Response to local corticosteroid injections in carpal tunnel syndrome with normal conduction studies.

INTRODUCTION: Nerve conduction studies (NCS) have been considered as the gold standard in carpal tunnel syndrome (CTS) diagnosis, despite correlation between clinical symptomatology and NCS severity has shown to be poor. In fact, clinical symptoms precede NCS changes in months or years. Few papers have been published about the clinical response to treatment of clinically typical CTS, but with normal NCS (NNCS). OBJECTIVE: To compare the clinical response to local corticosteroid injections (LCI) in clinically typical CTS, with NNCS and abnormal NCS (ANCS). METHOD: We included patients older than 18, with typical CTS symptoms (ongoing daily nocturnal pain/paresthesias in hand, at least during 3 months). Follow-up was done at 3, 6 and 12 months. Primary outcome was the visual analog scale for pain (p-VAS), comparing NNCS CTS wrists with ANCS CTS wrists. Statistic signification was established by the Student's t test, Mann-Whitney's "U", χ2 test and Yates' correction. RESULTS: We included 44 wrists in the NNCS group, and 83 in the ANCS group. There was no statistical significance between data in both groups, except in the 12-month follow-up, where the NNCS group achieved better results than the ANCS group in the 20% response (p=0.006). There was a trend toward a better 50% response in the 12-month follow-up. CONCLUSIONS: Our data suggest that LCI are similarly effective in both CTS with NNCS and ANCS. Nonetheless, there is a mild better effect in NNCS than in ANCS at 12-month follow-up.

Long-term Outcome of Local Steroid Injections Versus Surgery in Carpal Tunnel Syndrome: Observational Extension of a Randomized Clinical Trial.

Background: In a previous paper, we have demonstrated that: (1) local injection of corticosteroids for carpal tunnel syndrome (CTS) is as effective as decompressive surgery, at 1-year follow-up; and (2) surgery has an additional benefit in the 2-year follow-up. In this study, we assess the long-term outcomes of both therapies in an observational extension of the patients originally enrolled in our randomized clinical trial. Methods: Patients were included in an open, randomized clinical trial, comparing injections versus surgery in CTS. After the end of the clinical trial, patients received the treatment prescribed by their general practitioner or specialist. Therapeutic failure was defined as the need of any new therapeutic intervention on the involved wrist. Comparison between groups was made using Cox multiple regression analysis. Estimation of the accumulated incidence of new therapeutic failure was made considering the withdrawal as a competitive risk (Gooley's test). Results: Of 163 randomized wrists at the beginning of the study, only 148 were available at the final follow-up. The mean follow-up was 6.3 and the median was 5.9 years. In the long-term follow-up, the accumulated incidence of therapeutic failure in the surgery group was 11.6% versus 41.8% in the injection group. The Cox multiple regression analysis showed a risk of failure associated with injection group of 4.5 (95% confidence interval [CI], 2.1-9.8; P < .0001). Conclusions: In long-term follow-up, surgery seems more effective than local corticosteroid injections in primary CTS. Nonetheless, about 58% of the patients in the injection group will not need further therapeutic interventions during the follow-up.

Response to Local Corticosteroid Injections in Carpal Tunnel Syndrome With Normal Conduction Studies.

INTRODUCTION: Nerve conduction studies (NCS) have been considered as the gold standard in carpal tunnel syndrome (CTS) diagnosis, despite correlation between clinical symptomatology and NCS severity has shown to be poor. In fact, clinical symptoms precede NCS changes in months or years. Few papers have been published about the clinical response to treatment of clinically typical CTS, but with normal NCS (NNCS). OBJECTIVE: To compare the clinical response to local corticosteroid injections (LCI) in clinically typical CTS, with NNCS and abnormal NCS (ANCS). METHOD: We included patients older than 18, with typical CTS symptoms (ongoing daily nocturnal pain/paresthesias in hand, at least during 3 months). Follow-up was done at 3, 6 and 12 months. Primary outcome was the visual analog scale for pain (p-VAS), comparing NNCS CTS wrists with ANCS CTS wrists. Statistic signification was established by the Student's t test, Mann-Whitney's "U", χ2 test and Yates' correction. RESULTS: We included 44 wrists in the NNCS group, and 83 in the ANCS group. There was no statistical significance between data in both groups, except in the 12-month follow-up, where the NNCS group achieved better results than the ANCS group in the 20% response (p=0.006). There was a trend toward a better 50% response in the 12-month follow-up. CONCLUSIONS: Our data suggest that LCI are similarly effective in both CTS with NNCS and ANCS. Nonetheless, there is a mild better effect in NNCS than in ANCS at 12-month follow-up.

Local injection versus surgery in carpal tunnel syndrome: neurophysiologic outcomes of a randomized clinical trial.

OBJECTIVE: The aim of our study was to characterize the neurophysiologic outcomes in a randomized clinical trial comparing local corticosteroid injection and decompressive surgery in idiopathic carpal tunnel syndrome. METHODS: Clinical and neurophysiologic assessments were done at baseline and 12 months after treatment. Four parameters were evaluated in the nerve conduction study (NCS): distal motor latency, motor amplitude, sensory conduction velocity and sensory amplitude. Statistic signification was established by the Student's t test, independent and paired samples, and Mann-Whitney test. Repeated measures analysis of variance was used by the three domains of symptoms. Correlations between the changes showed in clinical parameters and those evidenced by electromyography were calculated by the Pearson's test. RESULTS: Both groups of therapy were comparable at baseline. In 95 wrists, a second NCS was done 12 months post-treatment. Although clinical outcome improved in a similar way in both groups, we found statistically significant improvement in three (distal motor latency, sensory conduction velocity and sensory amplitude) of four neurophysiologic parameters only in the surgery group, when compared to baseline values. CONCLUSIONS: Although local corticosteroid injection and decompressive surgery are clinically effective in reducing symptoms of carpal tunnel syndrome, only surgery results in an improvement of the neurophysiologic parameters, at 12-months follow-up. SIGNIFICANCE: Only decompressive surgery allows resolution of neurophysiologic changes. The symptoms of the syndrome are resolved with corticosteroid injections.

Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial.

OBJECTIVE: To compare the efficacy of surgical decompression vs local steroid injection in the treatment of idiopathic CTS. METHODS: This is an open, prospective, randomized clinical trial. We studied the effects of surgical decompression vs local steroid injection in 163 wrists with a clinical diagnosis and neurophysiological confirmation of CTS, with an extended follow-up of 2 years. The primary end point was the percentage of wrists that reached a ≥ 20% improvement in the visual analogue scale score for nocturnal paraesthesias. Statistical analysis was done by Student's t-test for continuous variables and by chi-square test for categorical variables. Analyses were performed on an intent-to-treat basis. P < 0.05 were considered statistically significant. RESULTS: Both treatment groups had comparable severity of CTS at baseline. Eighty wrists were randomly assigned to surgical decompression and 83 wrists to local steroid injection. Fifty-five wrists in the surgery group and 48 wrists in the injection group completed the 2-year follow-up. In the intent-to-treat analysis, at 2-year follow-up, 60% of the wrists in the injection group vs 69% in the surgery group reached a 20% response for nocturnal paraesthesias (P < 0.001). CONCLUSION: Our findings suggest that both local steroid injection and surgical decompression are effective treatments in alleviating symptoms in primary CTS at 2-year follow-up. Surgery has an additional benefit in the 2-year follow-up, although clinical relevance of those differences remains to be defined. TRIAL REGISTRATION: Current Controlled Trials, www.controlled-trials.com, ISRCTN26264638.

Reconstructive surgery in young women with breast cancer.

Recovery of body image after mastectomy is essential for physical and mental quality of life. Partial or total mastectomy deformities can be reversed by reconstructive surgical procedures. Young women with breast cancer have specific characteristics related to the age of onset of the disease, prognosis and reconstructive expectations. Patient individualization is the key to a successful breast reconstruction. Autologous and prosthetic reconstruction are the two main techniques used for breast reconstruction. Each reconstructive technique has its own indications, advantages and limitations. Timing of the surgery is primarily determined by the requirement for adjuvant radiotherapy, so an immediate or a delayed approach can be recommended. In patients in whom the need for adjuvant radiotherapy is in doubt, a delayed-immediate approach is the best to optimize aesthetic and oncologic outcomes. Prophylactic mastectomy is also being indicated in a growing number of patients. In these patients it is important to choose a similar reconstructive procedure on both sides to achieve breast symmetry.

Anatomic and clinical study of rectus abdominis musculocutaneous flaps based on the superior epigastric system: ipsilateral pedicled TRAM flap as a safe alternative.

This anatomic and clinical study supports the use of the ipsilateral transverse rectus abdominis musculocutaneous (TRAM) flap over the contralateral TRAM flap for breast reconstruction. The costomarginal artery was constant in these dissections and supplied a vascular pedicle to the rectus abdominis muscle. Radiologic studies confirmed the communications between the costomarginal artery and the deep epigastric system, the same as between the costomarginal artery and the musculophrenic and intercostal arteries. The results of the clinical series confirmed the costomarginal artery as an alternative or adjuvant vascular pedicle of the deep superior epigastric artery in cases of potential lesion of the latter. The lack of pedicle tension because of the shorter distance to be transposed allowed a greater versatility in flap shaping and positively affected its aesthetic result. This fact made the authors change from the contralateral to the ipsilateral pedicled TRAM flap as the first option for autologous breast reconstruction because of vascular security.

Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial.

OBJECTIVE: Optimal treatment of carpal tunnel syndrome (CTS) has not been established. This study compared the effects of local steroid injection versus surgical decompression in new-onset CTS of at least 3 months' duration. METHODS: In a 1-year, prospective, randomized, open, controlled clinical trial, we studied the effects of surgical decompression versus local steroid injection in 163 wrists with a clinical and neurophysiologic diagnosis of CTS. Clinical assessments were done at baseline and at 3, 6, and 12 months after treatment. The primary end point was the percentage of wrists that reached a >or=20% improvement in the visual analog scale score for nocturnal paresthesias at 3 months of followup. Statistical analysis was done by Student's t-test for continuous variables and by chi-square test for categorical variables. Analyses were performed on an intent-to-treat basis. P values less than 0.05 were considered statistically significant. RESULTS: Both treatment groups had comparable severity of CTS at baseline. Eighty wrists were randomly assigned to the surgery group and 83 wrists to the local steroid injection group. In the intent-to-treat analysis, at 3 months of followup, 94.0% of the wrists in the steroid injection group versus 75.0% in the surgery group reached a 20% response for nocturnal paresthesias (P = 0.001). At 6 and 12 months, the percentages of responders were 85.5% versus 76.3% (P = 0.163) and 69.9% versus 75.0% (P = 0.488), for local steroid injection and surgical decompression, respectively. CONCLUSION: Over the short term, local steroid injection is better than surgical decompression for the symptomatic relief of CTS. At 1 year, local steroid injection is as effective as surgical decompression for the symptomatic relief of CTS.

Basal cell carcinoma in childhood after radiation therapy: case report and review.

We describe 2 patients who received ionizing radiation as part of a curative regimen for childhood malignancy which later developed basal cell carcinoma at an early age. They do not occur within the context of well-defined syndromes, such like basal cell nevus syndrome, albinism, or xeroderma pigmentosum. Basal cell carcinomas appears on radiated areas in older individuals, less often in younger patients, in which the period of latency between exposure to radiation and the appearance of basal cell carcinomas is shorter than in older patients. Our 2 cases presented a period of latency of 11 and 10 years. Radiated skin areas must be explored as part of the follow-up in children who received radiotherapy and should probably be maintained for life. The basal cell carcinoma in childhood is best treated by excision.