Diagnosis of carpal tunnel syndrome – implications for therapy
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Domingo Ly-Pen
und
José Luis Andréu
Dear editor:
We have read with great interest the recent article “Diagnosis of carpal tunnel syndrome” by Kleggetveit and Jorum [1].
We would like to add some practical considerations regarding the conclusions of this paper. We feel that the real value of the proper diagnosis of any disease should involve aspects regarding their possible treatment.
We fully agree with the conclusions of Kleggetveit and Jorum [1] when they state that nerve conduction study is to be recommended in all patients with suspected carpal tunnel syndrome, due to the reasons they explain brilliantly. Furthermore, they also point out that: “Although there are reasonable arguments that some patients with typical and mild carpal tunnel syndrome may be treated conservatively without the urgent need of nerve conduction studies, the degree of nerve damage can be difficult to evaluate on clinical basis only”.
In the first published randomized trial comparing surgery vs local injections in the treatment of carpal tunnel syndrome [2], we found that, although local corticosteroid injection and decompressive surgery are equally effective in reducing symptoms of carpal tunnel syndrome, only surgery results in an improvement of the neurophysiologic parameters, at 12-month follow-up [3]. Our group demonstrated that local injections (despite being as useful as surgery at 12-month follow-up) did not mask carpal tunnel syndrome in nerve conduction studies. Other authors have also demonstrated improvement in conduction in surgical patients, but not in local corticosteroid injections, at 20-week follow-up [4].
However, our reflection goes beyond these conclusions: what will be our clinical attitude to the patient we have to care after a clinical diagnosis of carpal tunnel syndrome has been made? As it has been correctly pointed out, the diagnosis of carpal tunnel syndrome is a clinical one; we cannot just sit and wait until we can get a documented and infallible diagnosis of carpal tunnel syndrome with nerve conduction studies, whilst our patient is suffering pain and/ or paresthesiae. Unfortunately, in plenty of countries, the waiting list is close to one or even 2 years.
It seems reasonable that we should consider a conservative treatment whilst waiting for the nerve conduction studies. Many treatments have been advocated, among them: oral anti-inflammatories [5], splints [6, 7], oral corticosteroids [8, 9], gabapentin [10], or injected corticosteroids [2, 4, 11]. In our experience [5] local injections of corticosteroids have the greater evidence of effectiveness [2, 5, 12].
Of course, the patient should play a key role in the process diagnosis-treatment of carpal tunnel syndrome. We should put on the table all the available evidence, explaining in plain words the pros and cons of every procedure, and the patient should have the last say.
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Conflict of interest: None declared.
References
[1] Kleggetveit IP, Jørum E. Diagnosis of carpal tunnel syndrome. Scand J Pain 2018;18:333–7.10.1515/sjpain-2018-0089Suche in Google Scholar PubMed
[2] Ly-Pen D, Andreu JL, De Blas G, Sánchez-Olaso A, Millán I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum 2005;52:6129.10.1002/art.20767Suche in Google Scholar PubMed
[3] Andreu JL, Ly-Pen D, Millán I, de Blas G, Sánchez-Olaso A. Local injection versus surgery in carpal tunnel syndrome: neurophysiologic outcomes of a randomized clinical trial. Clin Neurophysiol 2014;125:1479–84.10.1016/j.clinph.2013.11.010Suche in Google Scholar PubMed
[4] Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, Li-Tsang CW, Wong LK, Boet R. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology 2005;64:2074–8.10.1212/01.WNL.0000169017.79374.93Suche in Google Scholar PubMed
[5] Ly-Pen D, Andréu JL. Treatment of carpal tunnel syndrome. Med Clin 2005;125:5859.Suche in Google Scholar
[6] Manente G, Torrieri F, Di Blasio F, Staniscia T, Romano F, Uncini A. An innovative hand brace for carpal tunnel syndrome: a randomized clinical trial. Muscle Nerve 2001;24:1020–5.10.1002/mus.1105Suche in Google Scholar PubMed
[7] Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Arch Phys Med Rehabil 2000;81:424–9.10.1053/mr.2000.3856Suche in Google Scholar PubMed
[8] Wong SM, Hui AC, Tang A, Ho PC, Hung LK, Wong KS, Kay R, Li E. Local vs. systemic corticosteroids in the treatment of carpal tunnel syndrome. Neurology 2001;56:1565–7.10.1212/WNL.56.11.1565Suche in Google Scholar PubMed
[9] Hui AC, Wong SM, Wong KS Li E, Kay R. Oral steroid in the treatment of carpal tunnel syndrome. Ann Rheum Dis 2001;60:813–4.10.1136/ard.60.8.813Suche in Google Scholar PubMed PubMed Central
[10] Eftekharsadat B, Babaei-Ghazani A, Habibzadehc A. The efficacy of 100 and 300 mg gabapentin in the treatment of carpal tunnel syndrome. Iran J Pharm Res 2015;14:1275–80.Suche in Google Scholar
[11] O’Gradaigh K, Merry P. Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis 2000;59:918–9.10.1136/ard.59.11.918Suche in Google Scholar PubMed PubMed Central
[12] Ly-Pen D, Andréu JL, Millán I, de Blas G, Sánchez-Olaso A. Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial. Rheumatology (Oxford) 2012;51:1447–54.10.1093/rheumatology/kes053Suche in Google Scholar PubMed
©2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
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Artikel in diesem Heft
- Frontmatter
- Editorial comment
- Support for mirror therapy for phantom and stump pain in landmine-injured patients
- Lifting with straight legs and bent spine is not bad for your back
- Bipolar radiofrequency neurotomy for spinal pain – a promising technique but still some steps to go
- Topical review
- Prevalence, localization, perception and management of pain in dance: an overview
- Clinical pain research
- Pain assessment in native and non-native language: difficulties in reporting the affective dimensions of pain
- Colored body images reveal the perceived intensity and distribution of pain in women with breast cancer treated with adjuvant taxanes: a prospective multi-method study of pain experiences
- Physiotherapy pain curricula in Finland: a faculty survey
- Mirror therapy for phantom limb and stump pain: a randomized controlled clinical trial in landmine amputees in Cambodia
- Pain and alcohol: a comparison of two cohorts of 60 year old women and men: findings from the Good Aging in Skåne study
- Prolonged, widespread, disabling musculoskeletal pain of adolescents among referrals to the Pediatric Rheumatology Outpatient Clinic from the Päijät-Häme Hospital District in southern Finland
- Impact of the economic crisis on pain research: a bibliometric analysis of pain research publications from Ireland, Greece, and Portugal between 1997 and 2017
- Measurement of skin conductance responses to evaluate procedural pain in the perioperative setting
- Original experimental
- An observational study of pain self-management strategies and outcomes: does type of pain, age, or gender, matter?
- Fibromyalgia patients and healthy volunteers express difficulties and variability in rating experimental pain: a qualitative study
- Effect of the market withdrawal of dextropropoxyphene on use of other prescribed analgesics
- Observational study
- Winning or not losing? The impact of non-pain goal focus on attentional bias to learned pain signals
- Gabapentin and NMDA receptor antagonists interacts synergistically to alleviate allodynia in two rat models of neuropathic pain
- Offset analgesia is not affected by cold pressor induced analgesia
- Central and peripheral pain sensitization during an ultra-marathon competition
- Reduced endogenous pain inhibition in adolescent girls with chronic pain
- Evaluation of implicit associations between back posture and safety of bending and lifting in people without pain
- Assessment of CPM reliability: quantification of the within-subject reliability of 10 different protocols
- Cerebrospinal fluid cutaneous fistula after neuraxial anesthesia: an effective treatment approach
- Pain in the hand caused by a previously undescribed mechanism with possible relevance for understanding regional pain
- The response to radiofrequency neurotomy of medial branches including a bipolar system for thoracic facet joints
- Letter to the Editor
- Diagnosis of carpal tunnel syndrome – implications for therapy
- Reply to the Letter to the Editor by Ly-Pen and Andréu
- Letter to the Editor regarding “CT guided neurolytic blockade of the coeliac plexus in patients with advanced and intractably painful pancreatic cancer”
- Reply to comments from Ulf Kongsgaard to our study
