carpal tunnel syndrome knife or needle?
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Carpal Tunnel Syndrome
Knife or Needle? Dr Jeremy D P Bland
Consultant in Clinical Neurophysiology
East Kent Hospitals University NHS Trust
ACPOMIT annual meeting, Milton Keynes, June 2015
Topics Epidemiology and Aetiology
Natural History
Diagnosis
Clinical
History
Examination
Provocative tests
Investigations
NCS
Ultrasound imaging
Screening for other diseases
Treatment
Splints
Steroids
Surgery
Topics Epidemiology and Aetiology
Natural History
Diagnosis
Clinical
History – do we pay enough attention?
Examination
Provocative tests – is it time for Jules Tinel to retire?
Investigations
NCS – what are they for?
Ultrasound imaging – is it a substitute for NCS?
Screening for other diseases – A waste of money?
Treatment
Splints
Steroids
Injected dose
Repeat injection
Ultrasound guidance
Surgery – Can we predict the outcome?
Diagnosis “A physician’s forecast of disease by the patient’s pulse and
purse” – Ambrose Bierce
“Listen to your patient – he is
telling you the diagnosis” - Osler
Diagnoses from: Published Papers
HISTORY
EXAMINATION
LAB (or NEVER!)
Sensitivity and specificity
A simplistic approach to diagnostic performance
Jeffrey N Katz
“The Carpal Tunnel Syndrome: Diagnostic Utility of the
History and Physical Examination Findings” Annals of
Internal Medicine 1990 Vol 112 No 5 p 321-327
Sensitivity Specificity
Neurologists assessment 0.84 0.72
Hand diagram 0.61 0.71
Proposed ‘point systems’ HISTORY Kamath 2003 Graham 2006 Lo 2009 Hems 2009 Bland 2011
Age <60 = 2
Gender female -5
Finger distribution no little finger 3 median = 3.5 median=7 median = 2
Timing Night Pain =1, Tingling = 1 4 6 2
Morning 1
Use/Working 1
Wake and Shake 1 2
Splint response 2 1
Dropping objects/clumsiness 1
Duration <2 0
2-12 7
>12 11
Symptoms in pregnancy 1
Neck pain 1 -6
Wrist pain -5
EXAMINATION
Tinel 4 2
Phalen 5 1
Sensory loss "Median" 2PD = 4.5 10 2
1st/2nd 2
2nd/4th 1
Beyond hand -11
Ulnar + -1
Thenar Wasting 7 2
APB Weakness 5 7
PERFORMANCE
Reference comparison Surgical outcome Expert opinion NCS Surgical outcome NCS
Suggested threshold >/=3 >/= 12 ??? >/= 7 >/= 40%
Sensitivity 85% 89% 76% 82% 78%
Specificity ??? 80% 68% 67% 68%
ROC 0.63 None 0.8 0.776 0.79
Frequency of history items in CTS cases Question NonCTS CTS Total % CTS Question NonCTS CTS Total % CTS
Handedness Right 12065 16616 28681 58% Flick N 7705 7553 15258 50%
Left 1243 1532 2775 55% Y 5942 10975 16917 65%
Ambidex 350 383 733 52% missing 11 3 14 21%
Sympside Right 5980 9555 15535 62% Splint N 1934 2309 4243 54%
Left 4601 5520 10121 55% U 10441 14078 24519 57%
Bilateral 2894 3347 6241 54% Y 1269 2137 3406 63%
Missing 183 109 292 37% missing 14 7 21 33%
Time_night N 5338 4305 9643 45% Duration missing 6 2 8 25%
Y 8314 14224 22538 63% <3m 1495 1730 3225 54%
missing 6 2 8 25% 3-6m 3244 4361 7605 57%
Time morning N 5671 5761 11432 50% 6-12m 3068 4043 7111 57%
Y 7980 12769 20749 62% 1-2y 2816 3829 6645 58%
missing 7 1 8 13% 2-5y 1763 2537 4300 59%
Time driving N 8812 10947 19759 55% 5-10y 769 1114 1883 59%
Y 4839 7582 12421 61% >10y 497 915 1412 65%
missing 7 2 9 22% Neckpain N 3067 4595 7662 60%
Time working N 4092 5860 9952 59% Y 2796 2769 5565 50%
Y 9537 12643 22180 57% missing 7795 11167 18962 59%
missing 29 28 57 49% CTS preg N 2429 3139 5568 56%
Newsknit N 3796 3909 7705 51% U 2921 3585 6506 55%
Y 2067 3455 5522 63% Y 372 441 813 54%
missing 7795 11167 18962 59% missing 7936 11366 19302 59%
Site tim 4137 8095 12232 66% Dominant N 7366 8620 15986 54%
lr 1182 335 1517 22% Y 6292 9911 16203 61%
mr 994 1936 2930 66%
all 4305 5642 9947 57%
4f 1772 1879 3651 51% TOTAL 32189 new cases
other 1257 637 1894 34%
missing 11 7 18 39%
Questionnaire tools for the diagnosis of carpal tunnel
syndrome from the patient history – 2011 Bland JDP,
Weller P, Rudolfer S, Muscle&Nerve 44:757-62
Kamath Questionnaire
New Models
2616 new patients
www.carpal-tunnel.net
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0+ 10+ 20+ 30+ 40+ 50+ 60+ 70+ 80+ 90+
Website diagnostic score
CTS or not - % confirmed CTS
p < 0.001
Diagnostic performance of carpal-tunnel.net in 2655 patients
0%
2%
4%
6%
8%
10%
12%
14%
16%
0+ 10+ 20+ 30+ 40+ 50+ 60+ 70+ 80+ 90+
Score distribution
Website scores of patients referred for NCS
Diagnostic score and NCS severity
A rational referral policy
GP Consultation
Website
Score threshold 20%
NCS
O&R
ICATS
74%
26%
Severe CTS
Mild CTS
Non-CTS
0
10
20
30
40
50
60
70
80
90
100
Sensitivity
Specificity
Diagnostic performance of Tinel’s sign
Average weighted for sample
size: sensitivity = 50%,
specificity = 77%
“Secondary” CTS – 16622 patients
Pregnancy (37 – 0.2%)
Rheumatoid arthritis (1348 – 8.1% – self reported, most not RA)
Acromegaly (5 – 0.03%)
Glucose (Diabetes) (1866 – 11.2%)
Mechanical (Fractures, anomalous muscle etc) ???
Amyloid ???
Thyroid (279 - 1.68% Hyper, 1213 – 7.3% Hypo)
Infection ??? (never seen a case)
Crystals (Gout and Pseudo-gout) (Never seen a definite case)
What are tests for?
Often not needed for diagnosis!
Graham B, 2008 “The value added by electrodiagnostic testing in
the diagnosis of carpal tunnel syndrome”, JBJS Am 90:2587-93
Reasons for investigation
(Diagnosis when genuinely uncertain)
Detection of other pathology
Prognosis
Follow-up
“SEVERITY” ?
“How bad is it doc?”
“Oh, that’s a pretty
severe one my dear”
…but what do they
mean?
The Patient -Subjective severity?
OED - 6 irrelevant
definitions before:
7.7 Grievousness (of pain,
affliction, penalties, etc.).
But she already knows what
it feels like!
The Doctor – Measures of Severity
‘MILD’
‘SEVERE’
‘WORST I’VE
EVER SEEN
The Real Question
MILD
SEVERE
TOOLS
Subjective severity –
Levine/Boston CTS assessment scale
Symptom Severity Night pain severity
Night pain frequency
Day pain severity
Day pain frequency
Day pain duration
Numbness severity
Weakness severity
Tingling severity
Night tingling severity
Night tingling frequency
Small object manipulation
Functional impairment Writing
Buttoning clothes
Holding a book to read
Gripping telephone
Opening jars
Household chores
Carrying groceries
Bathing/dressing
Each subscale produces a number ranging from 1 (no symptoms) to 5 (worst symptoms)
Subjective outcome- Global outcome scale
1 – Worse than before treatment
2 – Unchanged
3 – Slight improvement
Would still like something done if that is possible
4 – Much better but some residual symptoms
Not sufficient to require further intervention
5 – Complete cure
As good as new (apart from a scar if operated)
Physiological severity –
Canterbury NCS scale for CTS
6 (Extremely severe) – No motor or sensory potential
5 (Very severe) – DML to APB > 6.5msec
4 (Severe) – Prolonged DML, Absent SNAP
3 (Moderately severe)– Prolonged DML, preserved SNAP
2 (Mild) – Normal DML, delayed index SNAP
1 (Very slight)– Only demonstrable with sensitive tests
0 (None) – Normal NCS
Objective vs subjective change with treatment
MaxMin
Mean+2*SEMean-2*SE
Mean
Better ------- Change in neurophysiological grade ------ Worse
Mea
n s
ubje
ctiv
e opin
ion o
f outc
om
e
Worse
Unchanged
Slightly better
Much better
Cured
-5 -4 -3 -2 -1 0 1 2 3 4 5
Comparison of Surgery and Injection benefits
124
2300
90
225
1070
154
62
425
32
13
229
3 7
318 13
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Injection G1-G5 Historical (2y) GP Surgery (3m)
0
0.5
1
1.5
2
2.5
3
3.5
4
Worse Same Better Much Cured
Mean Pre/Post treatment SSS scores in 867 operations (3m) and 1917 injections (6w)
Pre-injection
Pre-surgery
Post-injection
Post-surgery
Measuring change with treatment
Prognosis “Guessing has never been widely acclaimed
as a good gambling strategy.” - Anon
Concannon MJ, et al 1997 The Predictive value of electrodiagnostic
studies in carpal tunnel syndrome. Plast Reconstr Surg 100(6) 1452
The similarities between these two groups suggests that the distinction between them (the positivity of electrodiagnostic studies) is an artificial one and that the clinical diagnosis of carpal tunnel syndrome is sufficient to predict the presence of the disease, as well as outcome of surgery
First group 62 hands with normal NCS
Second group 398 hands with abnormal NCS (348 mild/moderate, 50 ‘severe’
47 280
36
15 68
14
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Normal Mild/moderate Severe
Fail
Success
- P=0.39 --
- P=0.19 --
---------- P=0.67 ---------
Fisher’s exact test comparisons
Concannon MJ, et al 1997 The Predictive value of electrodiagnostic
studies in carpal tunnel syndrome. Plast Reconstr Surg 100(6) 1452
The similarities between these two groups suggests that the distinction between them (the positivity of electrodiagnostic studies) is an artificial one and that the clinical diagnosis of carpal tunnel syndrome is sufficient to predict the presence of the disease, as well as outcome of surgery
First group 62 hands with normal NCS
Second group 398 hands with abnormal NCS (348 mild/moderate, 50 ‘severe’
0
50
100
150
200
250
300
350
400
Normal' NCS Mild/Moderate NCS Severe NCS
Opera
ted H
ands
Fail
Success
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6
Surgical outcome in 7136 carpal tunnel decompressions
Worse
No change
Better
Much Better
Cured
How does ultrasound compare on:
Diagnosis
Severity
Other findings
Prognosis
NCS vs u/s for diagnosis
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<=30% 31-40% 41-50% 51-60% 61-70% 71-80% >80%
Probability of CTS from clinical questionnaire
Proportion of abnormal test results from u/s and NCS related to clinical probability of CTS
Proportion with CSA >10
Proportion >Grade 1 NCS
Ideal test
Severity - NCS grade vs u/s CSA – 1000 hands
Canterbury referrals for ?CTS
33,840 tests
21344 CTS
63%
12,496 NOT
CTS
826 Other
neurological
diagnosis (7%)
10 Non-
neurological
diagnosis
11,660
No Diagnosis
Other neurological diagnoses
Ulnar 513 Anatomical anomaly 2
Poyneuropathy 154 CVA 1
Injury 53 Deep palmar 1
Radiculopathy 44 Digital branch lesion 1
Ulnar+PN 26 (Meralgia) 1
TOS 7 MND 1
Motor branch lesions 5 Neurofibroma 1
Pronator syndrome 3 PN+Writers Cramp 1
Median neuropathy 2 Post herpetic neuralgia 1
Radial 2 TIA 1
Ulnar+Root 2 Tumour 1
Writers Cramp 2 Cramp 1
Concomitant disease in CTS
CTS
21,344
'Simple' 20,341
95%
CTS+
1103
Neurological
1074
Other
7
Uncertain
22
Other pathology
Common – osteoarthritis
38% of 13,580 patients
attending Canterbury
department described
themselves as having
osteoarthritis when asked
31% of those with normal
NCS
42% of those with
evidence of CTS
The apparent correlation
is probably mediated via
age
May be linked to CTS
Trigger finger
91/211 patients with
trigger finger but no
predisposing cause also
had CTS (43%) (Kumar
2009)
In Canterbury 11% of
patients with CTS report a
history of trigger finger
These disorders probably
share a common
predispostion
Other interesting findings on u/s?
Kele et al 2002 (110 wrists)
Synovitis (11)
Muscles in carpal tunnel (10)
High division of median nerve (3)
Thenar branch leaving proximally (3)
Radially positioned median nerve (1)
Ulnar artery near median nerve <3mm (11)
Patent median artery (1)
Thrombosed median artery (1)
My findings so far (350 wrists)
Synovitis (1)
Patent median artery (4)
High division of median nerve (9)
Ulnar artery near median nerve (2)
u/s for prognosis
(multivariate
analysis inc u/s)
Best multivariate model so far
Area under ROC curve = 0.84
Includes
- NCS grade
- u/s CSA
- SSS
- FSS
- Age
- BMI
- Duration
0.0
00
.25
0.5
00
.75
1.0
0
Se
nsitiv
ity
0.00 0.25 0.50 0.75 1.001 - Specificity
Area under ROC curve = 0.8396
Initial response to injection (6 weeks) vs ultrasound imaging
(138 hands - Canterbury Data, normal vs >15 groups p<0.05)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
6-9 10-15 >15
% w
ith init
ial good r
esp
onse
Median nerve CSA at pisiform (mmsq)
Treatment “When a lot of remedies are suggested for a disease, that means
it cannot be cured.”
― Anton Chekhov
What treatments are used ?
Surgery
Open
Endoscopic
Local steroid injection
Splinting
Rest/Job modification
Oral steroids
Steroid iontophoresis
Diuretics
NSAID’s
Vitamin B6
Magnet therapy
Exercise programmes (nerve/tendon gliding)
Yoga
Neurodynamic mobilisation
Carpal bone mobilisation
Chiropractic manipulation
Local ultrasound
Low level laser acupuncture
Microamps TENS
Acupuncture
Cognitive behavioural therapy
HRT
Non-invasive laser neurolysis
Biofeedback
Steroid
Injection
Some surgeons do not approve!
“ to suggest that patients should be offered steroid injection as definitive treatment….is both wrong and irresponsible.... the danger with injections is that the patient feels better, believes [they are] cured, and does not return to see the doctor for two or three years……by this time the thenar muscles may be wasted…….[and] it may not respond to surgical decompression - that is it is permanent” Wallace, BMJ 1999
Guidelines from UK hand surgery center describe steroids as “hazardous” and suitable only for use in CTS occurring during pregnancy. Hayward, Postgrad Med J 2002
“You are comparing a disease modifying treatment (surgery) to a treatment that is palliative at best (steroid injection). The study we need is a comparison of corticosteroid injection vs placebo injection. The results to date would suggest that corticosteroids might not even be palliative. So if corticosteroids are no more than wishful thinking and they simply distract the patient and the surgeon from the issues at hand, how will we change the culture and stop giving steroid injections” – anonymous reviewer of a grant application proposing an injection vs surgery trial
The surgical criticisms
Dangerous
Painful
Always temporary
Surgery is the only disease modifying treatment
Only suppresses the symptoms
Messes up later surgery
Risky? – Major Complications
7000+ injections
Fingertip Gangrene (2)
Tendon rupture
1 definite
1 possible
Intractable arm pain (1)
Risky? – Minor complications
55 Bilateral, 100 unilateral = 155 patients, 210 hands
No ill effects from 139 injections (66%)
Possible side-effects reported in:
23 bilateral injections (42%)
28 unilateral injections (28%)
Significantly more common after bilateral injections
(p=0.006)
Possible side effects – 6 weeks
Localised
Ache/Pain – 30
Depigmentation – 1
Bruising – 1
Stiffness – 1
Weakness – 1
Numbness – 2
Rash – 2
Tremor -1
Fat atrophy – 1
Tingling – 1
Swelling – 1
“weird feeling inside” - 1
Systemic
Facial flushing - 5
Menstrual disturbance – 3
Loss of diabetes control – 2
Night sweats – 1
Stomach upset – 1
Positive
Improved back pain
Improved tennis elbow
Neck and shoulder pain resolved
Painful? - Injection pain
Disease modifying? - Effect of
injection on ultrasound
Results from Cartwright (2011)
29
30
31
32
33
34
35
36
37
0
5
10
15
20
25
Baseline 7 days 30 days 180 days
SSS
SNAP
CSA-wrist
SCV
Unknowns
Always temporary?
Dose – 20/40/80 mg methyprednisolone equivalent?
Lignocaine?
Serial injection?
European recommendations
Our data so far
Ultrasound guidance?
Injection after failed surgery?
824 patients injected
5 year follow-up
372 second injections
(third?)
Surgery
1 year = 15%
5 years = 33%
Always temporary?
Dose? – Possibly the best steroid trial ever!
Rate of surgery at 1 year (111 pts)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Placebo 40mg 80mg
P=0.042
Effectiveness of second corticosteroid injections for
carpal tunnel syndrome. Ashworth NL, Bland JDP Muscle &
Nerve 2013; 48(1); 122-126
First injection (n=1675) Second injection
(n=229)
P value
Age (mean, sd) yrs 60.0 (15.7) 57.4 (14.8) 0.014 *
Gender (% female) 72 75 ns
BMI (mean,sd) 28.8 (5.9) 28.7 (6.0) ns
Duration symptoms before
initial presentation (median)
6-12 months 6-12 months ns
Initial electrodiagnostic
severity (mean Canterbury, sd)
2.5 (1.1) 2.3 (1.1) ns
No difference in SSS between first
and second injections
1.2 1.3
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1st Injection 2nd Injection
Mean improvement in SSS
Better improvement in FSS with
second injection (p<0.001)
0.4
0.7
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
1st Injection 2nd Injection
Mean improvement in FSS
No difference in Duration (Days)
336 348
0
50
100
150
200
250
300
350
400
1st Injection 2nd Injection
Are there any predictors of improved
outcome for 2nd injection?
• Δ SSS for 1st injection
• R sq = 0.13 Δ SSS
• Δ SSS for 1st injection
• Menopausal
• R sq =0.21 Δ FSS
Prejudicial to subsequent
surgery?
Telephone survey carried out in 2011 of all patients operated during
2005 at one centre in Estonia
Reliant on patient recall for record of injections
Most patients did not have NCS and almost no contemporaneous
information from the time of surgery was included in the analysis
Injection
Before
surgery
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Inject Inject Direct Direct Inject Inject Direct Direct
SSS (green pre-op, red post-op) FSS
Results – change in score
0
10
20
30
40
50
60
Direct
Pre-inject
All
Subjective improvement post surgery (%)
Ultrasound guidance – reasons
Safer?
Less risk of intraneural injection
Intraneural injections are pretty rare anyway
More precise site
Does it matter if the steroid ends up ‘in’ the carpal tunnel?
‘Hydro-dissection’
Ultrasound guidance? – Cochrane
Makhlouf T (2014) “ Outcomes and cost-effectiveness of carpal tunnel injections using
sonographic needle guidance” Clin Rheumatol 33(6):849-58
Lee J Y (2014) “Effectiveness of ultrasound guided carpal tunnel injection using in-
plane ulnar approach: a prospective randomized, single-blinded study” Medicine
(Baltimore) 93(29):1-6
Ustun N (2013) “ Ultrasound-guided vs blind steroid injections in carpal tunnel
syndrome: A single-blind randomized prospective study” Am J Phys Med Rehabil
92(11):999-1004
But…..
Limitations
No patient blinding – placebo and distraction effects from
very different procedures
In Ustun – different doses were used for the two arms of
the trial
How to do it better?
Use the scanner for both arms of a study but hide the
display from the injector in one arm
Compare an ultrasound guided injection placed between
nerve and ligament with one deliberately placed in the
distal forearm
Conclusions
Quantitative medicine
There are now quite good tools for:
Diagnosis
Severity assessment
Follow-up.......... Use them and record them!
Diagnostic tests
Tinel – forget it in CTS
Ultrasound
Complementary to NCS, not a replacement
Needs more work on injection guidance
Treatment
Injection
Starting to look like a viable alternative to surgery
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