High incidence of absent nerve conduction in older patients with bilateral carpal tunnel syndrome

Abstract

Ann R Coll Surg Engl 2010; 92: 403-405 403Carpal tunnel syndrome is common in the general population with approximately 1% incidence but can often be treated with simple night wrist splints.1 For those patients who do respond satisfactorily to conservative measures, surgical decompression is often successful.2 However, some investigators have reported that older patients can have a less satisfactory outcome after surgery, 3 though this impression is not universally shared. 4,5 To the author's knowledge, no objective explanation has been suggested for these observations. As the symptoms for carpal tunnel syndrome include wrist pain, paresthesia and weakness in grip strengths, a number of medical conditions can produce a similar clinical picture; therefore, as standard practice, our department investigates these patients with neurophysiology before a surgical treatment strategy is considered if conservative treatment is unsatisfactory. This is particularly relevant if the condition is bilateral.6 However, the author acknowledges that neurophysiological diagnosis prior to surgery for carpal tunnel syndrome is a controversial issue and that many surgeons operate on clinical grounds only. The aim of this paper was, therefore, to see if there was a significant difference in sensory or motor conduction speeds between a group of patients younger than 40 years and a group of patients older than 60 years who presented with bilateral carpal tunnel syndrome which was resistant to conservative treatment with night wrist splints. Patients and MethodsFrom a specialist hand surgical clinic, 10 patients below 40 years of age and 20 patients above 60 years of age with a clinical diagnosis of bilateral carpal tunnel syndrome who had not benefited from conservative treatment with night wrist splints were evaluated with nerve conduction studies. The length of the standard conservative treatment period was 3 months from the time they were first seen in the clinic until they were reviewed in the clinic and referred for pre-surgical neurophysiology confirmation if they wanted surgical release due to insufficient subjective improvements of their complaints. Patients with previous surgical treatment for carpal tunnel syndrome were excluded. Median nerves in both hands were tested across the wrist and conduction speeds were calculated for both motor and sensory nerves. The Mann-Whitney non-parametric test was used for the statistical evaluation. Carpal tunnel syndrome has been reported by some to have a less satisfactory outcome in older patients following surgery. However, this impression is not supported by other investigators but no objective explanation has been suggested for these differences. In our department, such patients are routinely treated with night wrist splints and, if this is unsatisfactory, they are investigated with nerve conduction studies prior to surgery. PATIENTS AND METHODS This paper reports the neurophysiological outcome in a young (< 40 years of age) and an older (> 60 years of age) group of patients with clinic...

Ultrasonography of Carpal Tunnel Syndrome: Clinical Significance and Limitations in Elderly Patients

“…As has been reported previously (17,18,26) and confirmed in the present study, the severity of CTS increases with age. It is unclear why CTS in elderly patients is more severe.…”

“…Thus, the present study was aimed to investigate whether measurement of the median nerve CSA actually contributes to assessing the severity of CTS. Because the risk of more severe CTS increases with age (17,18) and older patients have a less satisfactory outcome after surgery (19,20), the present study also was aimed to investigate the influence of aging on the median nerve CSA.…”

Carpal Tunnel Syndrome in Elderly Patients

“…In a series involving patients aged >70 years, 80% of the patients demonstrated electrophysiological study results indicating severe dysfunction of the median nerve 25) . Other studies have also reported similar results in elderly patients with CTS 9,20) . It is suggested that results of NCS indicating severe disease could be related to delayed treatment owing to age-related reduced pain sensitivity because of reduced nerve membrane excitability 21) .…”

Treating Carpal Tunnel Syndrome in the Elderly: Too little Too Late?

“…There are divided opinions regarding the impact of age on the efficacy of surgical decompression [2,3], but increasing evidence is mounting that older patients may have a less satisfactory outcome, though may still benefit from a release [4,5]. At the time of initial publishing, the article by Povlsen 'High incidence of absent nerve conduction in older patients with bilateral carpal tunnel syndrome' [6] was, to our knowledge, the first to suggest an explanation based on human patient data.…”

“…Since initial publication, further evidence has emerged that supports both the age-dependency of pre-operative conduction velocities in carpal tunnel syndrome, but also the rate of recovery of motor conduction post-operatively [6]. Explanations for these findings include 1) reduced pain sensitivity with age, thus delaying presentation in elderly patients with carpal tunnel syndrome to a point by which more severe and potentially irreversible nerve damage has already occurred [7] 2) the fact that aging even in healthy individuals reduces peripheral nerve conduction velocities [8] and 3) that aging reduces axonal regeneration capacity and Schwann cell neurotrophic factor production in animal models [9].…”