Correspondence

Entrapment Neuropathies of the Upper Extremities

N Engl J Med 1994; 330:1389-1390May 12, 1994

Article

To the Editor:

. . . Beware of a patient with obvious carpal tunnel syndrome who has any symptoms in the little finger or ulnar half of the ring finger: ulnar-nerve testing by electromyography or testing of nerve-conduction velocity seems of little value for this portion of the ulnar nerve, and in obvious clinical cases of ulnar-nerve compression, the result is reported as normal more frequently than not. The mere presence of such symptoms is justification enough to release Guyon's canal at the time of carpal tunnel release. In addition to compression of the ulnar nerve in Guyon's canal by the same type of pathologic process as that affecting the median nerve in the carpal tunnel, there is a communicating nerve branch that sweeps through the palm that is frequently identifiable during surgery and may play a part in such symptoms. I have operated on numerous patients who have had apparently unsuccessful surgery for carpal tunnel syndrome. In these patients the carpal tunnel had been adequately decompressed by the first surgeon, but I am convinced that it was release of Guyon's canal in the second operation that afforded substantial relief.

It is appropriate to mention conservative approaches to care such as splinting, antiinflammatory medications, and possibly corticosteroid injections. Nevertheless, most hand surgeons understand that the longer carpal tunnel syndrome has been symptomatic, the less likely it is that relief will be gained by conservative methods. As a physician who has patients referred from primary treatment sources (meaning their condition has existed for weeks to months before they see me), I almost never see a case of carpal tunnel syndrome that responds to conservative care or that does not immediately recur when the patient begins once again to use the hand vigorously. It is obvious in patients who have had symptoms for more than four weeks that conservative care is not cost effective.

Michael Roy Treister, M.D.
1431 North Western Ave., Chicago, IL 60622

To the Editor:

In his article on entrapment neuropathies of the upper extremities (Dec. 30 issue),1 Dr. Dawson suggests that “electrodiagnostic testing is important for the accurate diagnosis of carpal tunnel syndrome and should be carried out in most cases.” It is indeed important but is not necessary in most cases. Unfortunately, the test results are almost always positive and frequently provide a license for a surgeon to operate. An instructional lecture in a recent issue of the Journal of Bone and Joint Surgery2 states that “although carpal tunnel syndrome is the best understood and most frequently diagnosed compression neuropathy, it is also the most often overdiagnosed. The most prevalent management error . . . is an incorrect or incomplete diagnosis, which all too often leads to an inappropriate or unnecessary operation.” I believe that most hand surgeons would agree that electrodiagnostic tests are not necessary in a patient with clearly defined symptoms and physical findings. To subject a patient to the discomfort and cost of an electrodiagnostic study in the presence of clearly defined symptoms is inappropriate.

George L. Lucas, M.D.
University of Kansas Medical Center, Wichita, KS 67214-3882

2 References

1. 1

   Dawson DM. Entrapment neuropathies of the upper extremities. N Engl J Med 1993;329:2013-2018
   Full Text | Web of Science | Medline

2. 2

   Gelberman RH, Eaton R, Urbaniak JR. Peripheral nerve compression. J Bone Joint Surg Am 1993;75:1854-1878
   

To the Editor:

In our dialysis center, 28 of 148 patients (19 percent) have clinical signs of carpal tunnel syndrome. None of the patients who have undergone dialysis for less than five years have any signs of carpal tunnel syndrome. The syndrome has developed in 22 of the 32 patients (69 percent) who have undergone dialysis for more than 10 years. Seven patients who underwent surgical decompression had clinical and neurophysiologic improvement, but four had a relapse after three years.

With the extended survival of patients undergoing hemodialysis, new pathologic processes have emerged, including dialysis-related amyloidosis1. Carpal tunnel syndrome is one clinical manifestation of dialysis-related amyloidosis. An extremely high prevalence of carpal tunnel syndrome is observed among patients with uremia who are receiving long-term dialysis, one that exceeds the highest rates found in so-called high-risk occupations2.

Drasko Pavlovic, M.D.
Svjetlana Cala, M.D., Ph.D.
Nikola Jankovic, M.D.
Sveti Duh Hospital, 41000 Zagreb, Croatia

2 References

1. 1

   Koch KM. Dialysis-related amyloidosis. Kidney Int 1992;41:1416-1429
   CrossRef | Web of Science | Medline

2. 2

   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
   Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   J. Clarke Stevens, Benn E. Smith, Amy L. Weaver, E. Peter Bosch, H. Gordon Deen, James A. Wilkens. (1999) Symptoms of 100 patients with electromyographically verified carpal tunnel syndrome. Muscle & Nerve 22:10, 1448-1456
   CrossRef