5/17/19 1 “What’s New in Orthopaedics?” Carpal Tunnel Syndrome Joseph Morgan, MD Assistant Professor Division of Hand & Upper Extremity Surgery Department of Orthopaedic Surgery & Rehabilitation University of Nebraska Medical Center 14 May, 2019 Objectives u Anatomy of the carpal tunnel and median nerve u Clinical diagnosis and examination techniques u Decision-making for electrodiagnostic testing u Nonoperative and Operative treatment strategies u Based on the 2016 Clinical Practice Guidelines from the American Academy of Orthopaedic Surgeons
Transcript
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“What’s New in Orthopaedics?”
Carpal Tunnel Syndrome
Joseph Morgan, MDAssistant Professor
Division of Hand & Upper Extremity SurgeryDepartment of Orthopaedic Surgery & Rehabilitation
University of Nebraska Medical Center
14 May, 2019
Objectives
u Anatomy of the carpal tunnel and median nerve
u Clinical diagnosis and examination techniques
u Decision-making for electrodiagnostic testing
u Nonoperative and Operative treatment strategies
u Based on the 2016 Clinical Practice Guidelines from the American Academy of Orthopaedic Surgeons
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Disclosures
u None financial
u I do not own or hold copyright privileges on any of the images used for this presentation. u Several provided are referenced with their source material.
u Other images used are publicly available on the internet and have been cited accordingly.
The Median nerve
u Sensation to the radialmost 3.5 digits
u Motor function to the thumb and 2 radial lumbricalsu Abductor pollicis brevisu Opponens pollicisu Flexor pollicis brevis (superficial head)
u More proximally, the median nerve innervatesu Pronator teresu Flexor carpi radialisu Flexor digitorum superficialisu Palmaris longusu Anterior Interosseous Nerve
u Flexor pollicis longus
u Flexor digitorum profundus – Index/Long
u Pronator Quadratus
Murphy KA, Morrisonponce D. Anatomy, shoulder and upper limb, median nerve. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2019-.https://ranzcrpart1.fandom.com/wiki/Nerves:Arm/Shoulder:Median_nerve_course,_relations_and_innervation
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Anatomy of the Carpal Tunnel
u The Median Nerve enters carpal tunnel along with 9 other structuresu FPL tendon
u 4 FDS tendons
u 4 FDP tendons
u Roof - Transverse Carpal Ligament
u Floor – Carpal bones
Seiler JG III, Daruwalla JH, Payne SH, Faucher GK. Normal palmar anatomy and variations that impact median nerve decompression. J Am Acad Orthop Surg. 2017;25:e194-e203.
u 28.5 mm in length longitudinally, range 22-36 mm
u Widest at the proximal-distal ends, narrowest at the hook of the hamate
u Thickness of approximately 2.2 mm ± 0.32 mm
Seiler JG III, Daruwalla JH, Payne SH, Faucher GK. Normal palmar anatomy and variations that impact median nerve decompression. J Am Acad Orthop Surg. 2017;25:e194-e203.
u Provides motor innervation to thenar musculature
u Structure at potential risk during carpal tunnel release surgery
u Variability in anatomic course reported
u Subligamentous – 31%
u Extraligamentous – 46%
u Transligamentous – 23%
u Ulnar takeoff
Seiler JG III, Daruwalla JH, Payne SH, Faucher GK. Normal palmar anatomy and variations that impact median nerve decompression. J Am Acad Orthop Surg. 2017;25:e194-e203.Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am. 1977;2(1):44-53.
Carpal Tunnel Syndromeu Entrapment neuropathy of the median
nerve at the carpal tunnel
u Characterized by numbness/tingling in the thumb through ring fingers
u Volar wrist pain that can radiate proximally
u Fine motor weakness and/or atrophyu Clumsiness with small objects like coins or
buttons
u Often symptomatic at nightu Can disturb sleep quality in as much as 80%
of patients with CTS
Patel A, Culbertson MD, Patel A, et al. The negative effect of carpal tunnel syndrome on sleep quality. Sleep Disord. 2014;2014:962746.Burton CL, Chesterton LS, Chen Y, van der Windt DA. Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care. Clin Epidemiol. 2018:10;739-748.
u Incidence of clinically significant CTSu 104-496:100,000 person-years
u Prevalence of 7.8% in US working population
u Estimated 500,000 carpal tunnel release surgeries performed annually in US
u Age-dependent increase may exist in males
u Bimodal distribution shown in females
English JHJ, Gwynne-Jones DP. Incidence of carpal tunnel syndrome requiring surgical decompression: A 10.5-year review of 2,309 patients. J Hand Surg Am. 2015;40(12):2427-2434.Dale AM, Harris-Adamson C, Rempel D, et al. Prevalence and incidence of carpal tunnel syndrome in US working populations: Pooled analysis of six prospective studies. Scand J Work
Environ Health. 2013;39(5):495-505.Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet Disord. 2014;15:4.
Risk Factorsu Strong evidence
u High repetition rate of hand use
u BMI
u Moderate evidenceu See List à
u Limited evidenceu Dialysis
u Fibromyalgia
u Varicosis
u Distal radius fracture
Guan W, Lao J, Gu Y, Zhao X, Rui J, Gao K. Case-control study on individual risk factors of carpal tunnel syndrome. Exp Ther Med. 2018;15:2761-2766.American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
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Occupational Risk Factors
u Strong – Repetitive/Forceful exertion
u Moderate – Use of vibrational tools
u No direct relationship shown that typing or keyboard use increases risk for CTS
Kozak A, Schedlbauer G, Wirth T, Euler U, Westermann C, Nienhaus A. Association between work-related biomechanical risk factors and the occurrence of carpal tunnel syndrome: An overview of systematic reviews and a meta-analysis of current research. BMC Musculoskeletal Disorders. 2015;16:231.
Mediouni Z, Bodin J, Dale AM, et al. Carpal tunnel syndrome and computer exposure at work in two large complementary cohorts. BMJ Open. 2015;5:e008156.
u Moderate evidenceu No increased/decreased risk of CTS
associated with use of oral contraceptives or female hormone replacement therapy
u ~28% of females without prior symptoms will have symptoms of CTS in their 3rd
trimester of pregnancyu Majority resolve by 6 weeks postpartum
u Those with symptoms at 3 months postpartum often have persistent and/or worsening symptoms
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.Mora AN, Blazar PE, Teplitz BA, Rogers J, Economy K, Earp BE. Prospective evaluation of the incidence and persistence of gestational carpal tunnel syndrome. Presented at ASSH annual
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
u Described in Case-control study of 46 EMG-positive hands vs 50 control hands
u Direct pressure applied for up to 30 seconds
u Sensitivity of 87%
u Specificity of 90%
Durkan JA. A new diagnostic test for carpal tunnel syndrome. J Bone Joint Surg. 1991;73(4):535-538.
Thenar atrophy
u Strong evidence
u “Thenar atrophy is strongly associated with ruling-in CTS, but poorly associated with ruling-out CTS.”
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
u Strong and Moderate evidence supports the use of multiple physical examination tests to confirm diagnosis
u Individually, tests are poor to rule in or out CTS
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
u Ultrasound not routinely needed for diagnosis of CTS
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
Fowler JR, Cipolli W, Hanson T. A comparison of three diagnostic tests for carpal tunnel syndrome using latent class analysis. J Bone Joint Surg Am. 2015;97:1958-1961.Wessel LE, Marshall DC, Stepan JG-H, Sacks HA, Nwawka OK, Miller TT, Fufa DT. Sonographic findings associated with carpal tunnel syndrome. J Hand Surg Am. 2019;44(5):374-381.
u Sensitivity of 91%; Specificity of 94%
u Severity of CTS symptoms associated withu Greater decrease in cross-sectional area of
Sonoo M, Menkes DL, Bland JDP, Burke D. Nerve conduction studies and EMG in carpal tunnel syndrome: Do they add value? Clin Neurophysiol Pract. 2018;3:78-88.
u Opinions differ on utility of EMG testing for carpal tunnel syndrome
u Prosu Can add objective information to confirm diagnosis
when diagnosis not clearu Different sites of compression?
u Can serve as baseline info in case patient does not improve after surgery or if condition recurs
Sears ED, Swiatek PR, Hou H, Chung KC. Utilization of preoperative electrodiagnostic studies for carpal tunnel syndrome: An analysis of national practice patterns. J Hand Surg Am.. 2016;41(6):665-672.
Sears ED, Lu Y-T, Wood SM, Nasser JS, Hayward RA, Chung KC, Kerr EA. Diagnostic testing requested before surgical evaluation for carpal tunnel syndrome. J Hand Surg Am. 2017;42(8):623-629.
u Population study of 62,894 pts undergoing EMG
u Pts undergoing EMG…
u Waited 36% longer to undergo surgery, p < 0.001
u Had an extra doctor’s visit, p < 0.001
u Experienced overall average $996 greater cost
u Paid additional average $112 out of pocket
u Still…57% of hand surgeons in 1 study required EMG testing be performed prior to referral
How powerful a test is EMG?
Fowler JR, Cipolli W, Hanson T. A comparison of three diagnostic tests for carpal tunnel syndrome using latent class analysis. J Bone Joint Surg Am. 2015;97:1958-1961.Fowler JR, Byrne K, Pan T, Goitz RJ. False-positive rates for nerve conduction studies and ultrasound in patients without clinical signs and symptoms of carpal tunnel syndrome.
J Hand Surg Am. 2019;44(3):181-185.
u Cited sensitivity of 91%, specificity of 83%
u Prospective cohort study of 40 hands undergoing EMG for reasons other than CTS
u 43% false-positive rate for EMG
u Compared to 27% false-positive rate for U/S
u Authors recommended U/S over EMG for confirmation of CTS diagnosis
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Does EMG testing have prognostic value?
Rivlin M, Kachooei AR, Wang ML, Ilyas AM. Electrodiagnostic grade and carpal tunnel release outcomes: A prospective analysis. J Hand Surg Am. 2018;43(5):425-431.
u Prospective study of 256 hands in 199 patients
u No correlation of electrodiagnostic severity with relief of symptoms after carpal tunnel release surgery
Should referring providers obtain EMG’s prior to referral?
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
u They can be helpful if obtained prior to initial hand surgery evaluation, but I don’t mandate them.
u If patients demonstrate active denervation on EMG testing, I generally recommend prompt surgery.
u Limited evidenceu “hand-held nerve conduction study (NCS) device might
be used for the diagnosis of carpal tunnel syndrome.”
u Moderate evidenceu “diagnostic questionnaires and/or electrodiagnostic
studies could be used to aid the diagnosis of carpal tunnel syndrome.”
Weiss ND, Gordon L, Bloom T, So Y, Rempel DM. Position of the wrist associated with the lowest carpal-tunnel pressure: Implications for splint design. J Bone Joint Surg Am. 1995;77(11):1695-1699.
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
http://www.carpal-tunnel.net/treatments/splinting
u First-line treatment typically includes a period of night splinting
u Splints in neutral wrist posture (rather than extension) optimize volume in carpal tunnel
u Strong evidence
u Splinting “should improve patient-reported outcomes”
Steroid Injections
Agarwal V, Singh R, Sachdev A, Wiclaff, Shekhar S, Goel D. A prospective study of the long-term efficacy of local methyl prednisolone acetate injection in the management of mild carpal tunnel syndrome. Rheumatol. 2005;44:647-650.
Gelberman RH, Aronson D, Weisman MH. Carpal-Tunnel syndrome: Results of a prospective trial of steroid injection and splinting. J Bone Joint Surg Am. 1980;62(7):1181-1184.
u Often considered at the time of initial presentation or after splinting has failed to relieve symptoms
u For pts with mild CTSu 93.7% note considerable improvement in their
symptoms with improvement in nerve conduction and functional scores at 3 months post-injection
u For pts with more severe CTS (atrophy, weakness, symptoms > 1 year)u Only 22% symptom-free at mean 18 months post-
Stepan JG, London DA, Boyer MI, Calfee RP. Blood glucose levels in diabetic patients following corticosteroid injections into the hand and wrist. J Hand Surg Am. 2014;39(4):706-712.
u Steroid injections in the hand/wrist shown to elevate blood glucose measurements in the first 2 days
u Mean increase of 43.1 mg/dL over baseline on post-injection day 1
u Mean increase of 17.1 mg/dL over baseline on post-injection day 2
u No statistical difference compared to baseline from post-injection day 3 on
u Greater likelihood of glucose elevation in type 1 diabetics and those taking insulin
Steroid Injections
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
u “Use of steroid (methylprednisolone) injection should improve patient reported outcomes”
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Magnet therapy?
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
https://www.doctoroz.com/topic/pharmacy
u Moderate evidence
u No benefit to
u Diuretic
u Gabapentin
u Astaxanthin
u NSAIDs
u Pyridoxine
u “Oral steroids could improve patient reported outcomes as compared to placebo.”
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
Gould D, Kulber D, Kuschner S, Dellamaggiorra R, Cohen M. Our surgical experience: Open versus endoscopic carpal tunnel surgery. J Hand Surg Am. 2018;43(9):853-861.Vasen AP, Kuntz KM, Simmons BP, Katz JN. Open versus endoscopic carpal tunnel release: A decision analysis. J Hand Surg Am. 1999;24(5):1109-1117.
u Benefits of endoscopic cited in literatureu Same relief of symptoms in long-term
u Better recovery
u Earlier return to work
u Possibly better early satisfaction scores
u Benefits of openu Direct visualization of anatomic structures
u Generally costs less
u Lower complication rateu 0.1% vs 5%
Which technique is best?
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
https://www.youtube.com/watch?v=XA4xaB7MZA4
u Limited evidence
u Surgeon “might consider using endoscopic carpal tunnel release based on possible short term benefits.”
u Cost savings and drive to improve efficiency and convenience for patients and physicians has led surgeons to consider
u CTR in procedure room or clinic rather than OR
u Local anesthesia rather than regional or general anesthetic
u Limited evidence
u Supports Local anesthesia over Bier block for possibly longer post-op pain control
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
Anesthesia and Setting?
u Wide Awake Local anesthesia in Procedure room shown to have lowest total direct cost
Kazmers NH, Presson AP, Xu Y, Howenstein A, Tyser AR. Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery. J Hand Surg Am. 20143(11):971-977.
White M, Parikh HR, Wise K, Vang S, Ward CM, Cunningham B. Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: Time-driven activity-based-costing. Presented at ASSH Annual Meeting. Boston, MA. September 14, 2018.
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Outcomes after open CTR
Jansen MC, Evers S, Slijper HP, de Haas KP, Smit X, Hovius SE, Selles RW. Predicting outcome afer surgical treatment in patients with carpal tunnel syndrome. J Hand Surg Am. 2018;43(12):1098-1107.
u Cohort of 1,049 pts
u 93.8% had improvement at 6 months in functional outcome scores
u 1.9% complication rate
u Pts with more severe symptoms preop had better relief of symptoms post-op
Patients sleep better after surgery
Tulipan JE, Kim N, Abboudi J, Jones C, et al. Prospective evaluation of sleep improvement following carpal tunnel release surgery. J Hand Surg Am. 2017;42(5):390.e1-e6.
u Cohort of 398 patients undergoing CTR
u Statistically significant improvement in all 7 questions on the Insomnia Severity Index instrument at 2 weeks post-op
u Improvement not related to severity on pre-op EMG
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Depression may impact outcome
Datema M, Tannemaat MR, Hoitsma E, van Zwet EW, et al. Outcome of carpal tunnel release and the relation with depression. J Hand Surg Am. 2018;43(1):16-23.Shin YH, Yoon JO, Kim YK, Kim JK. Psychological status is associated with symptom severity in patients with carpal tunnel syndrome. J Hand Surg Am. 2018;43(5):484.e1-e8.
u Study of 227 pts with 1-year post-op follow-up
u Pts with depression demonstrated higher pre-op/post-op Boston CTQ scores and post-op palmar pain scores compared to those without, p< 0.05
u Depression does not independently predict persistent symptoms after surgery
u Symptoms of depression decrease with CTS symptoms after surgery
u Correlation unclear
Workers’ compensation
Dunn JC, Kusnezov NA, Koehler LR, Vanden Berge D, Genco B, Mitchell J, Orr JD, Pallis M. Outcomes following carpal tunnel release in patients receiving workers’ compensation: A systematic review. Hand. 2018;13(2):137-142.
u Systematic Review of CTR in work comp population
u WC pts returned to work almost 5 weeks later than non-WC pts
u WC pts “16% less likely to return to pre-injury vocation, and had lower SF-36 scores.”
u 3x increased complication rate
u Nearly 2x rate of persistent pain after surgery
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Risk factors for post-op infection
Werner BC, Teran VA, Deal DN. Patient-related risk factors for infection following open carpal tunnel release: An analysis of over 450,000 Medicare patients. J Hand Surg Am. 2018;43(3):214-219.
u Retrospective review of 454,987 Medicare pts
u Infection rate of 0.32%
u Independent risk factors
u Younger age
u Male sex
u Obesity (BMI 30+)
u Tobacco or Alcohol use
u Medical comorbidities
Diabetes mellitus
Zhang D, Blazar P, Earp BE. Rates of complications and secondary surgeries of mini-open carpal tunnel release. Hand (N Y). 2018 Mar 1:1558944718765226 [Epub ahead of print]Werner BC, Teran VA, Cancienne J, Deal DN. The association of perioperative glycemic control with postoperative surgical site infection following open carpal tunnel release in
patients with diabetes. Hand (N Y). 2017 Dec 1:1558944717743594. [Epub ahead of print]
u Retrospective cohort of 1,144 open CTR procedures
u 14 pts (1.2%) required secondary surgery for persistent symptoms, hematoma, or infection
u Increased risk of secondary surgery associated with diabetes
u Retrospective cohort of 7,958 diabetic pts undergoing open CTR with Hgb a1C measurements within 3 months of CTR
u Increased rate of surgical site infections in first year post-op above a Hgb a1C threshold between 7 and 8
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Postoperative pain management
Ilyas AM, Miller AJ, Graham JG, Matzon JL. Pain management after carpal tunnel release surgery: A prospective randomized double-blinded trial comparting acetaminophen, ibuprofen, and oxycodone. J Hand Surg Am. 2018;43(10):913-919.
u Double-blind PRT comparing acetaminophen, ibuprofen, and oxycodone after CTR in 105 pts
u For open CTR, mean total pill consumptionu OXY – 3.7 pills
u IBU – 5.1 pills
u ACE – 4.2 pills
u No statistical difference in average daily pain scores
Return to work after CTR
Newington L, Harris EC, Walker-Bone K. Carpal tunnel syndrome and work. Best Pract Res Clin Rheumatol. 2015;29(3):440–453.
u No clear guidelines exist, although a 2015 report from the UK provides general recommendations based on Level 5 evidence
u Supervisory/Managerial work: 1-2 weeks after surgery
u Light manual (clerical/secretarial): 2-4 weeks after surgery
u Medium manual (cleaner/carer/nurse): 4-6 weeks after surgery
u Heavy manual: 6-10 weeks after surgery
u Custodial/Rescue services: 6-10 weekshttp://phccglobal.com/https://www.hosthealthcare.com/10-tips-to-get-a-travel-nurse-job/https://www.thebalancecareers.com/construction-skills-list-2062378
Gellman H, Kan D, Gee V, Kuschner SH, Botte MJ. Analysis of pinch and grip strength after carpal tunnel release.J Hand Surg Am. 1989;14:863-864.Zumsteg JW, Crump MJC, Logan GD, Weikert DR, Lee DH. The effect of carpal tunnel release on typing performance. J Hand Surg Am. 2017;42(1):16-23.
u Prospective cohort study of 24 wrists before and after CTR
u Pinch strength reached 96% of preop level at 6 weeks
u Grip strength reached preop level at 3 months
u Typing speed returns to preop level between 2 and 3 weeks after surgery
u Mean improvement of 4 words per minute at 12 weeks post-op
Harness NG, Inacio MC, Pfeil FF, Paxton LW. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am. 2010;35:189-196.Bykowski MR, Sivak WN, Cray J, Buterbaugh G, Imbriglia JE, Lee WP. Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: A single-center, retrospective
review of 8,850 cases. J Hand Surg Am. 2011;36(11):1741-1747.Tosti R, Fowler J, Dwyer J, Maltenfort M, Thoder JJ, Ilyas AM. Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics. 2012;35(6):e829-833.American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published
February 29, 2016.
u Multiple studies now support no routine need for preoperative antibiotics before clean, elective hand surgery.
u Not shown to affect postoperative infection rates
u Even for pts with diabetes
u Limited evidenceu “no benefit to routine use of
prophylactic antibiotics prior to carpal tunnel release” https://www.wsj.com/articles/hospitals-wrestle-with-shortage-of-iv-bags-linked-to-hurricane-1515349271
American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
Peters S, Page MJ, Coppieters MW, Ross M, Johnston V. Rehabilitation following carpal tunnel release. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD004158. DOI: 10.1002/14651858.CD004158.pub3.
u Moderate evidence
u “no additional benefit to routine supervised therapy over home programs in the immediate postoperative period.”
u Cochrane review
u Overall limited and low-quality evidence in the literature to support any specific postoperative rehabilitation regimen
u Strong evidence
u No need for routine post-op immobilizationhttps://explorehealthcareers.org/career/occupational-therapy/occupational-therapist/
