Carpal Tunnel Syndrome and Diabetes, A Challenging Problem

Approximately 20% of diabetic patients will develop carpal tunnel syndrome. Peripheral neuropathy makes the condition of the carpal tunnel worse. It is suggested that the never that already has established hypoxia caused by diabetes is more vulnerable to local compression. Other mechanisms and explanations are also involved, so it is a difficult diagnosis). Some people believe that patients with diabetic neuropathy will have a high prevalence of carpal tunnel syndrome.

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Electrodiagnostic testing (EMG and nerve studies) cannot distinguish patients with clinical carpal tunnel syndrome from patients with diabetic polyneuropathy. The decision to treat these patients should be made independently of the electrodiagnostic findings. When treating the patient, try to figure out the patient’s blood sugar level. There may be difficulty in determining if the blood sugar is under control.

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HBA1C (the glycosylated hemoglobin test) is an important blood test that shows how well the diabetes is being controlled. The test provides an average blood sugar control over the last 2-3 moths. The normal range of hemoglobin A1c is between 4% and 5.6%. When the level is 6.5% or higher, this indicated diabetes. The goal of treatment is to make sure that the patient with diabetes has hemoglobin A1c less than 7%. The higher the levels of Hemoglobin A1c, the higher the risk of developing complications. People should have the test done every three months to check and see that their blood sugar is under control. At least, the test should be done twice a year.

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The difficulty in carpal tunnel syndrome in diabetic patients is the difficulty of diagnosis, the difficulty in determining if the diabetes is being controlled or not, and if there will be surgery needed, will the patient have complications or not.

Patients who develop complications in orthopedics include: diabetics, obese patients, heavy smokers and patients taking blood thinners.

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If the condition is acute or an emergency, we have to do surgery. If the condition is elective, then surgery can wait. If the patient has poor glycemic control, then you probably don’t want to perform elective surgery on the patient such as carpal tunnel release. Remember, elective surgery can wait.

High blood sugar is linked to increased wound complications after surgery. Hemoglobin A1c is used to monitor the patient’s blood sugar level. The higher preoperative Hemoglobin A1c level, the more there is a risk factor for surgical site infection. Elective surgery can be delayed until HBA1c level becomes normal or better. Joint replacement surgery for example is delayed until HBA1c levels are less than 7%.

Since carpal tunnel syndrome is common in patients with diabetes, we need to take time to sort things out with these conditions. We need to know that the patient has better control of their diabetes. Carpal tunnel syndromes is a small surgery, but it can have catastrophic effect if we do not have a good control of the patient’s diabetes. Hemoglobin A1c will help us monitor the patient. Carpal tunnel surgery can cause complications and infection providing that high levels of HBA1c levels is a true risk factor for infection postoperatively.

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What is Brachial Neuritis?

Brachial Neuritis is a condition of severe shoulder pain that usually radiates dowbrachial1n the arm and up to the neck and scapula. It can also be referred to as neuralgic amyotrophy (NA) and/or parsonage-turner syndrome. The pain is sudden, severe and may last for a few weeks. This pain may disturb sleep! It usually occurs on its own without a history of trauma. The condition occurs more in males and it may occur at any age.

The position of comfort is the shoulder adducted with the elbow flexed. Neck movement and Valsalva’s maneuver do not increase the pain. Pain is increased by movement of the arm. Although the pain is severe and sudden, lasting at least a few weeks, the condition is usually under diagnosed or not diagnosed at all.

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Weakness may be absent in the acute phase, however as the pain resolves, weakness of certain muscles will remain. The degree of weakness correlates with the severity of the initial pain.

brachial3The muscles that are commonly involved are the supraspinatus and the infraspinatus muscles. The suprascapular nerve is the most commonly involved followed by the deltoid, which is the abductor of the s shoulder innervated by the axillary nerve.

The condition may occur bilaterally and may occur subclinically (only seen on an EMG). Muscle weakness may continue for a significant period of time. Sensory changes may be variable. If there is no sensory loss, this is a classic finding that confirms the diagnosis. There is a decreased sensation in a lot of cases. The lateral antebrachial cutaneous nerve is usually involved.

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Motor changes predominantly occur over sensory changes and can involve the brachial plexus from C5-T1 with a variable degree of weakness. It can affect more than one nerve branch with certain patterns of involvement can be seen on the MRI.

It is a benign, self-limiting problem with 90% of patients returning to near normal condition in about 3 years. Only about 1/3 of the patients will recover at about 1 year. The etiology of brachial plexus neuritis is unknown.

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Hyperintense muscles involved in the sagittal plane (supraspinatus, infraspinatus, and deltoid). In advanced cases, the muscles will either be atrophied or have fatty infiltration.

EMG and Nerve studies are helpful for the diagnosis and the prognosis. In the first 4 weeks, there will be acute denervation in the roots and the peripheral nerves. EMG may be abnormal for up to 7 years after the diagnosis.

Rule out other conditions such as radiculopathy from a herniated disc. This can bebrachial6 excluded from imaging of the cervical spine. Other conditions that may be considered differential diagnoses are adhesive capsulitis and lyme disease. There are two particular conditions that are very interesting with acute brachial neuritis. The first is bilateral interosseous nerve palsy, which is caused by viral brachial neuritis. The patient has the inability to do the Ok sign. It is motor loss that follows intense shoulder pain and usually the condition resolves with time.

The second condition is winging of the scapula. The serratus anterior muscle involvement may cause dull aches and pain. Acute, sudden severe pain consider with acute brachial neuritis that involves the C7 nerve root. C7 nerve root gives the long thoracic nerve, which innervates the serratus anterior muscle. If the patient has severe shoulder pain and winging of the scapular rule out brachial neuritis!

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The treatment includes rest, observation and steroid injections. Avoid using a sling, a sling will cause flexion and internal rotation contracture of the shoulder. The sling may also cause a stiff elbow.

What is Rheumatoid Arthritis?

Rheumatoid arthritis involves the synovium of the joints. The condition of rheumatoid arthritis will result in deformities. Rheumatoid arthritis occurs in females more than males.

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There may be a hereditary component with rheumatoid arthritis. Rheumatoid arthritis has spontaneous remissions and exacerbations. The disease can have a systemic nature. Pain and stiffness of joints especially in the morning (morning stiffness). Rheumatoid arthritis is typically poly-articular, bilateral, and symmetrical and most commonly affects the hands and feet.

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X-rays show periarticular erosions at the time of diagnosis. Osteopenia and minimal osteophyte formation favors the diagnosis of rheumatoid arthritis.

Pathogenesis

Rheumatoid is an auto immune disease. The disease has two important components: immunological reactions and increased degradative enzymes. The IgM (rheumatoid factor) is produced by the plasma cell as an antibody to the native IgG, which is altered in RA. 70% of the patients with RA have rheumatoid factor positive. Leukocytes are attracted to the immune complex forming deposits over the inflammatory surface of the synovium. These leukocytes ingest fibrin and immune complex and is called the rheumatoid cells. The leukocytes release lysosomal enzymes that causes acute inflammatory response and tissue necrosis as well as inflammatory mediators (IL-1, IL-6, and TNFα). The chondrocytes respond to stimulation by TNFα, IL-1 and other inflammatory mediators causing cells to become activated and secrete more metalloproteinases which lead to cartilage damage. The synovium becomes hypertrophied (Pannus), showing intimal hyperplasis and infiltration by plasma cells and lymphocytes.

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Stages of Rheumatoid Arthritis

Early stages (acute) include hot, swollen, tender joints (synovitis), wrist swelling, MCP swelling and Flexor Sheath Synovitis. Complicated rheumatoid arthritis include digital vasculitis, ecchymosis, skin atrophy and nodules. Advanced rheumatoid arthritis includes swelling of the MCP joints, lateral slippage of extensor tendons and tendon ruptures and ulnar deviation of fingers. X-rays show destruction of MCP with subluxation, ulnar deviation and wrist destruction.

Finger deformities include mallet, boutonniere, and swan neck.

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The thumb is also involved. These changes occur due to proliferation, inflammation and hypertrophy of the synovium. Involvement of the distal radioulnar joint is usually associated with rupture of the extensor digiti minimi.

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Rheumatoid Nodules

25% of patients with RA will have subcutaneous nodules on extensor surfaces of elbow and forearm. Nodules are often multiple and seen along the ulnar margin of the forearm or pulp of the digits. Vasculitis is more common in patients with SC nodules, it is a strongly seropositive disease (aggressive) with a less than favorable prognosis.

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Treatment

If the patient has synovitis, it should be treated by a splint and medical treatment. If the patient has joint space narrowing, bone erosions and osteopenia the patient will need a synovectomy. If the patient has joint destruction/fixed deformity or loss of hand function, surgery is based on the conditions.

Before operating on RA patients, x-ray of the cervical spine is needed because the patient may have subluxation of C1-C2. Metacarpophalangeal joint arthroplasty of the fingers usually results in decreased extensor lag and improvement of the ulnar drift.

What is a Nerve?

In the simplest form, a nerve is a bundle of nerve fibers (Figure1, 2) that transmits electrical messages between the brain and other areas of the body. These messages convey sensory or motor function information.

Nerves are comprised of nerve cells called neurons.

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Figure 1

They receive and transmit electrical messages to and from the brain. One end of the neuron receives the message, while the other end transmits the message.

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Figure 2

When traveling from one neuron to the next, electrical messages cross a gap called a synapse. Neurons communicate with one another through axons and dendrites – projection of a neuron – that extend from their cell bodies.

 

Axons and dendrites of multiple neurons serving a similar function come together with a piece of connective tissue to form nerves.

Neurons are very similar to other cells in the body (Figure3) as they are surrounded by a cell membrane, have a nucleus that contains genes, and contain cytoplasm. However, they differ from other cells in the body because they have axons and dendrites that bring

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Figure 3

information to and from the cell body. In addition, they communicate with each other through electromechanical processes.

 

Nerves are part of the peripheral nervous system, which connects the central nervous system to the limbs and organs. While it is similar to the central nervous system, it differs because it is not as well protected, leaving it susceptible to toxins and mechanical injuries. There are two types of nerves: afferent nerves and efferent nerves.

1- Afferent nerves, also known as sensory nerves, convey sensory signals to the central nervous system. They receive sensory stimuli. For instance, if you stub your toe, you sense pain. These are your sensory nerves at work.

2-Efferent nerves, also known as motor nerves, send stimulatory signals from the central system to muscles and glands. Motor nerves lead to muscles and stimulate movement. For instance, when you move your arm to wave hello, your motor nerves are at work.

Damage to nerves can arise several different ways, including swelling, physical injury, infection, autoimmune disease, or failure of the blood vessels surrounding the nerve. Nerve damage may present symptoms such as pain, numbness, weakness or paralysis. An interesting aspect of pain related to nerve damage is that patients may feel symptoms in areas far from the actual site of damage. This type of pain, known as referred pain, occurs because signaling is defective from the damaged nerve area. Nerve damage is diagnosed several different ways. First, doctors rely on thorough physical examination that test reflexes, directed movements, muscle weakness, and sense of touch. Additional testing may be ordered in the form of a nerve conduction study and an electromyography.

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Figure 4