Hand Discomfort in a Middle-aged Woman
A 47-year-old otherwise healthy woman presents with symptoms of hand discomfort of at least one year’s duration. She has noted progressively worsening pain, weakness and tingling of her right hand, which is her dominant hand. She notes tingling in the thumb, index, and middle fingers at night and especially upon wakening. Of late, there has been weakness as well such as when trying to open a jar. Routine analgesics and anti-inflammatory medicines have not helped.
History
She has an important job with an IT company and has used the affected hand a lot on computers and similar devices. She likes tennis but lately her symptoms have impaired her ability to play. She is involved in an important ongoing project and would like to not be disabled by symptoms or treatment for the next 30 to 60 days.
Physical Examination
Pertinent physical examination reveals mild weakness and discomfort of the right thumb and index fingers with grip or turning movement. Percussion of the right anterior wrist near the thumb elicits significant tingling discomfort into her thumb, index, and middle fingers similar to the spontaneous symptoms she reported.
Which of the following is the most accurate prognostic and therapeutic plan in this patient?
A. Immediate and prolonged splinting of the wrist will result in prompt and prolonged relief in most cases.
B. She requires urgent surgery now regardless of mitigating factors in her personal life.
C. Steroid injections have a high probability of temporary symptom relief, but often surgery will most likely be eventually required.
D. Intermittent courses of steroid injections can be expected to provide definitive relief in a majority of cases.
(Answer and discussion on next page)
Correct Answer: C
The presented patient is manifesting signs and symptoms consistent with carpal tunnel syndrome (CTS). CTS is quite common in the United States and our patient’s demographics are typical—middle age (mean 45-50 years), female preponderance, symptomatology chronic, often >1 year before finally seeking medical attention and often made “obvious” by an employment or recreational repetitive use/motion across the carpal area where the median nerve is crossed.1 The diagnosis can often be accurately made using these histories and demographics and can be further reinforced using easy maneuvers such as the Phalen test—flexing the dorsum of the hands against themselves with wrist flexion and Tinel’s test where percussing the carpal area near the base of the thumb produces the typical symptoms. Phalen’s test will be positive in more than 90% of cases while Tinel’s test will be positive in 50%.2 Our patient was positive for Tinel’s. An objective definitive test is to perform a nerve conduction study of the compressed median nerve across the wrist, the delay of which can be quantitated and titrated for severity of the neuropathy and subsequent response to treatments.
Discussion
A progression of therapies have evolved for CTS. Splinting of the wrist is almost always initially tried and can produce some relief, but the degree is usually modest and transient in most patients with at least moderately severe CTS.2 Most certainly this maneuver would be tried as an adjunct in our patient when sleeping, but her history relates a need to be functional at work in the short-term and a splint would not allow this making Answer A incorrect. Steroid injections subfascially into the soft tissues of the carpal tunnel are an important intervention in CTS. The specific steroid and dosage used do not seem to make an overwhelming difference, methylprednisolone 80 mg being a common and well-demonstrated useful regimen.2,3 Such injections have an excellent response rate at 10 weeks post-injection. However, the response breaks down significantly with symptom recurrence occurring in 73 to 81%.3 In fact, a recently reported placebo (using saline) blinded trial demonstrated that although injections provide a brief period of relief, at 1 year the incidence of patients requiring definitive surgical relief of the carpal tunnel compression was no different statistically from the group of CTS patients who did not receive steroid injections. Thus, Answer D, steroid injections alone providing definitive (and note that repetitive injections can weaken the tissues and increase risk for tendon rupture) is an incorrect answer.
Despite the transient nature of response to steroid injection, using this maneuver to provide at least temporary relief fits the presented case perfectly—it is very likely to get her the relief and functionality she needs to complete her employment deadline and can then be followed at a later, more elective date by definitive surgery and its required recuperation time. Thus Answer C is the best route to proceed here.
Answer B, urgent and immediate surgery is not required here by either the medical or social/employment history facts. She almost certainly will obtain significant, albeit temporary relief by injections. And there is a small chance of long-term effect in that about 20% of cases in the above study did not require surgery at 1 year.3
Patient Follow-Up
The patient opted for the use of methylprednisolone injection as a temporary measure to get her through the important work project in question. She obtained adequate relief sufficient for this purpose. After returning from a vacation at the completion of the project, her symptoms began to recur such that definitive open surgery was performed. She had good symptom relief and maintains this at 18 months post-op.
Ronald Rubin, MD, is a professor of medicine at Temple University School of Medicine and chief of clinical hematology in the department of medicine at Temple University Hospital, both in Philadelphia, PA.
References:
1. Atroshi I, Englund M, Turkiewicz A, et al. Incidence of physician-diagnosed carpal tunnel syndrome in the general population. Arch Intern Med. 2011;171(10):943-944
2. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Randomized controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC Fam Pract. 2010;11:54
3. Atroshi I, Flondell M, Hofer M, and Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med. 2013;59(5):309-317