AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

AAHS Concurrent Scientific Paper Session 2A
The Cause of Carpal Tunnel Syndrome?
Institution where the work was prepared: University of Louisville, School of Public Health and Informatio, Louisville, KY, USA
Steven J. McCabe, MD, MSc1; Vasyl Pihur1; Roberto S. Rosales, MD, PhD2; Isam Atroshi, MD, PhD3; (1)University of Louisville, (2)Unit for Hand and Microsurgery,
(3)Kristianstad Hospital
Introduction:
Carpal Tunnel Syndrome (CTS) is thought to be due to compression of the median nerve in the carpal tunnel. It is known that carpal tunnel pressures are elevated
in wrist postures of flexion and extension and in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling and numbness.
These classic symptoms stimulated our interest in the relationship of sleep to the development of CTS.
Method:
We reviewed the literature surrounding the epidemiology of CTS and the literature regarding sleep disturbances such as insomnia, snoring, sleep apnea, and
sleep paralysis. Through careful distillation of these studies and a process of reasoning, we have developed a hypothesis for the cause of CTS.
Results:
Epidemiologically it has been shown that CTS is associated with age, gender, increased Body Mass Index (BMI), pregnancy, and is more common in some populations
of Americans compared to Japanese. In this report we first present a summary of the literature showing these associations. We then distill the literature
surrounding sleep disturbances with a special interest in sleep position. Interestingly, the same associations noted above for CTS are strongly associated
with sleep disturbances. For example, insomnia is associated with age and gender in a fashion that mimics the association with CTS. Similarly, like CTS, sleep
apnea is associated with age and BMI. By compiling information from a variety of sources on the influences of sleep disturbances on sleep position we come
to the startling but simple conclusion that the cause of CTS is sleeping on the side ie. in a lateral position.
Discussion:
We believe that age, gender, BMI, pregnancy, and certain populations have an association with CTS because they all act through a common causative mechanism,
they cause increased sleeping in a position on the side. We believe this position puts the wrist at increased risk of flexion or extension, compressing the
median nerve in the carpal tunnel. This realization has real clinical significance in that it focuses our attention on the early disorder when it is completely
reversible. Our hypothesis has several strengths. This hypothesis is simple and bundles together a previously unconnected group of epidemiologic associations.
It clarifies previously confused clinical circumstances such as the patient with classic symptoms and negative electrical studies. It creates research questions that
can be tested and it invites us to change our clinical perspective in this most common form of nerve compression.
Comparison of Psychosocial Profile of Patients with Neuropathic Conditions Treated with and without Surgery
Institution where the work was prepared: Hand and Microsurgery Center of El Paso, El Paso, TX, USA
Jose Monsivais, MD; Hand & Microsurgery Center; Kris Robinson, PhD, FNP; University of Texas at El Paso
Purpose:
The purpose of this study is to evaluate the functional results after surgical and non-surgical treatment of entrapment neuropathies and nerve injuries in chronic
pain patients, some who had failed surgical treatment elsewhere.
Methodology/Design:
We conducted an archival review of records from 91 patients treated for neuropathic pain over a ten-year period in a specialty clinic. Inclusion criteria included
individuals with proven nerve dysfunction experiencing pain > 3 months. Diagnosis was established by history, physical examination, electrodiagnostic studies
and imaging. Multiple methods were used to determine sensory and motor function. Surgical candidates were determined by severity of sensory-motor
abnormalities and had no evidence of untreated or uncontrolled depression or other psychological distress. Pain was not used as the sole indicator for any form
of treatment. Surgical procedures included nerve decompressions, reconstruction, neurolysis, and excision of neuromas. Medical treatment included analgesics,
adjuvants, and neuroleptic medications. Both groups received periodic clinical evaluation of sensory and motor function, and assessment of pain. Psychological
reports included psychological diagnosis, results of Oswestry Pain Questionnaire, GAF, and PSS. Statistician conducted analysis which consisted of correlations
and Chi Square using SAS statistical program. Sample size was set by power analysis. Using a correlational approach, a sample size of 85 is required to detect
a medium effect size with alpha set at .05 and power of .80.
Results:
The vast majority of patients returned to work and reported lower levels of pain up to 5 years after onset of nerve injury/ condition. Return to work was determined
by sensory and motor recovery. In addition, no differences were noted between groups on a variety of psychosocial measures after treatment including
pain level (p=.2), litigation status (p>0.5), and return to work (p>0.05). The majority of individuals expected total relief of pain with surgical treatment. Reported
drug and alcohol abuse was lower than that of the general population and did not differ between groups.
Conclusions:
With psychosocial assessment, support, and adequate pain treatment, there seems to be no difference in functional outcomes on several levels between those
patients receiving surgical and non-surgical treatment. Patients' expectations of surgery are unrealistic and must be addressed prior to treatment. Of interest,
prevalence of past history of psychological dysfunction in this group is about twice that of the general population. This signifies that patients with chronic
neuropathic pain are a group with special needs that if met may improve surgical outcomes.
97