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© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. in the clinic Carpal Tunnel Syndrome

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Who is at risk for carpal tunnel syndrome?  Occupational risk factors  Repetitive forceful hand work with wrist extension  Plus vibration or cold environment  Workers at increased risk  Aircraft engine workers and metal casting workers  Appliance and automobile manufacturers  Construction workers and electronic and forestry workers  Dental hygienists  Fish processing and cannery workers;  Frozen food/meat workers  Furniture factory, garment and textile

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Non-occupational Risk Factors  Female gender  Age  Pregnancy  Obesity  Wrist ratio*  Family history  Renal failure/dialysis  Amyloidosis  Drug treatment with aromatase inhibitors  Diabetes  Hypothyroidism  Acromegaly  Previous wrist fracture  Collagen vascular disease  Osteoarthritis of the wrist  Lipid abnormalities** *anterior to posterior wrist dimension divided by medial to lateral wrist dimension **Studies have shown conflicting data regarding this association of lipid abnormalities with carpal tunnel syndrome

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Are there measures that can prevent it?  Prevention measures that may be beneficial  Modification of work environment  Alternation of tasks to reduce high repetition work, vibration, and forceful hand exertion  Weight loss  Smoking cessation  Among hemodialysis patients: switch from conventional to high-flux membrane and use ultra-pure dialysate

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. CLINICAL BOTTOM LINE: Screening and Prevention...  Several occupational and nonoccupational risk factors may predispose to CTS  No evidence-based guidelines on the choice, usefulness, indications, and cost-effectiveness of sceening tools  Knowing important risk factors may be useful to implement preventive measures

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. What symptoms suggest CTS?  Pain in the hand and arm  Numbness and paresthesias in the hand  Weakness or clumsiness in the hand  Early stage often presents with nocturnal paresthesias  Hand diagram may help patient localize the symptoms

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Hand diagram showing median nerve sensory territory and location of paresthesias in CTS

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Elements of History  Dull, aching discomfort in hand, forearm, upper arm  Paresthesias in the hand  Hand weakness or clumsiness  Dry skin, swelling, or color changes in the hand  Age >40 years  Nocturnal paresthesias  Provocative factors  Worsening of symptoms at night  Sustained hand or arm positions  Repetitive hand and wrist movements  Improvement with changing position or shaking the hand

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. What physical examination findings are helpful in making a diagnosis?  Mild CTS  Nocturnal paresthesias  Swelling and pain relieved by shaking hand or changing hand position  Moderate CTS  Symptoms persist during the day  Decreasing sensation results in finger clumsiness  Severe CTS  Numbness without pain  Atrophy of the thenar eminence may occur

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Physical Examination Elements  Hypalgesia in median nerve territory  2-point discrimination; using calibers points 4-6mm apart  Atrophy restricted to thenar  Weak thumb abduction  Decreased vibratory sensation  Tinel sign  Phalen sign  Hand elevation test

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. What other conditions should be considered?  Cervical radiculopathy  Polyneuropathies or multiple mononeuropathies  Brachial plexopathy  Vascular disorders (Raynaud's)  Cervical myelopathy  Other CNS disorders  Other painful articular and soft tissue disorders  Proximal median neuropathy  Pronator teres syndrome (rare)  Anterior interosseus syndrome (rare)

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. What is the role of NCS and EMG?  Gold standard  Confirm diagnosis  Determine degree of severity based on nerve function  Exclude other neuromuscular conditions  Degree of functional impairment of median nerve (NCS)  Recommended when  Clinical diagnosis uncertain  Only a few or atypical clinical features are present  Other neurologic diagnoses are suspected  No response to conservative therapy  Thenar atrophy and/or persistent numbness present  Invasive treatment is considered

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. What is the role of imaging studies?  Useful when suspecting local structural disease  Wrist films or CT: to evaluate osseous carpal stenosis or bony tumors  MRI or ultrasonography: to visualize soft tissues  Specificity of MRI for diagnosing CTS is rather low  Emerging role for high-frequency ultrasound exam of of the median nerve

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Tests for CTS  NCS and electromyography  High-resolution sonography of the carpal tunnel  High-resolution CT of the wrist  MRI of the wrist  Wrist x-ray  Cervical spine MRI  Chest x-ray and/or MRI of brachial plexus  Polyneuropathy evaluation

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. What other laboratory studies may be useful when diagnosing CTS?  In patients with secondary CTS  Fasting plasma glucose for suspected diabetes  Thyroid function tests for suspected hypothyroidism  Renal function test and uric acid for suspected renal failure or gout  Rheumatoid factor, ESR, antinuclear antibodies, for suspected RA or other connective tissue disorders  Somatomedin-C, prolactin and phosphate levels, and growth hormone suppression test for suspected acromegaly  Serum protein immunofixation for paraproteinemia  Tissue biopsy for amyloid

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1.  Doubt about the diagnosis  Conservative treatment failed  Considering surgery or other invasive treatment  To assist with confirmatory NCS/EMG  Ultrasonographic diagnosis When should clinicians refer patients to a specialist for diagnosis?

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. CLINICAL BOTTOM LINE: Diagnosis...  Highly suggestive signs and symptoms of CTS  Pain in the hand and arm  Numbness and paresthesias in the hand  Weakness or clumsiness in the hand  Electrodiagnostic NCS/EMG confirmation and ultrasonographic evaluation often needed  Several conditions cause similar symptoms and findings  Imaging studies useful to detect rare structural anomalies  Further lab studies may confirm suspected secondary CTS

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. How should clinicians manage patients with CTS?  First-line treatment for mild CTS  Conservative non-drug modalities  Focused on symptom relief  Drug therapy may also be temporarily effective  If these modalities fail or nerve compression is advanced  Surgical decompression  Patients with secondary CTS  Target treatment at the primary disease

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1.  Splinting  Inexpensive and few complications  Mild to moderate CTS: first treatment option  Severe CTS: symptomatic relief while awaiting surgery  Use for at least 4 weeks  Full-time splinting more effective than night only  Neutral position splints relieve symptoms more than cock- up (extension) splints  Aerobic exercise for weight reduction may be useful What is the role of conservative measures, such as wrist splinting and activity modification?

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. What is the role of physical therapy?  Ultrasound for CTS  Short-wave diathermy treatment  Yoga-based intervention  Chiropractic or biobehavioral interventions  Magnet therapy  Low-level laser therapy,  Laser acupuncture

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. Which medications should clinicians prescribe first?  Non-steroidal anti-inflammatory drugs  Oral steroids  Lidocaine patch 5%  Diuretics

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. When should clinicians consider a corticosteroid injection?  Significant pain and mild to moderate CTS  Injection may provide relief  Effect less likely to last among women / patients with diabetes / those with nerve conduction abnormalities  Steroid injection contraindicated with  Thenar muscle weakness and atrophy  Advanced sensory loss indicating severe CTS  Acute CTS or wrist edema  Multiple injections not recommended

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. When should clinicians consider referral for surgical or nonsurgical specialist for treatment?  Failure to respond to conservative treatment for pain  Progressive sensory or motor deficits  Moderate-to-severe electrodiagnostic abnormalities  For consideration for surgery

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. How should clinicians follow patients?  Conservative treatment  Follow ≥6 months  Ensure clinical improvement and response to therapy  If conservative treatment fails  Consider surgical treatment  If patient has symptoms and progressive neurologic deficits  After surgery or injection  Return visits at 2- to 6-week intervals for up to 6 months  Attend to vascular status, wound healing, neurologic function

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. How should clinicians educate patients about CTS?  Education should address:  Known causes and risk factors  Exacerbating activities  Diagnostic methods  Therapeutic options

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (4): ITC4-1. CLINICAL BOTTOM LINE: Treatment...  Tailor treatment to individual  Mild to moderate CTS  Splinting in neutral wrist position  Mobilization therapy, steroid injection  For secondary CTS, treat the associated systemic disease  Severe CTS  Surgical decompression