{¹Associate Professor, Department of Medicine} {²Associate Professor, Department of Orthopaedics}

Government Medical College, Jammu, INDIA.

Email: thakuramit2277@gmail.com

 

Routine tests were done which included Blood sugar (Fasting), Thyroid function tests, ESR, RA factor, Lipid profile, RFT's, LFT's. Nerve conduction test was done on both hands. NCS was done on Recorders and Medicare Systems Machine. Motor nerve conduction was done by using surface electrodes placed over Abductor Pollicis Brevis for median nerve and Abductor Digiti minimi for Ulnar nerve and stimulating 3cm proximal to the distal crease of wrist. Sensory nerve conduction was done by antidromic stimulation using ring electrodes for recording placed over index finger in case of Median nerve and ring finger in case of Ulnar nerve and stimulating over mid-palm and wrist. CTS was diagnosed if any one of the following electro diagnostic findings were present.

1. distal median motor latency exceeded 4.4milliseconds.
2. difference in distal motor latency of median and ulnar nerve exceeded 1.1milliseconds.
3. distal sensory latency of median nerve exceeded 2.9milliseconds.
4. difference in distal sensory latency of Median and Ulnar nerves exceeded 0.2milliseconds.
5. sensory nerve conduction velocity of median nerve less than 40meters/second
6. CMAP of median nerve was less than 4millivolts.
7. or SNAP of Median nerve was less than 8 microvolts.

Carpal tunnel syndrome was classified as mild, moderate and severe groups according to nerve conduction findings. Mild CTS was diagnosed if NCS showed a prolonged distal motor latency but less than 5.4ms or a slowed SNCV but greater than 30.1meters per second or reduced CMAP or SNAP but greater than 3.9millivolts and 6.1microvolts respectively. Moderate CTS was diagnosed if distal motor latency was between 5.2 -7.2 milliseconds or SNCV was 20-30 meters per second or CMAP or SNAP was 2.5-3.8millivolt and 4-6 microvolt respectively. Severe CTS shower either distal motor latency over 7.2milliseconds or SNCV less than 20 meters per second or not obtainable or CMAP or SNAP below 2.5 millivolt or 4 microvolt respectively Abnormal result in any one of the three categories, including a prominently prolonged distal motor latency, a markedly slowed SNCV, a reduced amplitude of CMAP or SNAP is enough to diagnose a case as mild, moderate or severe.

Statistical Analysis: The collected data was evaluated using Mean, Percentages and Correlation; SPSS software was used.

 

RESULTS

A total of 50 patients (100 hands) were studied out of which CTS was diagnosed in 86 hands. Median age of the patients was 49.5 years with range from 20 to 75 years.37 (74%) were females and 13 (26%) were males.

Only 5 patients were left handed.19 patients had symptoms for less than 6 months, 26 between 7to 11months and only 5 patients had symptoms for 12 or more than 12 months. Hypothyroidism was present in 27 patients as a comorbid condition,9 patients were diabetic, obesity was present in 28 patients and rheumatoid arthritis was seen in 4 patients. 23 females were housewives, 9 patients were teachers by occupation, 8 were working in an office, 3 were computer operators, 2 were students and 3 were manual workers. Clinical severity score (BCTSAQ) was mild in 13, moderate in 13 and severe in 24 patients. (Table 1)

 

Table 1: Showing Clinical Characteristics of Patients

Bilateral disease was seen to be present electro diagnostically in 36 patients while 14 patients had unilateral disease. Right side was more involved than left in 19 patients, while left was more involved than right in 4 patients and 13 patients had equal severity on both sides. Pure sensory involvement was seen in 9 patients. Electro diagnostic severity was mild in 22 patients, moderate in 14 patients and severe in 14 patients. There were 2 cases of concomitant ulnar nerve compression. (Table 2; Figure 1,2,3)

Table 2: Showing Electrodiagnostic Features Of Patients

Figure 1: showing distribution of unilateral or bilateral disease according to disease severity

Figure 2: showing correlation between clinical and electro diagnostic severity

Figure 3: showing Correlation Between Duration Of Symptoms And Electrodiagnostic Severity

 

DISCUSSION

In our study, out of 50 patients (100 hands), 86 hands were having CTS. Female cases were more as compared to males (Female:Male ratio was 3:1) Maximum patients were in the age group of 40 to 60 years. These findings are consistent with those of Goyal et al.¹⁴ Most of the patients were housewives . Obesity and hypothyroidism were the most common comorbidities seen in more than half of the patients similar to the study by Kasundra GM et al.¹⁵ Most common symptom was paraesthesia present in 80% of the patients. Most of the patients had symptoms for less than 1 year which shows that symptoms start early in the course of the disease. Disease duration showed a correlation with electro diagnostic severity similar to the study by Tay LB et al.¹⁶ Bilateral disease was more as compared to unilateral disease and even patients with unilateral symptoms were seen to have involvement of the other side as well on nerve conduction study.Dominant hand was involved in most of the cases. Malibary et al.¹⁷ also found bilateral involvement more as compared to unilateral involvement. Clinically, more patients were having severe symptoms (48%) than detected by electrodiagnosis(24%) and electrodiagnostic severity did not correlate with clinical severity. This has also been observed in some previous studies. Leighton Chan et al.¹⁸ in their study found that there was no statistically significant relationship between electro diagnostic findings and the patient functional status and symptom severity. Firosh Khan et al.¹⁹ also found in their study that subjective symptoms of CTS correlated more with psychological factors than with electrophysiological severity.Itsubo et al.,²⁰ Longstaff et al.,²¹ De Campos et al.,²²de la Llave et al.²³,Schrijver H M et al.²⁴, and Makanji et al.²⁵ found similar results in their studies. Simultaneous involvement of the ulnar nerve was seen in 2 patients. The cause for discrepancy in patient related symptoms and electro diagnostic findings may be due to differential involvement of thin myelinated A delta and unmyelinated C fibres early in the course of the disease which carry the pain sensations and their dysfunction is not picked up in nerve conduction studies. Thick myelinated A Beta fibres are involved at a later stage and their involvement results in the electro diagnostic findings in nerve conduction studies.²⁶ Another reason may be that patient is not used to the new onset symptoms early in the course of the disease but later on he is habituated and compensated, so has less symptoms. Moreover, painful symptoms of CTS are also dependent on the psychological state and mood of the patient ²⁷ which should also be evaluated.

 

CONCLUSION

In our study, CTS is seen to be more in females, obese and hypothyroid patients with bilateral involvement in most of the cases. Majority of the patients had symptoms for the last less than 1 year. Severity of the disease correlated with the duration of symptoms while clinical severity had no correlation with electro diagnostic severity. So, symptoms alone cannot be considered in determining the severity of CTS and its definitive treatment but electro diagnostic studies should be considered together and also psychological status of the patient should be evaluated and further studies are needed to see this correlation with mood of the patient.

 

 

REFERENCES

1. Atroshi I, Gummesson C, Johnsson R, Ornsein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999 Jul 14;282(2):153–158.
2. De Krom M, Knipschild PG, Kester ADM, Thijs CT, Boekkooi PF, Spaans F. Carpal tunnel syndrome – prevalence in the general-population. J Clin Epidemiol. 1992 Apr;45(4):373–376.
3. Stevens JC, Sun S, Beard CM, Ofallon WM, Kurland LT. Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Neurology. 1988 Jan;38(1):134–138
4. Gupta, S., and Benstead, T. (1997). Symptoms Experienced by Patients with Carpal Tunnel Syndrome. Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques,24(4), 338-342.
5. Nora DB, Becker J, Ehlers JA, Gomes I (2005) What symptoms are truly caused by median nerve compression in carpal tunnel syndrome? Clin Neurophysiol 116:275–283
6. Zanette G, Marani S, Tamburin S (2006) Extra-median spread of sensory symptoms in carpal tunnel syndrome suggest the presence of pain-related mechanisms. Pain 122:264–2
7. Zanette G, Marani S, Tamburin S (2007) Proximal pain in patients with carpal tunnel syndrome. A clinical neurophysiological study. J Peripher Nerv Syst 12:91–97
8. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hubbard R. Risk factors in carpal tunnel syndrome. J Hand Surg. 2004;29:315–20.
9. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome. Ann plast surg. 2002;48(3):269–73. 
10. Solomon DH, Katz JN, Bohn R, Mogun H, Avorn J. Nonoccupational risk factors for carpal tunnel syndrome. Journal of general int med. 1999;14(5):310–14.
11. de Krom MC, Knipschild PG, Kester AD, Spaans F. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Lancet. 1990;335:393–395.
12. Katz JN, Larson MG, Sabra A, et al.The carpal tunnel syndrome: Diagnostic utility of the history and physical examination findings. Ann Intern Med. 1990;112:321–327
13. Werner RA, Andary M. Electrodiagnostic evaluation of carpal tunnel syndrome.Muscle Nerve. 2011 Oct;44(4):597–607.
14. Goyal V, Bhatia M, Padma MV, et al.Electrophysiological evaluation of 140 hands with carpal tunnel syndrome. J Assoc Physicians India 2001;49:1070-3.
15. Nakhosin Ansari, Noureddin and Adelmanesh, Farhad and Naghdi, et al. The relationship between symptoms, clinical tests and nerve conduction study findings in carpal tunnel syndrome. Electromyography and clinical neurophysiology.2009Jan –Feb; 49(1). 53-7. 
16. Tay LB, Urkude R, Verma KK. Clinical profile, electrodiagnosis and outcome in patients with carpal tunnel syndrome: a Singapore perspective. Singapore Med J 2006;47(12):1049-52.
17.  Malibary HM, Al-Najjar AT, Yassen DM, et al. Clinical profile of carpal tunnel syndrome in a teaching hospital. Pak J Med Sci 2013;29(1):119-21. 
18. Leighton Chan, MD, MPH, Judith A. Turner, PhD, Bryan A. Phys Med Rehabil 2007;88:19-24. Objective: To examine whether, in patients with carpal
19. Khan F, Shehna A, Ramesh S, Sandhya KS, Paul R. Subjective symptoms of carpal tunnel syndrome correlate more with psychological factors than electrophysiological severity. Ann Indian Acad Neurol 2017;20:69-72
20. Itsubo, T., Uchiyama, S., Momose, T. et al.Electrophysiological responsiveness and quality of life (QuickDASH, CTSI) evaluation of surgically treated carpal tunnel syndrome. J Orthop Sci 2009;14(1):17-23
21. L. Longstaff, R. H. Milner, S. O'Sullivan, P. Fawcett Carpal tunnel syndrome: the correlation between outcome, symptoms and nerve conduction study findings. J Hand Surg Br. 2001 Oct; 26(5): 475–480. 
22. de Campos, C. C., Manzano, G. M., Leopoldino, J. F., Nobrega, J. A., Sanudo, A., de Araujo, P. C., et al.(2004). The relationship between symptoms and electrophysiological detected compression of the median nerve at the wrist. Acta Neurologica Scandinavica,110, 398–402
23. de la Llave-Rincón AI1, Fernández-de-las-Peñas C, Laguarta-Val S, et al..Increased pain sensitivity is not associated with electrodiagnostic findings in women with carpal tunnel syndrome.Clin J Pain. 2011 Nov-Dec;27(9):747-54. 
24. Schrijver HM, Gerritsen AA, Strijers RL, Uitdehaag BM, Scholten RJ, de Vet HC, et al. Correlating nerve conduction studies and clinical outcome measures on carpal tunnel syndrome: Lessons from a randomized controlled trial. J Clin Neurophysiol. 2005;22:216–21.
25. Makanji HS, Zhao M, Mudgal CS, et al.Correspondence between clinical presentation and electrophysiological testing for potential carpal tunnel syndrome. J Hand Surg Eur Vol. 2013;38:489–495.
26. Truini A, Padua L, Biasiotta A, Caliandro P, et al. Differential involvement of A-delta and A-beta fibres in neuropathic pain related to carpal tunnel syndrome. Pain. 2009 Sep;145(1-2):105-9. 
27. Nunez, Fiesky et al. “Determinants of pain in patients with carpal tunnel syndrome.” Clinical orthopaedics and related research vol. 468,12 (2010): 3328-32.

 

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