Transcript Clinical Slide Set. Carpal Tunnel Syndrome

* For Best Viewing:
Open in Slide Show Mode
Click on
icon
or
From the View menu, select the
Slide Show option
* To help you as you prepare a talk, we have included the
relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (4): ITC4-1.
Terms of Use
 The In the Clinic® slide sets are owned and copyrighted by the
American College of Physicians (ACP). All text, graphics,
trademarks, and other intellectual property incorporated into the
slide sets remain the sole and exclusive property of ACP. The slide
sets may be used only by the person who downloads or purchases
them and only for the purpose of presenting them during not-forprofit educational activities. Users may incorporate the entire slide
set or selected individual slides into their own teaching
presentations but may not alter the content of the slides in any way
or remove the ACP copyright notice. Users may make print copies
for use as hand-outs for the audience the user is personally
addressing but may not otherwise reproduce or distribute the slides
by any means or media, including but not limited to sending them as
e-mail attachments, posting them on Internet or Intranet sites,
publishing them in meeting proceedings, or making them available
for sale or distribution in any unauthorized form, without the
express written permission of the ACP. Unauthorized use of the In
the Clinic slide sets constitutes copyright infringement.
© 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.
When should clinicians refer patients to a
specialist for diagnosis?
 Doubt about the diagnosis
 Conservative treatment failed
 Considering surgery or other invasive treatment
 To assist with confirmatory NCS/EMG
 Ultrasonographic 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.
What is the role of conservative measures,
such as wrist splinting and activity
modification?
 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 cockup (extension) splints
 Aerobic exercise for weight reduction may be useful
© 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
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (4): ITC4-1.