Download - Carpal Tunnel Syndrome

Carpal Tunnel SyndromeCarpal Tunnel SyndromeStacey Harris-Carriman, M.D.Stacey Harris-Carriman, M.D.

Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation

Noon Conference, CCRMCNoon Conference, CCRMCMay 8, 2009May 8, 2009

ObjectivesObjectives

• Be familiar with the basic neuroanatomy of the upper limb

• Understand factors involved in diagnosing CTS

• Recognize the goals and limitations of NCS

• Review treatment of CTS

OutlineOutline

• Definition

• Etiology and Risk Factors

• Neuroanatomy of the Upper Limb

• Diagnosis: Symptoms and signs

• Differential diagnosis

• NCS/EMG and US

• Treatment

Definition of CTSDefinition of CTS

• Constellation of symptoms and signs secondary to a median neuropathy at the wrist

OutlineOutline

• Definition





• NCS/EMG and US

• Treatment

EtiologyEtiology

• Majority of CTS cases idiopathic

EtiologyEtiology

• Small percentage of CTS due to an identifiable cause, such as:– DM, RA, thyroid

disease– Conditions that

increase total body fluid (e.g. pregnancy, hemodialysis)

– Local wrist lesion (e.g. cyst, fracture, infection, tumor)

– Congenital (e.g. small carpal tunnel)

Risk FactorsRisk Factors

• Gender: F 3x>M

• Age: – Older > younger; very rare in children– Peak prevalence in women >55


• Family history• Certain medical

conditions• Workers that use

hands and wrists repetitively, especially with high force

• Musicians


• Other: Smoking, alcohol, poor nutrition, obesity, high cholesterol

OutlineOutline

• Definition





• NCS/EMG and US

• Treatment

SymptomsSymptoms

• Pattern recognition

• Wide variety of symptoms in CTS

• Some symptoms are more suggestive of CTS than other symptoms

SymptomsSymptoms

• Classic symptoms in CTS:– Waking up with pain and

numbness/paresthesias of the hand – Triggered by driving, holding phone, reading

book, typing, writing– Relieving factors

• Flick sign• Changes in hand posture

SignsSigns

• Key signs suggestive of CTS– Impaired sensation of the lateral 3-1/2 digits– Weakness of APB and other median-

innervated muscles of thenar eminence– Phalen’s, reverse Phalen’s– Tinel’s– Other: Pressure provocation test, hand

elevation test, tourniquet test

Signs Signs NOTNOT consistent with CTS consistent with CTS

– Impaired sensation over the lateral palm (thenar region)

– Impaired sensation proximal to wrist– Weakness of hypothenar muscles or other

non-median-innervated muscles– Impaired deep tendon reflexes

OutlineOutline

• Definition





• NCS/EMG and US

• Treatment

Differential Diagnosis of CTSDifferential Diagnosis of CTS

– Peripheral NS• Cervical radiculopathy• Brachial plexopathy• Proximal median

neuropathy (e.g. in forearm or elbow)

• Other mononeuroapthy (e.g. ulnar, radial)

• Underlying polyneuropathy

– Central NS (e.g. TIA, small lacunar infarct, myelopathy)

– Musculoskeletal • Shoulder pain with

distal paresthesias• Osteoarthritis• Cumulative trauma

disorder

Differential DiagnosisDifferential Diagnosis

• Peripheral NS: Cervical radiculopathy

DDx: Cervical RadiculopathyDDx: Cervical Radiculopathy

• Especially mild cases of cervical radiculopathy

• C6, C7

• Neck pain, radiation to shoulder, arm, +/- distally

• Worse with neck movement

• Impaired reflexes and strength

• Sensory loss beyond distribution of median nerve


• Peripheral NS: Brachial Plexopathy

DDx: Brachial PlexopathyDDx: Brachial Plexopathy

• Uncommon • Etiology: – Trauma– Tumor, Mass– Delayed radiation

injury– Plexitis– Postop (e.g. CABG)– Neurogenic TOS


• Trauma• Most common cause of brachial

plexopathy• Mechanism:

– Traction• Car/motorcycle/bike accident, newborn • Upper trunk C5/6-Erb’s palsy• Lower trunk C8/T1-Klumpke’s palsy

– Penetrating (knife, bullet)


• Neoplasm, Mass• Metastasis to lymph nodes (most common),

especially lymphoma, breast, lung cancer• Local tumor: Pancoast• Other

– Direct infilration of nerve: Lymphoma, leukemia– Rare: Primary nerve sheath tumor– Non-neoplastic (unusual): hematoma, vascular

anomaly


• Delayed Radiation VS• Onset: Progressive,

years after radiation• Risk correlated with

dose of radiation• Sensory sx

prominent (paresthesias, numbness)

• (Recurrent) Neoplasm• Onset: Slowly

progressive• Prominent pain • Horner’s syndrome


• Brachial Plexitis• AKA Neuralgic

amyotrophy, Parsonage-Turner

• Idiopathic• Often preceded by: viral

illness or immunization; also surgery

• Long thoracic nerve, anterior interosseous nerve, other

• Shoulder pain– Onset: days to weeks after

inciting event– Severe pain, awakens from

sleep

• Weakness and atrophy– Onset: Generally after pain

subsides (1-2 weeks)

• +/- Sensory s/sx


• Neurogenic TOS• Most cases due to

fibrous band between cervical rib and 1st thoracic rib

• Lower trunk, C8/T1

• Exam:– Muscles: hand

intrinsics, esp thenar T1; +/- FPL, FDP

– Sensory: Ulnar, MABC


• Peripheral NS: Proximal Median Neuropathy

DDx: Proximal Median NeuropathyDDx: Proximal Median Neuropathy

• Rare• Trauma• Ligament of Struthers• Anterior Interosseous

Syndrome– Pure motor: FPL, PQ,

FDP to #2-3– “Okay” sign

• “Pronator Syndrome”• Possible sites of

entrapment– Pronator teres

– Lacertus fibrosus (b/t biceps tendon and proximal flexor forearm muscles)

– Aponeurotic ridge of FDS (sublimis bridge)


• Peripheral NS: Other Mononeuropathy

• Ulnar, Radial


• Peripheral NS: Peripheral Polyneuropathy


• CNS: Cervical Myelopathy


• Musculoskeletal: Shoulder Pathology with Distal Paresthesias

OutlineOutline

• Definition





• NCS/EMG and US

• Treatment

Nerve Conduction Studies (NCS)Nerve Conduction Studies (NCS)

• [NOTE: NCS sometimes called NCV “Nerve Conduction Velocity”]

NCSNCS

• Picture here of NCS set-up

NCSNCS

• NCS can be useful in confirming CTS and assessing severity of CTS

NCSNCS

• An extension of the clinical examination

• Each NCS study must be individualized

NCSNCS

• NCS is positive in 91-98% of patients with clinically diagnosed CTS

• (Source: Keles et al, Diagnostic precision of ultrasonography in patients with CTS, Am J Phys Med Rehabil 2005)

• Risk of false negatives on NCS generally implies very mild CTS

Diagnostic Ultrasound Diagnostic Ultrasound

• Real-time imaging of median nerve in carpal tunnel

• Qualitative and quantitative

• Measurements can include:– Cross-sectional area (CSA) of median nerve– Bowing of flexor retinaculum– Flattening of median nerve in carpal tunnel

Diagnostic UltrasoundDiagnostic Ultrasound

• Relatively new development

• Aids in diagnosis

• Aids in treatment, ultrasound-guided injection of steroid into carpal tunnel

OutlineOutline

• Definition





• NCS/EMG and US

• Treatment

Treatment of CTSTreatment of CTS

Summary and ConclusionSummary and Conclusion

CTS: Summary and ConclusionCTS: Summary and Conclusion

• The diagnosis of CTS is made on clinical grounds

• Pattern recognition

• Be systematic: history, physical, differential diagnosis

Summary and ConclusionSummary and Conclusion

• NCS/EMG can be useful in confirming CTS and assessing severity of CTS

• Ultrasound can be a helpful adjunct in assessing and treating CTS

Thank YouThank You

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QuestionsQuestions