Bertelsmann, F.W.

Bouter, L.M.

Dekrom, M.C.T.F.

Scholten, R.J.P.M.

Scholten, R. J.

de Krom, M. C.

Bertelsmann, F. W.

Bouter, L. M.

NARCIS 

Variation in the treatment of carpal tunnel syndrome

VU Research Portal

VU Research PortalVariation in the treatment of carpal tunnel syndromeScholten, R.J.P.M.; Dekrom, M.C.T.F.; Bertelsmann, F.W.; Bouter, L.M.published inMuscle and Nerve1997DOI (link to publisher)10.1002/(SICI)1097-4598(199710)20:10<1334::AID-MUS25>3.0.CO;2-1document versionPublisher's PDF, also known as Version of recordLink to publication in VU Research Portalcitation for published version (APA)Scholten, R. J. P. M., Dekrom, M. C. T. F., Bertelsmann, F. W., & Bouter, L. M. (1997). Variation in the treatmentof carpal tunnel syndrome. Muscle and Nerve, 20(10), 1334-1335. https://doi.org/10.1002/(SICI)1097-4598(199710)20:10<1334::AID-MUS25>3.0.CO;2-1General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            • Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying the publication in the public portal ?Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.E-mail address:vuresearchportal.ub@vu.nlDownload date: 13. Dec. 2021rable to that obtained using the microneurographic tech-nique.4,6,9 Being less affected by the conduction time ofthe afferent somatosensory fiber and by central process-ing, SuCV may be a useful parameter with which to evalu-ate efferent sudomotor function. Denišlič et al., however,noted that it is not based on the activity of the same un-myelinated axons and sweat glands.1 Elie et al., who triedto determine SuCV in the lower extremities of normalsubjects, failed to obtain SSRs at the proximal site (innerside of the thigh) in 13 of 30 subjects.4 Further study isneeded to determine the meaning of the decrease inSuCV.The SSR amplitude varies greatly even in normal sub-jects; therefore, some authors have suggested that ampli-tude is an unreliable parameter for SSR,3,9 but others havereported the SSR amplitude is important clinically.8,10 Weagree with the opinion expressed by Denišlič et al. that thepresence or absence of SSR is only one aspect of the over-all considerations. The problem of variability may be coun-tered, to some extent, by using an amplitude parameterwith reproducibility. Although all SSR amplitude param-eters in our study showed considerable inter- and intrasub-ject variability, the maximum amplitude gave the best re-sults in terms of reproducibility (Fig. 1). High intersubjectvariability, shown as a large standard deviation (SD) valueor coefficient of variation across subjects (CVAS), makes itdifficult to set a normative range of SSR amplitudes. Forexample, we found that the mean maximum amplitude (n= 35) minus 2 SD gives a value below 0 mV. We think adefinition of normative range based on percentile wouldbe practical. The log transformation also is used to achievenormality.5Latency showed less variation than the SSR amplitude.In our study the mean value (n = 35) of the mean laten-cies of 20 SSRs in each subject was 7.1% of the CVAS,which corresponds to the value for minimum F latency(6.1%, median nerve and 7.0%, tibial nerve)7 obtainedfor 45 normal subjects. In terms of the other reportedSSR latency CVAS (4.7% to 12.9%),4,6,8,9 our 7.1% isan intermediate value. If the normative range is definedas the mean ± 2.5 SD (range 1.16–1.66 s), only onemeasurement in the 82 total test sessions, including thefollow-up examination (n = 35), would be beyond thisrange.Minoru Toyokura, MDKeiichi Murakami, MDDepartment of Rehabilitation MedicineTokai University School of MedicineBoseidai, Isehara,Kanagawa 259-11, Japan1. Denišlič M, Trontelj JV: Autonomic function in HMSN: evi-dence of slowed sudomotor conduction? Muscle Nerve 1993;16:114–115.2. Denišlič M, Meh D: Neurophysiological assessment of periph-eral neuropathy in primary Sjögren’s syndrome. Clin Invest1994;72:822–829.3. Dettmers C, Fatepour D, Faust H, Jerusalem F: Sympatheticskin response abnormalities in amyotrophic lateral sclerosis.Muscle Nerve 1993;16:930–934.4. Elie B, Guiheneuc P: Sympathetic skin response: normal re-sults in different experimental conditions. ElectroencephalogrClin Neurophysiol 1990;76:258–267.5. Levy DM, Reid G, Rowley DA, Abraham RR: Quantitative mea-sures of sympathetic skin response in diabetes: relation tosudomotor and neurological function. J Neurol Neurosurg Psy-chiatry 1992;55:902–908.6. Shahani BT, Halperin JJ, Boulu P, Cohen J: Sympathetic skinresponse: a method of assessing unmyelinated axon dysfunc-tion in peripheral neuropathies. J Neurol Neurosurg Psychiatry1984;47:536–542.7. Toyokura M, Saitoh E, Tanaka H, Ishida A, Kotoku H, Mu-rakami K: Various parameters of F-response: normal value (inJapanese). Jpn J Rehabil Med 1989;26:43–49.8. Tzeng S, Wu Z, Chu F: The latencies of sympathetic skinresponses. Eur Neurol 1993;33:65–68.9. Uncini A, Pullman SL, Lovelace RE, Gambi D: The sympa-thetic skin response: normal values, elucidation of afferentcomponents and application limits. J Neurol Sci 1988;87:299–306.10. Watahiki Y, Baba M, Matsunaga M, Takebe K, Onuma T: Sym-pathetic skin response in diabetic neuropathy. ElectromyogrClin Neurophysiol 1989;29:155–159.– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –VARIATION IN THE TREATMENT OFCARPAL TUNNEL SYNDROMECarpal tunnel syndrome (CTS) is a common disorder, es-pecially among female adults.1 No consensus exists withrespect to the treatment of choice of CTS. Some physiciansprefer early surgery in electrophysiologically confirmedCTS cases without an underlying reversible disorder,4 butothers refer to the potential complications of surgery andsupport conservative therapy as the first treatment optionof CTS.2In order to assess the current practice of neurologistsin The Netherlands regarding the treatment of CTS, aquestionnaire was sent to each of 134 Dutch neurologicalpractices. The questionnaire included queries regardingthe preferred initial treatment, the annual frequency ofthe responders’ application of various treatment modali-ties (never versus ever), and the responders’ opinion ofthe acceptability of early surgery as the first treatment op-tion of CTS.The questionnaire was returned by 92 (69%) represen-tatives of the 134 neurological practices. Early surgery wasindicated as the preferred initial treatment of a CTS pa-tient by 36 neurologists (39%), whereas 37 neurologists(40%) preferred conservative treatment. The remaining19 responders (21%) reported either surgery or conserva-tive therapy as the preferred initial treatment (Table 1).Regarding the annual frequency of the responders’ appli-cation of various treatment modalities (data not shown),wrist splinting (76%) and referral for surgery (88%) werethe most frequently mentioned CTS treatments. Local cor-ticosteroid injections, systemic corticosteroid therapy, an-algesics, physiotherapy, and pyridoxine were mentionedby 20 (22%), 2 (2%), 21 (23%), 6 (7%), and 1 (1%)responders, respectively. For only 4 neurologists (4%),early surgery was not acceptable.We conclude that both in the medical literature2,4 and1334 Letters to the Editor MUSCLE & NERVE October 1997in a relatively small country like The Netherlands there isno consensus regarding the optimal treatment of CTS.This might be due to the lack of scientific evidence of theefficacy of the various treatment modalities for CTS.3 Todate, the medical literature does not support the selectionof either early surgery or conservative management as thetreatment of choice for CTS. Conservative managementseems to be attractive because it is easily applicable and notvery demanding. However, recovery might occur morequickly after early surgery, resulting in a shorter durationof the disease.Therefore, properly designed randomized clinical tri-als comparing the efficacy of early surgery with conserva-tive management (e.g., immobilization of the wrist bysplinting) with a sufficient number of patients and relevantoutcome measures are urgently needed to enable the se-lection of the best treatment option for patients with car-pal tunnel syndrome.Rob J.P.M. Scholten, MD, PhDInstitute for Research in Extramural Medicine, VrijeUniversiteit, Van der Boechorststraat 7, 1081 BTAmsterdam, The NetherlandsMarc C.T.F.M. de Krom, MD, PhDDepartment of Neurology, Maastricht UniversityHospital, Maastricht, The NetherlandsFrits W. Bertelsmann, MD, PhDDepartment of Neurology, Academic Hospital ofthe Free University, Amsterdam, The NetherlandsLex M. Bouter, PhDDepartment of Epidemiology and Biostatistics,Vrije Universiteit, Amsterdam, The Netherlands1. de Krom MC, Knipschild PG, Kester AD, Thijs CT, BoekkooiPF, Spaans F: Carpal tunnel syndrome: prevalence in the gen-eral population. J Clin Epidemiol 1992;45:373–376.2. Johnson EW: Should immediate surgery be done for carpaltunnel syndrome?—No [letter]. Muscle Nerve 1995;18:658–659.3. Eisen AA: Editorial comment. Muscle Nerve 1995;18:663.4. Wilson JR, Sumner AJ: Immediate surgery is the treatment ofchoice for carpal tunnel syndrome [letter]. Muscle Nerve 1995;18:660–662.– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –SELECTIVE BILATERAL AMYOTROPHYOF THE ANTERIOR TIBIAL MUSCLE: ACASE REPORTNumerous instances of unilateral muscular atrophy involv-ing only a single muscle in either the upper or lower limbhave been reported in Japan,6–9 and less frequently in thewestern countries.1,2,4,5 Most of these conditions involvemuscle wasting of neurogenic origin. Here we describe amale patient, aged 22, with a selective amyotrophy affect-ing only the anterior tibial muscle in both legs.The patient was in good health until age 19, when hestarted experiencing difficulties in flexing his feet. Thepatient was brought to our attention at age 21. Examina-tion showed marked bilateral wasting of the tibialis ante-rior muscle. Dorsiflexion of the feet was not possible.Muscle strength was normal in all other muscles exam-ined. Electromyogram (EMG) of the anterior tibial muscleshowed bilateral changes with positive potentials and fi-brillations. During maximal voluntary effort, only a singlemotor unit discharge per insertion could be recorded. F-wave latency recorded from extensor digitorum brevis bystimulating the deep peroneal nerve was normal. All othermuscles were normal by EMG. A muscle computed tomog-raphy (CT) scan showed hypodensity of the anterior tibialmuscles (Fig. 1B). By magnetic resonance imaging (MRI),the spinal cord was shown to be of normal diameterthroughout. The muscle CT scan was normal for both par-ents. A skeletal muscle biopsy was obtained from the righttibialis anterior muscle. Light microscopy showed a mark-edly increased variation in fiber size. Interstitial connectivetissue was increased (Fig. 1A). Some atrophic muscle fibersshowed clusters of nuclei. Adenosine triphosphatase reac-tion was uniform under all conditions. We believe that thiscase can be classified with previously reported instances ofselective muscle amyotrophy. To date no isolated cases inwhich only the anterior tibial muscle was affected in bothlimbs have been described. Similar cases previously de-scribed all significantly differ from the present case. Mostof the similar cases reported in the literature are con-cerned with monomelic amyotrophy.1,2,4–9 Some authorshave described segmental atrophy of the spinal cord usingmyelography and postmyelographic CT.10 We performedan MRI of the spinal cord in our patient, but could notdemonstrate a segmental spinal cord atrophy. A clinicalcase similar to our patient’s, but involving the bilateralquadriceps femoris, was reported in 2 patients by Fu-rukawa et al.3 and Serratrice et al.12 A familial form ofsymmetrical anterior tibial muscular dystrophy has beendescribed in Finland by Udd et al.13 The lack of dystrophicchange and the normal muscle CT scan in the parents ofTable 1. Preferred initial treatment of patients with carpaltunnel syndrome according to 92 representatives of Dutchneurologic practices.TreatmentmodalityNo. ofresponders(%)Surgery 36 (39.1%)Conservative management 37 (40.2%)Wrist splinting 24 (26.1%)Corticosteroid injection intothe carpal canal 4 (4.3%)Splinting and/orcorticosteroid injection 3 (3.3%)Splinting and/or analgesics 3 (3.3%)Splinting and/or systemiccorticosteroids 1 (1.1%)Systemic corticosteroids 1 (1.1%)Pyridoxine (vitamin B6) 1 (1.1%)Either surgery or conservative management 19 (20.7%)Surgery or wrist splinting 13 (14.1%)Surgery or another conservativetreatment 6 (6.5%)Percentage of total between brackets.Letters to the Editor MUSCLE & NERVE October 1997 1335

English

DSpace at VU

rable to that obtained using the microneurographic tech-
nique.4,6,9 Being less affected by the conduction time of
the afferent somatosensory fiber and by central process-
ing, SuCV may be a useful parameter with which to evalu-
ate efferent sudomotor function. Denisˇlicˇ et al., however,
noted that it is not based on the activity of the same un-
myelinated axons and sweat glands.1 Elie et al., who tried
to determine SuCV in the lower extremities of normal
subjects, failed to obtain SSRs at the proximal site (inner
side of the thigh) in 13 of 30 subjects.4 Further study is
needed to determine the meaning of the decrease in
SuCV.
The SSR amplitude varies greatly even in normal sub-
jects; therefore, some authors have suggested that ampli-
tude is an unreliable parameter for SSR,3,9 but others have
reported the SSR amplitude is important clinically.8,10 We
agree with the opinion expressed by Denisˇlicˇ et al. that the
presence or absence of SSR is only one aspect of the over-
all considerations. The problem of variability may be coun-
tered, to some extent, by using an amplitude parameter
with reproducibility. Although all SSR amplitude param-
eters in our study showed considerable inter- and intrasub-
ject variability, the maximum amplitude gave the best re-
sults in terms of reproducibility (Fig. 1). High intersubject
variability, shown as a large standard deviation (SD) value
or coefficient of variation across subjects (CVAS), makes it
difficult to set a normative range of SSR amplitudes. For
example, we found that the mean maximum amplitude (n
= 35) minus 2 SD gives a value below 0 mV. We think a
definition of normative range based on percentile would
be practical. The log transformation also is used to achieve
normality.5
Latency showed less variation than the SSR amplitude.
In our study the mean value (n = 35) of the mean laten-
cies of 20 SSRs in each subject was 7.1% of the CVAS,
which corresponds to the value for minimum F latency
(6.1%, median nerve and 7.0%, tibial nerve)7 obtained
for 45 normal subjects. In terms of the other reported
SSR latency CVAS (4.7% to 12.9%),4,6,8,9 our 7.1% is
an intermediate value. If the normative range is defined
as the mean ± 2.5 SD (range 1.16–1.66 s), only one
measurement in the 82 total test sessions, including the
follow-up examination (n = 35), would be beyond this
range.
Minoru Toyokura, MD
Keiichi Murakami, MD
Department of Rehabilitation Medicine
Tokai University School of Medicine
Boseidai, Isehara,
Kanagawa 259-11, Japan
1. Denisˇlicˇ M, Trontelj JV: Autonomic function in HMSN: evi-
dence of slowed sudomotor conduction? Muscle Nerve 1993;
16:114–115.
2. Denisˇlicˇ M, Meh D: Neurophysiological assessment of periph-
eral neuropathy in primary Sjo¨gren’s syndrome. Clin Invest
1994;72:822–829.
3. Dettmers C, Fatepour D, Faust H, Jerusalem F: Sympathetic
skin response abnormalities in amyotrophic lateral sclerosis.
Muscle Nerve 1993;16:930–934.
4. Elie B, Guiheneuc P: Sympathetic skin response: normal re-
sults in different experimental conditions. Electroencephalogr
Clin Neurophysiol 1990;76:258–267.
5. Levy DM, Reid G, Rowley DA, Abraham RR: Quantitative mea-
sures of sympathetic skin response in diabetes: relation to
sudomotor and neurological function. J Neurol Neurosurg Psy-
chiatry 1992;55:902–908.
6. Shahani BT, Halperin JJ, Boulu P, Cohen J: Sympathetic skin
response: a method of assessing unmyelinated axon dysfunc-
tion in peripheral neuropathies. J Neurol Neurosurg Psychiatry
1984;47:536–542.
7. Toyokura M, Saitoh E, Tanaka H, Ishida A, Kotoku H, Mu-
rakami K: Various parameters of F-response: normal value (in
Japanese). Jpn J Rehabil Med 1989;26:43–49.
8. Tzeng S, Wu Z, Chu F: The latencies of sympathetic skin
responses. Eur Neurol 1993;33:65–68.
9. Uncini A, Pullman SL, Lovelace RE, Gambi D: The sympa-
thetic skin response: normal values, elucidation of afferent
components and application limits. J Neurol Sci 1988;87:
299–306.
10. Watahiki Y, Baba M, Matsunaga M, Takebe K, Onuma T: Sym-
pathetic skin response in diabetic neuropathy. Electromyogr
Clin Neurophysiol 1989;29:155–159.
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
VARIATION IN THE TREATMENT OF
CARPAL TUNNEL SYNDROME
Carpal tunnel syndrome (CTS) is a common disorder, es-
pecially among female adults.1 No consensus exists with
respect to the treatment of choice of CTS. Some physicians
prefer early surgery in electrophysiologically confirmed
CTS cases without an underlying reversible disorder,4 but
others refer to the potential complications of surgery and
support conservative therapy as the first treatment option
of CTS.2
In order to assess the current practice of neurologists
in The Netherlands regarding the treatment of CTS, a
questionnaire was sent to each of 134 Dutch neurological
practices. The questionnaire included queries regarding
the preferred initial treatment, the annual frequency of
the responders’ application of various treatment modali-
ties (never versus ever), and the responders’ opinion of
the acceptability of early surgery as the first treatment op-
tion of CTS.
The questionnaire was returned by 92 (69%) represen-
tatives of the 134 neurological practices. Early surgery was
indicated as the preferred initial treatment of a CTS pa-
tient by 36 neurologists (39%), whereas 37 neurologists
(40%) preferred conservative treatment. The remaining
19 responders (21%) reported either surgery or conserva-
tive therapy as the preferred initial treatment (Table 1).
Regarding the annual frequency of the responders’ appli-
cation of various treatment modalities (data not shown),
wrist splinting (76%) and referral for surgery (88%) were
the most frequently mentioned CTS treatments. Local cor-
ticosteroid injections, systemic corticosteroid therapy, an-
algesics, physiotherapy, and pyridoxine were mentioned
by 20 (22%), 2 (2%), 21 (23%), 6 (7%), and 1 (1%)
responders, respectively. For only 4 neurologists (4%),
early surgery was not acceptable.
We conclude that both in the medical literature2,4 and
1334 Letters to the Editor MUSCLE & NERVE October 1997
in a relatively small country like The Netherlands there is
no consensus regarding the optimal treatment of CTS.
This might be due to the lack of scientific evidence of the
efficacy of the various treatment modalities for CTS.3 To
date, the medical literature does not support the selection
of either early surgery or conservative management as the
treatment of choice for CTS. Conservative management
seems to be attractive because it is easily applicable and not
very demanding. However, recovery might occur more
quickly after early surgery, resulting in a shorter duration
of the disease.
Therefore, properly designed randomized clinical tri-
als comparing the efficacy of early surgery with conserva-
tive management (e.g., immobilization of the wrist by
splinting) with a sufficient number of patients and relevant
outcome measures are urgently needed to enable the se-
lection of the best treatment option for patients with car-
pal tunnel syndrome.
Rob J.P.M. Scholten, MD, PhD
Institute for Research in Extramural Medicine, Vrije
Universiteit, Van der Boechorststraat 7, 1081 BT
Amsterdam, The Netherlands
Marc C.T.F.M. de Krom, MD, PhD
Department of Neurology, Maastricht University
Hospital, Maastricht, The Netherlands
Frits W. Bertelsmann, MD, PhD
Department of Neurology, Academic Hospital of
the Free University, Amsterdam, The Netherlands
Lex M. Bouter, PhD
Department of Epidemiology and Biostatistics,
Vrije Universiteit, Amsterdam, The Netherlands
1. de Krom MC, Knipschild PG, Kester AD, Thijs CT, Boekkooi
PF, Spaans F: Carpal tunnel syndrome: prevalence in the gen-
eral population. J Clin Epidemiol 1992;45:373–376.
2. Johnson EW: Should immediate surgery be done for carpal
tunnel syndrome?—No [letter]. Muscle Nerve 1995;18:
658–659.
3. Eisen AA: Editorial comment. Muscle Nerve 1995;18:663.
4. Wilson JR, Sumner AJ: Immediate surgery is the treatment of
choice for carpal tunnel syndrome [letter]. Muscle Nerve 1995;
18:660–662.
– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –
SELECTIVE BILATERAL AMYOTROPHY
OF THE ANTERIOR TIBIAL MUSCLE: A
CASE REPORT
Numerous instances of unilateral muscular atrophy involv-
ing only a single muscle in either the upper or lower limb
have been reported in Japan,6–9 and less frequently in the
western countries.1,2,4,5 Most of these conditions involve
muscle wasting of neurogenic origin. Here we describe a
male patient, aged 22, with a selective amyotrophy affect-
ing only the anterior tibial muscle in both legs.
The patient was in good health until age 19, when he
started experiencing difficulties in flexing his feet. The
patient was brought to our attention at age 21. Examina-
tion showed marked bilateral wasting of the tibialis ante-
rior muscle. Dorsiflexion of the feet was not possible.
Muscle strength was normal in all other muscles exam-
ined. Electromyogram (EMG) of the anterior tibial muscle
showed bilateral changes with positive potentials and fi-
brillations. During maximal voluntary effort, only a single
motor unit discharge per insertion could be recorded. F-
wave latency recorded from extensor digitorum brevis by
stimulating the deep peroneal nerve was normal. All other
muscles were normal by EMG. A muscle computed tomog-
raphy (CT) scan showed hypodensity of the anterior tibial
muscles (Fig. 1B). By magnetic resonance imaging (MRI),
the spinal cord was shown to be of normal diameter
throughout. The muscle CT scan was normal for both par-
ents. A skeletal muscle biopsy was obtained from the right
tibialis anterior muscle. Light microscopy showed a mark-
edly increased variation in fiber size. Interstitial connective
tissue was increased (Fig. 1A). Some atrophic muscle fibers
showed clusters of nuclei. Adenosine triphosphatase reac-
tion was uniform under all conditions. We believe that this
case can be classified with previously reported instances of
selective muscle amyotrophy. To date no isolated cases in
which only the anterior tibial muscle was affected in both
limbs have been described. Similar cases previously de-
scribed all significantly differ from the present case. Most
of the similar cases reported in the literature are con-
cerned with monomelic amyotrophy.1,2,4–9 Some authors
have described segmental atrophy of the spinal cord using
myelography and postmyelographic CT.10 We performed
an MRI of the spinal cord in our patient, but could not
demonstrate a segmental spinal cord atrophy. A clinical
case similar to our patient’s, but involving the bilateral
quadriceps femoris, was reported in 2 patients by Fu-
rukawa et al.3 and Serratrice et al.12 A familial form of
symmetrical anterior tibial muscular dystrophy has been
described in Finland by Udd et al.13 The lack of dystrophic
change and the normal muscle CT scan in the parents of
Table 1. Preferred initial treatment of patients with carpal
tunnel syndrome according to 92 representatives of Dutch
neurologic practices.
Treatment
modality
No. of
responders
(%)
Surgery 36 (39.1%)
Conservative management 37 (40.2%)
Wrist splinting 24 (26.1%)
Corticosteroid injection into
the carpal canal 4 (4.3%)
Splinting and/or
corticosteroid injection 3 (3.3%)
Splinting and/or analgesics 3 (3.3%)
Splinting and/or systemic
corticosteroids 1 (1.1%)
Systemic corticosteroids 1 (1.1%)
Pyridoxine (vitamin B6) 1 (1.1%)
Either surgery or conservative management 19 (20.7%)
Surgery or wrist splinting 13 (14.1%)
Surgery or another conservative
treatment 6 (6.5%)
Percentage of total between brackets.
Letters to the Editor MUSCLE & NERVE October 1997 1335


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Variation in the treatment of carpal tunnel syndrome

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