Atraumatic Acute Carpal Tunnel Syndrome in a Patient Taking Dabigatran

Abstract

Acute carpal tunnel syndrome is an uncommon diagnosis most often related to blunt trauma requiring immediate surgical decompression to avoid serious sequelae. Patients who present with bleeding-related acute carpal tunnel syndrome tend to have severe pain, rapid onset of swelling, and neurologic symptoms that appear early and progress rapidly secondary to mass effect. Acute carpal tunnel syndrome can occur in anticoagulated patients spontaneously or after minor trauma. This article describes a case of a 57-year-old man with progressive pain and paresthesias in the median nerve distribution after reaching for a picture frame. He was taking dabigatran, a direct thrombin inhibitor, for atrial fibrillation. He developed acute carpal tunnel syndrome secondary to spontaneous bleeding into the carpal canal and flexor tenosynovium with hematoma formation requiring surgical decompression. He reported immediate pain relief postoperatively, had no further bleeding complications, and regained full median nerve function within 2 months.Dabigatran has gained recent popularity for the treatment of atrial fibrillation. Unlike warfarin, its use does not involve regular laboratory monitoring or dose titration. The risks and benefits of dabigatran should be considered carefully by the prescriber, particularly in patients taking medications that may alter its metabolism. Aspirin and nonsteroidal anti-inflammatory drugs may have effects similar to dabigatran and may increase the risk of bleeding problems. Should acute carpal tunnel syndrome occur, the authors recommend prompt surgical decompression rather than conservative management. The modification of anticoagulant therapy should be considered on a case-by-case basis.

Acute Carpal Tunnel Syndrome in A Rheumatoid Patient on Warfarin Due to Spontaneous Median Nerve Intraneural Hemorrhage Treated Successfully with Carpal Tunnel Decompression

“…To our knowledge, our case is the first patient with rheumatoid arthritis on methotrexate and warfarin who developed spontaneous median intraneural hemorrhage causing ACTS and had successful surgical open decompression. We found a few case reports [2][3][4][5][6][7][8][9] dating back to 1986, describing ACTS in patients on anticoagulation medication. The collection of case reports showed that five out of the seven patients were on longterm warfarin therapy, while one patient was on aspirin, one was on dabigatran and another on apixaban.…”

“…However, Dussa et al [12] reported a case of a patient with spontaneous ACTS whose diagnosis was missed on three previous presentations by several clinicians. While there has been debate regarding whether treatment should be operative or non-operative, the authors favored an operative approach as advocated by Black et al [13], Sibley et al [8] highlight that non-operative treatment may not be possible due to the severity of symptoms and that delays in surgical decompression may lead to longer recovery times. Continuation with anti-coagulation therapy is also a controversial issue, with Kokosis arguing that the decision should be made on a case by case basis.…”

Untitled

“…To our knowledge, our case is the first patient with rheumatoid arthritis on methotrexate and warfarin who developed spontaneous median intraneural hemorrhage causing ACTS and had successful surgical open decompression. We found a few case reports [2][3][4][5][6][7][8][9] dating back to 1986, describing ACTS in patients on anticoagulation medication. The collection of case reports showed that five out of the seven patients were on longterm warfarin therapy, while one patient was on aspirin, one was on dabigatran and another on apixaban.…”

Carpal Tunnel Syndrome Associated with Oral Bisphosphonates. A Population-Based Cohort Study

“…In a study carried out with a twin registry in the UK, a genetic predisposition was found to be the single strongest factor in predicting CTS [ 15 ]; BMI increase has also been consistently identified as a risk factor [ 16 , 17 ]. Other medications such as lithium [ 18 ], oral contraceptives [ 19 ], exemestene [ 20 ]—an aromatase inhibitor used to treat breast cancer—and dabigatran [ 21 ] have occasionally been involved in CTS. The aim of this study was to explore whether bisphosphonates may be associated with carpal tunnel syndrome.…”