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Sensitization of the Proximal Median Nerve in Carpal Tunnel Syndrome: Do Proximal Nerve Physical Exam Findings Resolve After Single Site of Release? A prospective clinical trial
Lazaro Mesa, MD
1, Sameer Puri, MD
2, Kathryn M. Peck, M.D.
2, Nicholas Crosby, MD
3, Gregory A Merrell, MD
2; Brandon S. Smetana, MD
2(1)Indiana Hand to Shoulder Center, indianapolis, IN, (2)Indiana Hand to Shoulder Center, Indianapolis, IN, (3)Hand Surgery, Indiana Hand to Shoulder Center, Indianapolis, IN
Purpose:
The purpose of this study is to determine whether patients with carpal tunnel syndrome and exam findings consistent with secondary nerve sensitivity at the proximal forearm improve clinically after isolated carpal tunnel release.
Materials & Methods:
We performed a single center prospective non-randomized study. Inclusion criteria: patients undergoing isolated carpal tunnel release, >18 years of age, and electrodiagnostic studies consistent with CTS but without other electrodiagnostic concerns. Patients were then examined on day of surgery for proximal nerve findings using a standardized physical examination. Patients with ? 2 exam proximal findings were followed longitudinally. Clinical and PROM data were collected at 6 weeks by same physician who enrolled the patient.
Results:
42 patients met the inclusion criteria and completed the study. 27 patients (64%) demonstrated signs of proximal median nerve sensitivity. These patients were statistically younger (52 vs 65 p=0.01) and more likely to have more severe CTS by PROM (BCTSs 3.24 vs 2.5 p=0.05 and BCTQf 2.63 vs 1.93 p=0.02). After isolated carpal tunnel release Patients improved clinically and by PROM. Average BCTQs improvement of 1.1 (MCID= 0.64) and BCTQf of 0.38 (MCID= 0.23). Preoperatively, patients had an average of 3.4 proximal median nerve exam findings and 0.3 findings postoperatively (p=<.01). Eight patients (30%) had improvement but incomplete proximal median nerve exam findings at 6 weeks. One patient (4%) did not have improvement in physical exam findings postoperatively.
Conclusion
Patients indicated for carpal tunnel release occasionally present with proximal median nerve signs and symptoms. 96% of patients experienced improvement in the proximal exam findings after isolated carpal tunnel release. The presented data supports single site median nerve decompression in select patients with proximal median nerve sensitivity. We term this clinical entity longitudinal nerve sensitivity (LNS). The previously used term "double crush syndrome" classically describes patients with multiple discrete sites of compression often requiring secondary site decompression. This term may more accurately describe patients whose symptoms persist after single site release while LNS describes patients whose secondary symptoms improve after single site release.
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