Review Question - QID 9029

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Carpal Tunnel Syndrome QID: 9029 (OBQ16.267)

QID 9029 (Type "9029" in App Search)

A 55-year-old woman presents with a 6-month history of left hand pain, numbness, and tingling involving the thumb, index, and long fingers. Her symptoms wake her at night despite appropriate splinting. She endorses concomitant neck pain with radiation to the hand as well as forearm pain. Examination demonstrates a positive Tinel sign at the midforearm. EMG/NCS is within normal limits. Which of the following is most appropriate next step?

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Repeat EMG in 3 months

11%

292/2688

Carpal tunnel release

187/2688

Wrist ultrasound

122/2688

Corticosteroid injection into the carpal tunnel

52%

1403/2688

Forearm median nerve decompression

24%

642/2688

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A corticosteroid injection into the carpal tunnel can help differentiate symptoms originating from carpal tunnel compression versus more proximal median nerve compression and cervical radiculopathy in patients with equivocal clinical presentations and EMG/NCS.

Corticosteroid injections into the carpal tunnel have diagnostic, therapeutic, and prognostic benefits in the management of carpal tunnel syndrome (CTS). It can delineate the degree to which carpal tunnel compression contributes to the patient's symptoms and may provide a period of relief in patients with mild and moderate CTS. More complete and longer the periods of relief correlate with more favorable prognoses following carpal tunnel release.

Ponnappan et al reviewed etiologies of upper extremity pain and how to differentiate between them clinically. They discuss neurologic and musculoskeletal etiologies involving the neck, shoulder girdle, elbow, forearm, wrist, and hand. They highlight the diagnostic utility of corticosteroid injections into the carpal tunnel in equivocal cases.

Kane et al reviewed double crush syndrome where a nerve can be compressed at two distinct places along its course. In carpal tunnel syndrome, concomittant cervical radiculopathy can lead to suboptimal results following carpal tunnel release. They highlight the importance of recognizing cervical radiculopathy and underlying systemic neuropathy in patients complaining of carpal tunnel symptoms.

Incorrect Answers:
Answer 1: The patient has a negative EMG and clinical signs of carpal tunnel syndrome. Repeating the EMG in 3 months would not necessarily clarify if her symptoms are coming from her cervical spine or carpal tunnel. A corticosteroid injection can do this and in a much more timely manner.
Answer 2: The patient's diagnosis of carpal tunnel syndrome is not confirmed. Therefore, it is not advisable to proceed with surgery when additional diagnostic and therapeutic options are available.
Answer 3: Ultrasound can be used to diagnose carpal tunnel syndrome; however, it will not help in differentiating the degree of symptoms from the carpal tunnel versus the cervical spine.
Answer 5: The diagnosis is not established in this patient and therefore surgery is not advised.