Guidelines
Guidelines Summary
Carpal tunnel syndrome
In February 2016, the American Academy of Orthopaedic Surgeons released an evidence-based clinical practice guideline on the management of CTS. Recommendations based on strong or moderate evidence included the following [50] :
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Thenar atrophy is strongly associated with ruling in CTS but is poorly associated with ruling it out.
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Do not use the Phalen test, Tinel sign, flick sign, or upper limb neurodynamic/nerve tension test (ULNT) criterion A/B as independent physical examination maneuvers to diagnose CTS because alone, each has a poor or weak association with ruling in or ruling out the condition.
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Do not use the following as independent physical examination maneuvers to diagnose CTS because alone, each has a poor or weak association with ruling in or ruling out the condition: carpal compression test, reverse Phalen test, thenar weakness or thumb abduction weakness or abductor pollicis brevis manual muscle testing, 2-point discrimination, Semmes-Weinstein monofilament test, CTS-relief maneuver, pin prick sensory deficit (thumb or index or middle finger), ULNT criterion C, tethered median nerve stress test, vibration perception (tuning fork), scratch collapse test, Luthy sign, and pinwheel.
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Do not use the following as independent history interview topics to diagnose CTS because alone, each has a poor or weak association with ruling in or ruling out the condition: sex/gender, ethnicity, bilateral symptoms, diabetes mellitus, worsening symptoms at night, duration of symptoms, patient localization of symptoms, hand dominance, symptomatic limb, age, and body mass index.
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Do not routinely use magnetic resonance imaging (MRI) for the diagnosis of CTS.
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Diagnostic questionnaires and/or electrodiagnostic studies can be used to aid the diagnosis of CTS.
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The following factors are associated with increased risk of developing CTS: perimenopausal status, wrist ratio/index, rheumatoid arthritis, psychosocial factors, distal upper extremity tendinopathies, gardening, American Conference of Governmental Industrial Hygienists (ACGIH) hand activity level at or above threshold, assembly line work, computer work, vibration, tendonitis, and workplace forceful grip/exertion.
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Physical activity/exercise is associated with decreased risk of developing CTS.
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Use of oral contraception or female hormone replacement therapy is not associated with increased or decreased risk of developing CTS.
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Immobilization (brace/splint/orthosis) should improve patient-reported outcomes.
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Steroid (methylprednisolone) injection should improve patient-reported outcomes.
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Magnet therapy should not be used for treatment of CTS.
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No benefit is derived from oral CTS treatments (diuretic, gabapentin, astaxanthin capsules, nonsteroidal anti-inflammatory drugs [NSAIDs], or pyridoxine) over placebo.
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Oral steroids could improve patient-reported outcomes in comparison with placebo.
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Ketoprofen phonophoresis could provide pain reduction in comparison with placebo.
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Surgical release of the transverse carpal ligament should relieve CTS symptoms and improve function.
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Surgical treatment of CTS should have greater therapeutic benefit at 6 and 12 months in comparison with splinting, NSAID therapy, and a single steroid injection.
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No benefit is derived from routine postoperative immobilization after carpal tunnel release.
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No benefit is associated with routine inclusion of the following adjunctive techniques: epineurotomy, neurolysis, flexor tenosynovectomy, and lengthening/reconstruction of the flexor retinaculum (transverse carpal ligament).
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Buffered lidocaine rather than plain lidocaine should be used for local anesthesia because buffered lidocaine could result in reduced injection pain.
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No additional benefit is seen with routine supervised therapy over home programs in the immediate postoperative period; no evidence meeting the inclusion criteria was found when the potential benefit of exercise versus no exercise after surgery was assessed.
ACR Appropriateness Criteria imaging in the diagnosis of thoracic outlet syndrome
The American College of Radiology has noted the following regarding diagnosis of thoracic outlet syndrome [51] :
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TOS is characterized by compression of the neurovascular bundle as it passes from the upper thorax to the axilla. Arterial, venous, and neurogenic forms have been identified.
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TOS may be congenital or acquired and may be secondary to bony issues such as first rib abnormalities, cervical ribs, and bony tubercles, or to soft tissue anomalies such as fibrous bands or cervical muscle hypertrophy.
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The goals of further imaging are to confirm the diagnosis of TOS, exclude mimics such as cervical spondylosis or shoulder joint or lung apex pathology, allow accurate classification into neurogenic TOS versus venous (Paget-Schroetter) versus arterial TOS, and guide treatment selection to minimize morbidity and mortality.
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Abduction of the upper limb has been shown to be relevant in diagnosing TOS and is the postural maneuver of choice for cross-sectional imaging.
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Digital subtraction angiography, US, CTA, and MRA may allow evaluation of vascular structures and secondary effects of compression, whereas CT and MRI may allow identification and evaluation of surrounding neurologic, soft tissue, and bony structures.
Media Gallery
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Chest PA radiograph showing a right cervical rib (arrows), a possible cause of thoracic outlet syndrome.
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Ulnar nerve (U) transposition at the elbow. A: The medial intermuscular septum (arrows) is resected to prevent compression of the transposed nerve. Vasoloops are around the ulnar nerve and a vascular pedicle between the nerve and the septum that has been preserved. B: After subcutaneous transposition, the ulnar nerve is observed lax in elbow flexion. The ulnar nerve and its distal branches are surrounded by vasoloops.
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Common peroneal nerve decompression at the fibular neck. A: The common peroneal nerve (P) has been identified and mobilized proximal to the fibular tunnel region, fascia (F) covering peroneus longus. B: The common peroneal nerve has been traced through the fibular tunnel. The fascia overlying the peroneus longus muscle has been divided and the muscle (M) has been retracted. The fascial band overlying the nerve is released.
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Median nerve (M) after decompression at the wrist; note the congestion from the longstanding compression. The transverse carpal ligament (arrows) has been transected. Fat is observed distally.
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