Epidemiology Carpal Tunnel Syndrome

Epidemiology Carpal Tunnel Syndrome

Carpaal Tunnel Syndroom Carpal tunnel syndrome (CTS) is a neuropathy caused by compression of the median nerve within the carpal tunnel.1
Incidence: A general population survey in Rochester, Minnesota, found the age-adjusted incidence of CTS to be 105 (95% CI 99 to 112) cases per 100,000 person years.4,5Incidence rates of CTS increased with age for men, whereas for women they peaked between the ages of 45 and 54 years. A general population survey in the Netherlands found prevalence to be 1% for men and 7% for women.6
Prevalence In the Netherlands the prevalence is estimated to be 9% at adult women and 0,6% at adult man.3
Function: The flexion tendons of the hand and the nervus medianus are positioned in this tunnel
Sex: Female > male ratio for carpal tunnel syndrome is 3-10:1.6Among older people, the prevalence in women was almost four times that in men age group 65-74 years. Over 50% of pregnant women develop symptoms of CTS.8,9
Age: 40 to 60 years gives the highest peak in carpal tunnel syndrome. In children non-traumatic CTS rarely occur.7
Pain location: Wrist, can radiate to hands, fingers and elbow
Pain sensation/ Symptoms: Classical symptoms of CTS include numbness, tingling, burning, or pain in at least two of the three digits supplied by the median nerve (i.e., the thumb and the index and middle fingers).2Another symptom is difficulty grabbing. Weakness of the muscles and sensory system can be a result of CTS. Even atrophy of the Thenar muscle can appear (ball of the thumb).11
History of injury: Most cases of CTS have no easily identifiable cause (idiopathic).4 Secondary causes of CTS include the following: space-occupying lesions (tumours, hypertrophic synovial tissue, fracture callus, and osteophytes), metabolic and physiological (pregnancy, hypothyroidism, and rheumatoid arthritis), infections, neuropathies (associated with diabetes mellitus or alcoholism), and familial disorders. 4Carpal tunnel syndrome is not fatal, but it can lead to complete, irreversible median nerve damage, with consequent severe loss of hand function, if left untreated.
Pathology Carpal tunnel syndrome (CTS) is a neuropathy caused by compression of the median nerve within the carpal tunnel.1When circulation stagnates for a longer time by a higher pressure than the capillary blood pressure the nerve cells stagnate. At heavier compression the Cells of Schwann can get damaged locally, without the neurons being interrupted. This doesn’t mean the axons aren’t broken but the rhythm can be delayed or even interrupted. The loss of myelin sheaths block the rhythm of action potentials in the damaged area.10
Prognosis Carpal tunnel syndrome is a progressive pathology and can lead to permanent damage of the n. medianus. 90% of all patients with mediocre complains react to conservative treatment. Patients with secondary CTS like diabetis or fractures have a less positive prognosis than primary CTS. Prognosis of CTS is mainly made by the damage of the nervus medianus.12
Literature
  1. Rozmaryn LM. Carpal tunnel syndrome: a comprehensive review. Curr Opin Orthop 1997;8:33-43.
  2. Review Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. Rempel D, Evanoff B, Amadio PC, de Krom M, Franklin G, Franzblau A, Gray R, Gerr F, Hagberg M, Hales T, Katz JN, Pransky G Am J Public Health. 1998 Oct; 88(10):1447-51.
  3. de Krom MC, Knipschild PG, Kester AD, et al. Carpal tunnel syndrome: prevalence in the general population. J Clin Epidemiol. Apr 1992;45(4):373-6.
  4. Review Carpal tunnel syndrome. von Schroeder HP, Botte MJ Hand Clin. 1996 Nov; 12(4):643-55
  5. Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Stevens JC, Sun S, Beard CM, O’Fallon WM, Kurland LT Neurology. 1988 Jan; 38(1):134-8.
  6. Dumitru D. Textbook of electrodiagnostic medicine Hanley and Belfus, eds. Philadelphia, PA: Mosby Publications; 1995.
  7. NVvN. Richtlijn Diagnostiek en behandeling van het carpale-tunnelsyndroom. Nederlandse Vereniging voor Neurologie/ CBO, 2005.
  8. Carpal tunnel syndrome in pregnancy. Voitk AJ, Mueller JC, Farlinger DE, Johnston RU Can Med Assoc J. 1983 Feb 1; 128(3):277-81.
  9. Multicenter study on carpal tunnel syndrome and pregnancy incidence and natural course. Pazzaglia C, Caliandro P, Aprile I, Mondelli M, Foschini M, Tonali PA, Padua L, Italian CTS and others entrapment Study Group Acta Neurochir Suppl. 2005; 92():35-9.
  10. Dynamiek Van Het Menselijk Bindweefsel Morree de JJ, 2001 (Book)
  11. Rosenbaum R.B, Ochoa J.L,  Carpal tunnel syndrome and other disorders of the  median nerve,  Butterworth-Heinemann Stoneham (USA), 1993
  12. Marshall S, Tardif G, Ashworth N.Local corticosteroid injection for carpal tunnelsyndrome.In:Cochrane Library:Issue 4, 2006.Chichester, UK:John Wiley &Sons.Search date 2002;primary sources Cochrane Neuromuscular DiseaseGroup Register, Medline, Embase, and Cinahl.No company sponsorship declared

 

Examination

List of tests
Katz Hand Diagram

Wrist Ratio Index

Thenar Atrophy

Wrist Flexin(Phalen’s)

Flick Maneuver

Wrist Flexion and Median Nerve Compression

Two-point discrimination

Hand Elevation Test

Phalen’s test

Tinnel’s test

Katz Hand DiagramThe patient gets a diagram for both hands and arms. Patient then has to fill in the diagram and fill in the locations where the symptoms occur. ( Irvm, 2006)
  1. Nederlandse Vereniging voor Arbeids- en Bedrijfsgeneeskunde. Handelen van de bedrijfsarts bij werknemers met klachten aan arm, schouder of nek: geautoriseerde richtlijn. Utrecht: NVAB, 2003.
  2. Irvm (2006), Uitgebreide toelichting van het meetinstrument, katz klachtendiagram carpaaltunnel syndroom

 

 

Evidence Based Practice


 Katz Hand Diagram                                                                                        Utility 2

Study Sensitivity (include) Specificity (exclude)
Szabo et al.69 76 98
Katz et al.36 61 71
Katz & Stirrat37 80 90
Artoshi et al.4 80 90
Gunnarsson et al.29 66 69
O’Gradaigh & Merry54 72 53

 

Wrist Ratio Index                                                                                            Utility 2

Study Sensitivity (include) Specificity (exclude)
Kuhlman & Hennessey41 69 73
Radecki60 47 83
Wainner et al.73 93 26

 

Thenar Atrophy                                                                                               Utility 2

Study Sensitivity (include) Specificity (exclude)
De Krom et al.14 70 45
Gerr & Letz25 28 82
Golding et al.27 04 99
Katz et al.36 14 90

 

Wrist Flexin(Phalen’s)                                                                                      Utility 2

Study Sensitivity (include) Specificity (exclude)
Phalen58 74 NT
Seror64 62 90
Buch-Jaeger & Foucher8 58 54
Gerr & Letz25 75 33
Wainner et al.73 77 40
Szabo et al.69 75 95
Lajoie et al.43 92 88
Williams et al.77 88 100

 

Flick Maneuver                                                                                                Utility 2

Study Sensitivity (include) Specificity (exclude)
Pryse-Phillips59 93 96
Hansen et al.31 37 74
Gunnarsson et al.29 90 30

 

Percussion (Tinel’s)                                                                                         Utility 2

Study Sensitivity (include) Specificity (exclude)
Katz et al.36 60 67
Hansen et al.31 27 91
Gunnarsson et al.29 62 57
Wainner et al.73 41 58

 

Wrist Flexion and Median Nerve Compression                                                  Utility 2

Study Sensitivity (include) Specificity (exclude)
Tetro et al.70 86 95
Edwards19 62 92

 

Median Nerve Compression Test/Pressure provocation test                              Utility 2

Study Sensitivity (include) Specificity (exclude)
Williams et al.77 100 97
Kaul et al.39 55 68
Yii & Elliot 81 100

 

Two-point discrimination                                                                                  Utility 2

Study Sensitivity (include) Specificity (exclude)
Katz et al.36(Moving) 32 80
Gerr & Letz25(Static) 28 64
Gellman et al.23 (Static) 33 100

 

Hand Elevation Test

Study Sensitivity (include) Specificity (exclude)
Ahn1 76 99
Amirfeyz et al.3 88 98

 

  1. Ahn DS. Hand elevation: a new test for carpal tunnel syndrome. Ann Plats Surg. 2001;46:120-124
  2. Amirfeyz R, Gozzard C, Leslie IJ. Hand elevation test for assessment of carpal tunnel syndrome. J Hand Surg[Br]. 2005;30:361-364
  3. Atroshi I, Breidenbach WC, McCabe SJ. Assessment of the carpal tunnel outcome instrument in patients with nerve-compression symptoms. J Hand Surg [Am]. 1997;22:222-227
  4. Buch-Jaeger N, Foucher G. Correlation of clinical signs with nerve conduction tests in the diagnoseis of carpal tunnel syndrome. J Hand Surg [Br]. 1994;19:720-724
  5. Buehler MJ, Thayer DT. The elbow flexion test. A clinical test for the cubtial tunnel syndrome. Clin Orthop Relat Res. 1988:213-216
  6. Cozen L. The painful elbow. Ind Med Surg. 1962;31:369-371
  7. de Krom MC, Knipschild PG, Kester AD, Spaans F. Efficiacy of provocative test for diagnosis of carpal tunnel syndrome. Lancet. 1990;335:393-395
  8. Edwards A. Phalen’s test with carpal compression: testing in diabetics for the diagnoses of capal tunnel syndrome. Ortopedics. 2002;25:519-520
  9. Gerr F, Letz R. The sensitivity and specificity of tests for carpal tunnel syndrome vary with the comparison subjects. J Hand Surg [Br]. 1998;23:151-155
  10. Gerr F, Letz R, harris-Abbott D, Hopkins LC. Sensitivity and specificity of vibrometry for detection of carpal tunnel syndrome. J Occup Environ Med. 1995;37:1108-1115.
  11. Golding DN, Rose DM, Selvarajah K. Clinical tests for carpal tunnel syndrome: an evaluation. Br J Rheumatol. 1986;25;388-290
  12. Gunnarrson LG, Amilon A, Hellstrand P, Leissner P, Philipson L. The diagnosis of carpal tunnel syndrome: sensitivity and specificity of some clinical and electrophysiological tests

 

 

 

BEHANDELING

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