Progesterone - new therapy in mild carpal tunnel syndrome? Study design of a randomized clinical trial for local therapy

Abstract BACKGROUND: Local corticosteroid injection for carpal tunnel syndrome (CTS) provides greater clinical improvement in symptoms one month after injection compared to placebo but significant symptom relief beyond one month has not been demonstrated and the relapse of symptoms is possible.Neuroprotection and myelin repair actions of the progesterone was demonstrated in vivo and in vitro study.We report the design of a randomized controlled trial for the local injection of cortisone versus progesterone in "mild" idiopathic CTS. METHODS: Sixty women with age between 18 and 60 years affected by "mild" idiopathic CTS, diagnosed on the basis of clinical and electrodiagnostic tests, will be enrolled in one centre. The clinical, electrophysiological and ultasonographic findings of the patients will be evaluate at baseline, 1, 6 and 12 months after injection.The major outcome of this study is to determine whether locally-injected progesterone may be more beneficial than cortisone in CTS at clinical levels, tested with symptoms severity self-administered Boston Questionnaire and with visual analogue pain scale.Secondary outcome measures are: duration of experimental therapy; improvement of electrodiagnostic and ultrasonographic anomalies at various follow-up; comparison of the beneficial and harmful effects of the cortisone versus progesterone. CONCLUSION: We have designed a randomized controlled study to show the clinical effectiveness of local progesterone in the most frequent human focal peripheral mononeuropathy and to demonstrate the neuroprotective effects of the progesterone at the level of the peripheral nervous system in humans

Reappraisal of the F/M amplitude ratio in carpal tunnel syndrome

The F-wave/M-wave amplitude (F/M-amp) ratio has been shown to be increased in peripheral neuropathies, provided the maximum M-wave is relatively preserved. Reduced M-wave amplitudes and central facilitation of antidromically-induced reactivation of the anterior horn cells’ axon hillocks (F-wave) are believed to contribute to higher F/M-amp ratios. The present study was undertaken to re-evaluate mechanisms responsible for higher F/M-amp ratios in carpal tunnel syndrome (CTS). We enrolled 232 cases affected by CTS and 108 controls. F-and M-wave amplitudes and F-wave chronodispersion were analyzed for the median and ulnar nerves. The F/M-amp ratio of the median nerve in CTS subjects with moderate-severe nerve damage was significantly higher than that of mild CTS subjects and controls. Chronodispersion of the median nerve F-wave increased with increasing CTS severity. We conclude that the relative preservation of the median nerve F-wave is due to damage to the large diameter muscle afferent fibers responsible for the monosynaptic response. Absence of the monosynaptic response makes the small motoneurons, usually inaccessible to the antidromic volley because of its collision with the orthodromic reflex volley, able to fire in the F-wave

O8D.8 Severity of carpal tunnel syndrome and manual work: findings from a case-control study

ObjectiveCarpal tunnel syndrome (CTS) is a socially relevant condition. This case-control study aims to investigate the association between CTS severity and manual work considering personal anthropometric risk factors as well.MethodsWe consecutively enrolled one CTS case for two controls (subjects without clinical and electrophysiological CTS signs) regardless of age and gender who were admitted to the same three outpatient electromyography labs.CTS cases were grouped in three classes of progressive clinical and electrophysiological severity according to two validated five-stage scales. Anthropometric measures and occupational history were collected. Job titles were coded according to the International Standard Classification of Occupations (ISCO 88) by two occupational physicians who were blind to case/control status. Job titles were grouped in two main occupational categories: manual workers and non-manual workers.To assess the association between CTS severity and manual work, ordered logistic regression models (adjusted for age, sex, wrist-palm ratio and waist-stature ratio) were performed. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.ResultsThis case-control study enrolled 370 cases and 747 controls. After the exclusion of retired subjects, subjects older than 65 years and subjects with no information about occupational history, we included 183 cases and 445 controls in the main analysis.For manual workers with respect to non-manual workers, the OR for the electrophysiological severity scale was 2.4 (95%CI 1.5–3.7). Regarding the clinical severity scale, the OR for manual workers compared to non-manual workers were 2.3 (95%CI 1.5–3.7).ConclusionThis study confirms that manual work is an important risk factor for CTS. The association between manual work and CTS severity tends to increase from mild to severe stage of both electrophysiological and clinical scale

Diagnostic Accuracy of Sensory Clinical Findings of the Hand Dorsum and of Neurography of the Dorsal Ulnar Cutaneous Nerve in Ulnar Neuropathy at the Elbow

Objective: The main objective is to investigate the diagnostic accuracy and the relation of touch sensation and subjective sensory symptoms in the medial aspect of the hand dorsum, and neurography of the dorsal ulnar cutaneous nerve (DUCN) in ulnar neuropathy at the elbow (UNE). Secondary objective is to report the electrophysiological occurrence of anatomical variant of sensory innervation of the medial aspect of the hand dorsum from superficial radial nerve (SRN). Design: Prospective, cohort study. Setting: Electromyography laboratory. Participants: Consecutive participants (N=282), those with UNE (n=81) and those without UNE (n=201), were enrolled. Interventions: Not applicable. Main Outcome Measures: Accuracy and agreement between sensory clinical findings of the medial hand dorsum and neurography of DUCN in UNE diagnosis. Results: DUCN neurographic and sensory findings had high specificity and relatively low sensitivity. Normal or abnormal sensory nerve action potential (SNAP) of DUCN matched with normal or abnormal touch sensation of the medial aspect of hand dorsum. Abnormal DUCN SNAP was related to the clinical severity of UNE and to the axonal damage of the ulnar nerve. Anatomical variant of the innervation of hand dorsum from SRN was demonstrated in 31 of 564 hands (6.2%) belonging to 26 of 282 participants (9.2%). If the variant was present, DUCN SNAP of the same side was more frequently absent or of low amplitude. Conclusions: The utility of DUCN neurography and sensory findings of the medial aspect of the dorsum of the hand is limited in the diagnosis of UNE. However, if DUCN SNAP is absent or low in amplitude, it is advisable to check the presence of the anatomical variant of the innervation of the medial aspect of the hand dorsum from SRN

Relations between sensory symptoms, touch sensation, and sensory neurography in the assessment of the ulnar neuropathy at the elbow.

Objectives: To evaluate sensitivity, specificity and predictive values of sensory findings in ulnar neuropathy at the elbow (UNE), differences according to UNE localization and pathophysiology, and relation between the sites of sensory symptoms, abnormal evaluation of sensation and neurographic findings of ulnar sensory nerve. Methods: Hand diagram and Semmes-Weinstein monofilaments were used for clinical evaluation in four ulnar hand territories. Sensory neurography was measured in the fourth and fifth digits-wrist segments (U5) and in the dorsal ulnar cutaneous nerve. Results: We enrolled 75 idiopathic UNE cases and 180 controls. Symptoms in the fifth digit, reduction of touch sensation and U5 sensory nerve action potential amplitude (SNAPa) had the highest sensitivity, specificity and predictivity in UNE diagnosis. The normal/abnormal sensory clinical findings of the fifth digit matched with normal/abnormal U5 SNAP more than the matching of sensory parameters in the other ulnar hand sites. Sensory anomalies were more frequent in predominantly axonal than demyelinating UNE. There were no differences according to UNE location. Conclusion: Sensory anomalies of the fifth digit are constant findings in UNE more than anomalies of the other ulnar nerve hand regions. Significance: Probably the fascicles from fifth digit are the most liable to damage at elbow. © 2018 International Federation of Clinical Neurophysiolog

Knowledge of electromyography (EMG) in patients undergoing EMG examinations

The aim of this study was to evaluate knowledge of electromyography (EMG) in patients undergoing the procedure. In one year, 1,586 consecutive patients (mean age 56 years; 58.8% women) were admitted to two EMG labs to undergo EMG for the first time. The patients found to be “informed” about the how an EMG examination is performed and about the purpose of EMG numbered 448 (28.2%), while those found to be “informed” only about the manner of its execution or only about its purpose numbered 161 (10.2%) and 151 (9.5%), respectively. The remaining 826 (52.1%) patients had either no information, or the information they had was very poor or incorrect (this was particularly true if they had been consulting websites). Being “informed” was associated with level of education (high), type of referring physician (specialist) and with an appropriate referral diagnosis specified in the EMG request. The quality of patient information on EMG was found to be very poor and could be improved. Physicians referring patients for EMG examinations, especially general practitioners, should assume primary responsibility for patient education and counseling in this field

SENSORY NEUROPATHY MAY CAUSE CENTRAL NEURONAL REORGANIZATION BUT DOES NOT RESPECIFY PERCEPTUAL QUALITY OR LOCALIZATION OF SENSATION

3Abstract OBJECTIVES: Functional reorganization in the somatosensory network after peripheral nerve lesions has been suspected to modify the clinical expression of symptoms. However, no conclusive evidence exists to support this notion. We addressed this question by investigating the topographic distribution of the subjective sensory report in various chronic human mononeuropathies. METHODS: We report the clinical results of 86 patients who were diagnosed with meralgia paresthetica, 86 patients with ulnar neuropathy at the elbow, and 203 patients with carpal tunnel syndrome. RESULTS: In the carpal tunnel syndrome group, 10% of the patients exhibited a spread of sensory symptoms beyond the innervation territory of the median nerve. As previously reported, this spread was contingent upon an indirect compressive lesion of the ulnar nerve at the wrist. In all of the patients who were affected with meralgia paresthetica or ulnar neuropathy at the elbow, the peripheral referral of sensation was always within the anatomic distribution of the affected nerve. DISCUSSION: In human neuropathies, the projected sensory symptoms are restricted to the innervation territories of the affected nerves, with no extraterritorial spread. Thus, the somatosensory localization function remains accurate, despite the central reorganization that presumably occurs after nerve injury. We conclude that reorganization of the sensory connections within the central nervous system after peripheral nerve injury in humans is a clinically silent adaptive phenomenon. PMID: 22699137 [PubMed - indexed for MEDLINE]nonemixedGINANNESCHI F; MONDELLI M; ROSSI AGinanneschi, Federica; Mondelli, M; Rossi, Alessandr

Impact of carpal tunnel syndrome on ulnar nerve at wrist: Systematic review.

Considerable debate exists in the literature about possible anomalies of ulnar nerve at wrist in carpal tunnel syndrome (CTS). We systematically reviewed the literature about electrophysiologic and morphologic changes of ulnar nerve at wrist in CTS. We carried out a comprehensive search using PubMed from 1963 through October 2017. Data were extracted and the quality of the included studies was evaluated. Twenty-eight studies were selected. Seventy-nine percent of the studies report abnormalities of the ulnar nerve conduction. There was a relation between the median and ulnar nerve conduction in almost all the papers, i.e., conduction impairment of the ulnar nerve increased with increasing severity of median nerve involvement, emerging as a process correlated with damage of the median nerve. Seventy-five percent of ultrasonographic studies report changes of ulnar nerve cross sectional area in CTS. Morphologic and functional changes of the ulnar nerve and/or Guyon canal are reported by 100% of papers addressed to this topic. Several papers quoted in this review have some flaws. The key message of present review is that electrophysiological and morphological changes of the ulnar nerve at the wrist can occur in CTS, although the possibility of an overestimation of the phenomenon needs to be considered

PATHOPHYSIOLOGY OF THE KNEE JERK REFLEX ABNORMALITIES IN L5 ROOT INJURY

Although the knee jerk reflex is mediated by the L3 and L4 nerve roots, evidence exists that altered knee jerk expression may occur with exclusively L5 radiculopathy. The present study set out to identify the factors responsible for knee jerk reflex abnormalities in L5 monoradiculopathy. We analyzed clinical and electrophysiological data in 56 subjects affected by L5 monoradiculopathy. Seventeen patients (30.3%) showed an abnormal knee reflex. L5 patients with an abnormal knee reflex differed significantly, in severity of pretibial muscle damage, from those with a normal knee reflex. On the basis of evidence, in humans, of a specific spinal pathway linking the pretibial and quadriceps muscles, we infer that an impairment of the proprioceptive drive from the pretibial muscles to spinal premotor excitatory interneurons contacting quadriceps motor neurons is the main causative factor responsible for reducing knee jerk expression. This mechanism should be considered to avoid misinterpretation of knee jerk reflex changes in lumbar radiculopathie