Natural evolution of carpal tunnel syndrome in untreated patients

doi:10.1016/j.clinph.2008.02.012

Clinical Neurophysiology

Volume 119, Issue 6, June 2008, Pages 1373-1378

https://doi.org/10.1016/j.clinph.2008.02.012 Get rights and content

Abstract

Objective

To describe the clinical and electrophysiological evolution of a group of patients diagnosed with carpal tunnel syndrome (CTS) who have not undergone any type of treatment (injections, braces or surgery).

Methods

Clinical and electrophysiological monitoring was done consecutively in a series of patients who were admitted with a diagnosis of CTS. The average time for follow-up was 2 years. The Historic and objective Classification scale (HiOb) was used to establish the severity of the disease in the test group, and neuro conductions were done to determine the electrophysiological classification.

Results

A total of 132 patients were monitored. In 31 patients (23.4% of the cases), the HiOb classification deteriorated, 28.8% remained stable, and 47.6% showed recovery. In the nerve conduction studies, 10 cases (7.6%) exhibited electrophysiological deterioration, 67.4% remained constant and 25% improved.

Conclusions

A significant percentage of patients with carpal tunnel syndrome had no change in their clinical and electrophysiological condition, while some improved spontaneously without treatment.

Significance

Given that most patients diagnosed with CTS remain stable or even improve over time, a conservative treatment may be all that is needed in a selection of patients with this disorder.

Introduction

Carpal tunnel syndrome is a clinical condition that is frequently seen in medical evaluations by primary healthcare practitioners (Latinovic et al., 2006). The recommended therapies are substantiated by randomly allocated sample studies that demonstrate the benefits of injections or surgery. It is believed that due to its progressive nature, the disease produces severe sensory alterations and a greater disability if it is not treated in time. Transversal studies suggest that the disease progresses rapidly with age (Bland and Rudolfer, 2003). In the presence of co-morbidities such as diabetes or hypothyroidism, the progress of CTS is worse, due to the pathophysiological nature of these conditions (Kennedy and Zochodne, 2005). However, it is not yet known whether idiopathic CTS follows a defined pattern or that regardless of its severity, the duration of CTS itself is enough to produce functional and electrophysiological deterioration.

This study monitored patients diagnosed with CTS to determine the evolution of the disease, using clinical and electrophysiological classification.

Section snippets

Materials and methods

Since 2001, in our Electrophysiological Laboratory at the Carlos Lleras Restrepo Clinic, a clinical examination and a standardized questionnaire were applied to every patient that was referred for the evaluation of CTS. Demographic, clinical and electrophysiological data were collected. Specifically, databases including age, sex, Rempel’s clinical criteria for CTS (Rempel et al., 1998), functional tests and musculoskeletal co-morbidities (rheumatoid arthritis, cervical pain, shoulder

Results

One hundred and eighty-nine patients accepted the invitation to return for the clinical and electrophysiological follow-up exam. Fifty-seven patients of this group were treated with surgery, a brace or injections. One hundred and thirty-two patients did not receive any form of treatment. These patients did not receive treatment because of institutional difficulties. Testing was done at 24.2 months (SD = 4.2). The average age was 48.8 years (SD = 10.2), and 81.1% of the patients were female. Primary

Discussion

This research examined the natural evolution of idiopathic CTS in a group of patients who did not undergo any form of treatment. It was observed that over a period of approximately 24 months, the disease remained in a relatively stable electrophysiological state. This study confirms the natural course of CTS. In general, the findings support the conclusions obtained by other authors (Padua et al., 2001).

Although a high number of patients did not return for a follow-up exam, we consider that the

Acknowledgments

The authors thank Patricia Sierra, Sandra Katerine Garzón, Darío Vargas and Miguel Gutierrez for their editorial assistance in preparation of this manuscript.

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Cited by (46)

Point of care ultrasound combined with CTS-6 to diagnose idiopathic carpal tunnel syndrome
2024, Journal of Orthopaedic Science
This study aimed to demonstrate the effectiveness of our new diagnostic chart using point of care ultrasound combined with CTS-6 for diagnosing idiopathic carpal tunnel syndrome.
We conducted a retrospective analysis of the data of patients who visited our department and received point of care ultrasound combined with CTS-6 from 2020 to 2023. Data regarding age, sex, initial and final diagnosis, cross-sectional area of the median nerve, CTS-6 score, and electrodiagnostic severity were obtained and statistically analyzed.
Of the 177 wrists included in our study, 138 (78 %) were diagnosed with carpal tunnel syndrome, while 39 (22 %) were not (non-carpal tunnel syndrome). With our diagnostic method, 127 wrists (72 %) were diagnosed initially with carpal tunnel syndrome, 23 wrists (13 %) with non-carpal tunnel syndrome, and the rest 27 wrists (15 %) as borderline. Our initial diagnoses of carpal tunnel syndrome and non-carpal tunnel syndrome were maintained in all cases except for two. Cross-sectional area, CTS-6 score, and electrodiagnostic severity showed a positive correlation. A post hoc analysis showed that the new scoring system (CTS-6 score + 2 × cross-sectional area) with a cutoff value of 31.25 points showed a sensitivity as high as 95 % and a specificity of 100 %.
Our findings suggest that most suspected idiopathic carpal tunnel syndrome cases can be diagnosed correctly using the diagnostic chart. Although additional tools, including electrodiagnostic studies, may be needed for borderline cases, the use of point of care ultrasound combined with CTS-6 may be a recommendable first-line confirmatory test because point of care ultrasound and CTS-6 could be complementary tools, and this chart may be especially beneficial for atypical or outlier cases.
Diagnostic III.
Natural evolution of idiopathic carpal tunnel syndrome with respect to wrist and hand anthropometry: A prospective cohort study
2024, Clinical Neurology and Neurosurgery
A greater wrist depth/width ratio and wrist depth/palm length ratio are known risk factors for carpal tunnel syndrome. We hypothesized that these parameters might also predict progression in patients who were not surgically treated.
Seventy-eight patients with moderately severe idiopathic carpal tunnel syndrome of at least 10 months duration at recruitment, who declined surgical treatment and steroid injection, underwent repeated neurophysiological assessments after 3 years. A > 10% increase in median SNAP latency was taken as evidence of significant deterioration.
Patients with a wrist ratio ≥ 0.72 showed a statistically significant deterioration in SNAP latency from 5.46 (SD 2.09) to 7.16 (SD 1.56) ms and in SNAP amplitude from 30.19 (SD 13.8) to 16.62 (SD 14.42) µv. For those with a wrist-to-palm ratio ≥ 0.42, SNAP latency deteriorated from 5.27 (SD 1.21) to 7.1 (SD 1.52) ms, and amplitude from 32.78 (SD 13.76) to 19.45 (SD 16.62) µv. Patients with lower ratios did not show significant changes in any neurophysiological parameter. The relative risk of significant deterioration in SNAP latency in patients with a wrist ratio ≥ 0.72 was 2.04 (95% CI 1.27–3.27).
In untreated idiopathic carpal tunnel syndrome, patients with larger wrist and wrist-to-palm ratios are more likely to show neurophysiological progression.
Response to local corticosteroid injections in carpal tunnel syndrome with normal conduction studies
2022, Reumatologia Clinica
Citation Excerpt :
Furthermore, there is also the possibility that in some patients this process will never turn into ANCS. There may be other variables that are not well understood; it has been published that in some patients with CTS and ANCS, after a period and without any active treatment, their symptoms vanish and, at least in some patients, their ANCS can even improve spontaneously.8–10 When the pressure in the carpal tunnel reaches 20–30 mmHg, we can have a mild reduction in epineurial blood flow, this being the first manifestation of the median nerve compression; clinically we will have very mild paresthesia.11
Nerve conduction studies (NCS) have been considered as the gold standard in carpal tunnel syndrome (CTS) diagnosis, despite correlation between clinical symptomatology and NCS severity has shown to be poor. In fact, clinical symptoms precede NCS changes in months or years. Few papers have been published about the clinical response to treatment of clinically typical CTS, but with normal NCS (NNCS).
To compare the clinical response to local corticosteroid injections (LCI) in clinically typical CTS, with NNCS and abnormal NCS (ANCS).
We included patients older than 18, with typical CTS symptoms (ongoing daily nocturnal pain/paresthesias in hand, at least during 3 months). Follow-up was done at 3, 6 and 12 months. Primary outcome was the visual analog scale for pain (p-VAS), comparing NNCS CTS wrists with ANCS CTS wrists. Statistic signification was established by the Student's t test, Mann–Whitney's “U”, χ² test and Yates’ correction.
We included 44 wrists in the NNCS group, and 83 in the ANCS group. There was no statistical significance between data in both groups, except in the 12-month follow-up, where the NNCS group achieved better results than the ANCS group in the 20% response (p = 0.006). There was a trend toward a better 50% response in the 12-month follow-up.
Our data suggest that LCI are similarly effective in both CTS with NNCS and ANCS. Nonetheless, there is a mild better effect in NNCS than in ANCS at 12-month follow-up.
Los estudios de conducción nerviosa (NCS) se consideran el patrón oro diagnóstico del síndrome del túnel carpiano (CTS), aunque la correlación entre síntomas clínicos y gravedad de NCS es escasa. De hecho, los síntomas preceden a los cambios en NCS en meses o años. Hay pocos estudios publicados sobre la respuesta al tratamiento del CTS con sintomatología típica, pero NCS normales (NNCS).
Comparar la respuesta clínica a infiltraciones locales de corticoides en CTS con sintomatología típica, con NNCS vs. NCS anormales (ANCS).
Incluimos pacientes mayores de 18 años, con síntomas típicos de CTS (dolor y/o parestesias continuas, nocturnas, en la mano, un mínimo 3 meses seguidos). El seguimiento se realizó a los 3, 6 y 12 meses. La medida de resultado primaria fue por la escala analógica visual para el dolor, comparando los CTS con NNCS y los CTS con ANCS. Establecimos la significación estadística mediante la «t» de Student, «U» de Mann-Whitney, el test de χ² y la corrección de Yates.
Incluimos 44 muñecas en el grupo de NNCS y 83 en el grupo de ANCS. No hubo diferencias estadísticamente significativas entre ambos grupos, excepto en el seguimiento a 12 meses, en donde el grupo NNCS obtuvo mejores resultados que el grupo ANCS en la respuesta al 20% (p = 0,006). Hubo una tendencia similar en la mejoría de la respuesta al 50%, en el seguimiento a 12 meses.
Nuestros datos sugieren que las infiltraciones locales de corticoides son de similar eficacia en ambos grupos de CTS, los de NNCS y los ANCS. No obstante, hay una discreta mejoría en el grupo NNCS sobre el ANCS en el seguimiento a 12 meses.
Gradual Onset Diseases: Misperception of Disease Onset
2017, Journal of Hand Surgery
Gradual onset diseases (eg, carpal tunnel syndrome, cubital tunnel syndrome, and trapeziometacarpal arthrosis) tend to go unnoticed for years. When a slowly progressive disease transitions from asymptomatic to symptomatic, it may seem like an acute event. The primary aim of this study was to determine the percentage of patients who perceive the slowly progressive disease as having started within 1 year. We also hypothesized that (1) there would be no factors associated with perception of an onset of disease within 1 year, more specifically among patients with advanced disease; and (2) there would be no difference in a decision to pursue operative treatment between patients who perceived the onset of the disease to be recent and those who perceived it to be long-standing.
In this retrospective study, we reviewed the medical records of 732 patients newly diagnosed with carpal tunnel syndrome (n = 114), cubital tunnel syndrome (n = 276), or trapeziometacarpal arthrosis (n = 342), for the onset of symptoms. Multiple factors were assessed for (1) association with perception of disease onset within 1 year, and (2) choice for operative treatment in bivariate and multivariable analyses.
A total of 69% of all subjects and 68% of patients with advanced disease perceived the disease as having started within 1 year. A perceived provocation (such as an injury or surgery) was associated with a perception of recent onset. A decision to pursue operative treatment was not different between the 2 groups.
Slowly progressive diseases are often misperceived as relatively new.
Effective communication strategies are important to ensure that people make choices consistent with their values and not based on misconceptions.
Clinical Course and Prognostic Factors in Conservatively Managed Carpal Tunnel Syndrome: A Systematic Review
2016, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
Three studies provided conservative management without specifying which mode exactly. In 4 studies,20-23 the course of (clinically) untreated CTS was observed. In some studies, parts of the cohort were treated surgically.
To summarize the available evidence regarding the course of symptoms and prognostic factors in patients with diagnosed carpal tunnel syndrome (CTS) who are treated conservatively.
Computerized databases, reference checking, and experts in the field were used to identify studies for inclusion in the review.
Multiple reviewers were used to identify studies which included adults (aged ≥18y) diagnosed with CTS in either a clinical setting or population setting. The study must have observed the course of CTS over at least a 6-week period in patients receiving no treatment or usual care that included conservative (nonsurgical) treatments. The design was of a longitudinal cohort study with either prospective or retrospective data collection. There were no language restrictions, and none of the research identified was only reported in abstract form.
Methodological bias was assessed using the Quality in Prognosis Studies tool. A high risk of bias (predominantly relating to study attrition, confounding, and/or statistical analysis and reporting) was judged to be present in 8 studies. Designs showed wide variability with respect to characteristics of the included population, definition of CTS, assessment of prognostic factors, types of interventions provided, and types of outcome measures applied. This prevented pooled estimates from being produced.
A negative outcome at 3 years' follow-up of conservatively treated participants ranged from 23% to 89%. Four included studies observed the rate of surgical intervention after initial conservative management and found this to be 57% to 66%. Evidence regarding factors predicting the negative outcome of no treatment or conservative treatment was graded, taking into account the number of studies evaluating the factor, the methodological quality of these studies, and the consistency of the available evidence. There was 100% agreement in at least 3 cohorts with a medium or high risk of bias that symptom duration, a positive Phalen's test, and thenar wasting were associated with a negative outcome of conservative management; however, not all results were statistically significant, and hence the overall judgment remained inconclusive.
Results of this review should be treated with caution because of the heterogeneity of studies and the risks of bias identified. However, the course of CTS appears variable, and poor prognosis may be predicted by a longer symptom duration, a positive Phalen's test, and thenar wasting.
Is carpal tunnel syndrome a slow, chronic, progressive nerve entrapment?
2014, Clinical Neurophysiology
The aim of this study is to investigate the presenting profile of patients with carpal tunnel syndrome (CTS) at various ages.
We performed a cross-sectional study of CTS, analysing the correlation between severity and age.
We examined 3108 subjects with CTS, whose frequency increased from 20.9% for the age group 20–29 years to 61.7% for the age group 50–59 years. It remained at almost 50% in people aged over 80 years (49.2%). More than 50% of people younger than 30 years had mild CTS. Severe CTS progressively increased, reaching more than 50% of the CTS diagnoses in people over 80 years. Of the total number of cases, 80.8% of subjects had bilateral CTS. Mild NCS–EMG abnormalities were seen in 74.1% of patients with unilateral involvement, whereas moderate and severe CTS appeared in 70.3% of patients with bilateral involvement.
There was a clear trend of deterioration with advancing years when comparing severity to age.
CTS seems to be a chronic condition whose signs and symptoms may vary and progress, becoming worse over time.

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Natural evolution of carpal tunnel syndrome in untreated patients

Abstract

Objective

Methods

Results

Conclusions

Significance

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgments

Clin Neurophysiol

Clin Neurophysiol

Arch Phys Med Rehabil

Clinical surveillance of carpal tunnel syndrome in two areas of the United Kingdom, 1991–2001

J Neurol Neurosurg Psychiatry

Impaired peripheral nerve regeneration in diabetes mellitus

J Peripher Nerv Syst

Incidence of common compressive neuropathies in primary care

J Neurol Neurosurg Psychiatry