Surgical versus non-surgical treatment for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome results from entrapment of the median nerve in the wrist. Common symptoms are tingling, numbness, and pain in the hand that may radiate to the forearm or shoulder. Surgical treatment is widely preferred to non-surgical or conservative therapies for people who have overt symptoms, while mild cases are usually not treated. OBJECTIVES: The objective is to compare the efficacy of surgical treatment of carpal tunnel syndrome with non-surgical treatment. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register and MEDLINE, EMBASE and LILACS (to October 2002). We checked bibliographies in papers and contacted authors for information about other published or unpublished studies. SELECTION CRITERIA: We included all randomised and quasi-randomised controlled trials comparing any surgical and any non-surgical therapies. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the eligibility of the trials. MAIN RESULTS: We found two randomised controlled trials involving 198 participants in total. The first trial included 22 participants, 11 allocated to surgery and 11 to splinting for one month. The trial was not blinded nor was it clear if allocation was properly concealed. In the second trial, 87 participants were allocated to surgery and 89 to splinting for at least six weeks. The trial was not blinded but allocation concealment was adequate. The second trial considered our primary outcome measure, relevant clinical improvement at three months. Sixty-two people out of 87 allocated to surgery (71%) qualified for treatment success. Forty-six people out of 89 allocated to splinting (51.6%) qualified for treatment success. The confidence interval favoured the surgical group (relative risk 1.38 95% confidence interval 1.08 to 1.75). We were able to pool data from both trials for two secondary outcomes. For clinical improvement at one year of follow-up, the pooled estimate favoured surgery (relative risk 1.27, 95% confidence intervals 1.05 to 1.53). For need for surgery during follow-up, the pooled estimate indicates that a significant proportion of people treated medically will require surgery while the risk of re-operation in surgically treated people is low (relative risk 0.04 in favour of surgery, 95% confidence intervals 0.01 to 0.17). REVIEWER'S CONCLUSIONS: Surgical treatment of carpal tunnel syndrome relieves symptoms significantly better than splinting. Further research is needed to discover whether this conclusion applies to people with mild symptoms.

Surgical versus non-surgical treatment for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome is the clinical condition resulting from the entrapment of the median nerve in the wrist. It has been accepted as the most frequent entrapment neuropathy. The most common symptoms are tingling, numbness, and pain in the hand that may radiate to the forearm or shoulder. There may be weakness and atrophy of the thenar muscles associated with sensory loss in the affected fingers. There is no universally accepted therapy for carpal tunnel syndrome. Surgical treatment is widely preferred to non-surgical or conservative therapies for overtly symptomatic patients, while mild cases are usually not treated. OBJECTIVES: The objective of this review is to compare the efficacy of surgical treatment of carpal tunnel syndrome with non-surgical treatment in improving clinical outcome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register for randomised or quasi-randomised trials as well as MEDLINE, EMBASE and LILACS (to July 2001). We checked the bibliographies in relevant papers and contacted the authors to obtain information about other published or unpublished studies. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing any surgical and any non-surgical therapies. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility of the trials. MAIN RESULTS: Only one randomised controlled trial was found. It included 22 female patients, 11 allocated to surgical section of the anterior carpal ligament and 11 to splinting for one month. The trial was not blinded and it is not clear if the allocation was properly concealed. Data reported allowed an intention-to-treat analysis on two secondary outcomes. The results favour surgery for both of them. There was a significant clinical improvement at one year follow-up in 10 out of 11 patients allocated to surgery and two out of 11 allocated to splinting (relative risk 5.00, 95% confidence interval 1.41, 17.76). Eight out of 11 patients allocated to splinting required surgery during follow-up, compared with apparently no re operation in the surgical group (relative risk 0.06, 95% confidence interval 0.00, 0.91). REVIEWER'S CONCLUSIONS: Surgical treatment of carpal tunnel syndrome seems to be better than splinting. There is a need for randomised controlled trials comparing surgical and non-surgical therapies for carpal tunnel syndrome, particularly in patients with mild symptoms in whom there is greater uncertainty concerning the balance of risks versus benefit of surgical therapy.

Sensory dysfunction in HTLV-I-associated myelopathy/tropical spastic paraparesis. A comprehensive neurophysiological study.

We performed a comprehensive clinical and neurophysiological evaluation of function of the large- and small-caliber afferent pathways in 29 patients with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Sensory symptoms, particularly cutaneous paresthesias, were present in 11 (37.9%) patients. On examination, a mild distal impairment of vibration and sense of position were found in 14 (48.2%) and 5 (17.2%) patients, respectively. Ten (34.4%) patients had distal tactile hypoesthesia and 7 (24.1%) presented pinprick hypoesthesia. Quantitative somatosensory thermotest showed cold hypoesthesia in 58.6% of patients. Nerve conduction studies and electromyography were normal. Tibial somatosensory evoked potentials were abnormal in 88.5% of patients. All of the sensory abnormalities found were restricted to sensations carried by myelinated (A-beta and A-delta) fibers. Unmyelinated C fibers mediating warm sensation and thermal pain appeared unimpaired. Our findings indicate that the sensory dysfunction in HAM/TSP patients is probably due to a lesion restricted to the central nervous system.

Clinical and neuropathological study of six patients with spastic paraparesis associated with HTLV-I: an axomyelinic degeneration of the central nervous system.

Between 1990 to 1994, 6 TSP/HAM patients, 3 women and 3 men with an average age of 57.1 years (39 to 76 years old), who died in the Salvador Hospital were submitted to postmortem examination. The mean time of paraparesis was 7 years (3 to 17 years), and 2 patients had pseudobulbar signs. Three cases had macroscopic atrophy of the spinal cord. Histologically, all cases had lesions in the pyramidal tracts and 4 cases showed somatotopic lesions of the Goll's tracts which followed a "dying back" ascendant and descendant distribution, respectively. In 2 cases, both of which had intellectual impairment, demyelination of the subcortical and parathalamic areas was observed without U fiber involvement. Abnormal vessels with gross thickening of the adventitia, many of them with lymphocytic cuffs, were seen everywhere, especially in the spinal cord, brain stem, midbrain and meninges, but no relation between these findings and the parenchymal lesions was observed. Also, in the cases with posterior column involvement, neuronal changes and proliferation of satellite cells in the dorsal ganglia were found. All cases showed histological sialoadenitis and none had inflammatory muscle changes. We conclude that the lesions affected the neuraxis in a systemic axial fashion as in degenerative diseases, and did not seem to be secondary to vascular or inflammatory abnormalities.

[Myopathy caused by acid maltase deficiency in an adult]. / Miopatía por déficit de maltasa ácida en el adulto.

We report a 46 years old male presenting with tetraparesis and severe respiratory involvement. He had moderately elevated serum creatine phosphokinase values and the electromyography showed myopathic alterations and irritative signs. In the muscle biopsy, a vacuolar myopathy with increased collagen deposits was found. Circulating lymphocytes presented abnormal PAS positive granules in their cytoplasm.

Chronic dacryosialadenitis in HTLV I associated myelopathy.

A prospective study was carried out on 48 patients with HTLV I associated myelopathy/tropical spastic paraparesis (HAM/TSP) to assess the association between this entity and Sjögren's syndrome. Fourteen patients (29.1%) had chronic dacryosialadenitis confirmed by a positive Schirmer's test and salivary gland biopsy. None of these patients had evidence of collagen disease and tests for Ro, La, and rheumatoid factor were negative except in one case. Therefore, the dacryosialadenitis could not be classified as either primary or secondary Sjögren's syndrome. Ten of the 14 patients (71.4%) had other systems (haematological, articular, dermatological, or respiratory) involved apart from the neurological and exocrine gland pathology. The findings suggest that the dacryosialadenitis associated with HTLV I is a disease of viral origin distinct from Sjögren's syndrome.