generally resolve.

If untreated, more severe cases of CTS can lead to numbness and weakness in the hand, atrophy of the thenar muscles, and permanent loss of median nerve function.

COMPLICATIONS

Postoperative infection (rare)

Injury to the median nerve or its recurrent (motor) branch

REFERENCES

1.Page MJ, Massy-Westropp N, O’Connor D, et al. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;(7):CD010003.

2.Atroshi I, Flondell M, Hofer M, et al. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med. 2013;159(5):309–317.

3.Louie DL, Earp BE, Collins JE, et al. Outcomes of open carpal tunnel release at a minimum of ten years. J Bone Joint Surg Am. 2013;95(12):1067–1073.

4.Sayegh ET, Strauch RJ. Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials. Clin Orthop Relate Res. 2015;473(3):1120–1132.

5.Page MJ, O’Connor D, Pitt V, et al. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012; (6):CD009899.

6.Graham B, Peljovich AE, Afra R, et al. The American Academy of Orthopaedic Surgeons evidence-based clinical practice guideline on:

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management of carpal tunnel syndrome. J Bone Joint Surg Am.

2016;98(20):1750–1754.

ADDITIONALREADING

Middleton SD, Anakwe RE. Carpal tunnel syndrome. BMJ. 2014;349:g6437.

Page MJ, O’Connor D, Pitt V, et al. Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database Syst Rev. 2013;(3):CD009601.

Peters S, Page MJ, Coppieters MW, et al. Rehabilitation following carpal tunnel release. Cochrane Database Syst Rev. 2013;(6):CD004158.

Shi Q, MacDermid JC. Is surgical intervention more effective than nonsurgical treatment for carpal tunnel syndrome? Asystematic review. J Orthop Surg Res. 2011;6:17.

Tai TW, Wu CY, Su FC, et al. Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy. Ultrasound Med Biol. 2012;38(7):1121–1128.

Vasiliadis HS, Georgoulas P, Shrier I, et al. Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev. 2014;(1):CD008265.

SEE ALSO

Arthritis, Rheumatoid (RA); Hypoparathyroidism; Lupus Erythematosus,

Systemic (SLE); Scleroderma

Algorithms: Carpal Tunnel Syndrome; Pain in Upper Extremity

CODES

ICD10

G56.00 Carpal tunnel syndrome, unspecified upper limb

G56.01 Carpal tunnel syndrome, right upper limb

G56.02 Carpal tunnel syndrome, left upper limb

CLINICALPEARLS

Paresthesias associated with CTS are characteristically confined to the thumb, index, long, and radial 1/2 of the ring fingers of the affected hand.

Thenar atrophy is a late finding, indicating severe nerve damage.

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The Durkan (carpal compression) test is superior to Tinel sign (tapping on median nerve over carpal tunnel) and Phalen maneuver (holding wrists in flexion) for the clinical diagnosis of CTS.

Steroid injections offer short-term relief, but clinical outcomes at 1 year are no different than placebo.

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