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Thesis (M.Sc.)--York University, 2007. Graduate Programme in Kinesiology & Health Science. / Typescript. Includes bibliographical references (leaves 72-83). Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&res_dat=xri:pqdiss&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&rft_dat=xri:pqdiss:MR38803

Thesis (doctoral)--Uppsala University, 1983. / Includes bibliographical references (p. 19-21).

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Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment seen within the outpatient orthopaedic clinic; therefore assessment and management of this common condition is of significant importance. Traditionally diagnosis has been made through detailed questioning; clinical examination and nerve conduction studies (NCS). There is however no true consensus as to the gold standard assessment of CTS and the use of NCS can confer additional costs and delay treatment. Previous studies have explored methods of predicting the presence of CTS including the clinician-administered Carpal Tunnel Questionnaire (CTQ) (Kamath and Stothard, 2003). The aim of the present studies is therefore to explore the versatility of the CTQ to see how a novel Patient-completed Version of the CTQ compares to the original Clinican-completed version. Psychometric properties of the questionnaire will be explored together the economic impact of integrating both versions within an orthopaedic care pathway. A further aim is to answer whether the CTQ more effective and cost-effective than NCS for patients referred to an orthopaedic clinic with suspected CTS. Method: 100 patients referred for further investigation of suspected CTS were assessed using parallel patient and clinician-completed versions of the CTQ and results were subsequently compared with those obtained from NCS. Item analysis explored each of the nine constructs of the questionnaire and the original scoring algorithm was validated using binary logistic regression and compared with alternative algorithms. Sensitivity and specificity of the questionnaire when compared to results of NCS was explored using Receiver Operating Characteristic (ROC) analyses. Inter-rater reliability was explored through Pearson’s correlation coefficient. Economic analysis and modelling was carried out to explore potential cost savings of use of the questionnaire rather than NCS for those with suspected CTS. Results demonstrated sensitivity of 92% and specificity of 54.67% (positive predictive value 95.35%) for the patient-completed questionnaire and 96% sensitivity with 70.67% specificity (98.15 positive predictive value) for the clinician-completed questionnaire when used to predict the outcome of NCS. Binary logistic regression confirmed the original scoring algorithm and a revised algorithm did not significantly improve sensitivity. Adoption of the clinician-completed CTQ would have screen out 54% of referrals for NCS, which in the case of the study site would have conferred cost savings of £73,305 per annum (base upon a referral rate of 750 per annum). The patient-completed CTQ in the current sample resulted in 43% of referrals with suspected CTS not requiring NCS to assist in diagnosis with a potential saving of £58,372.5 per annum. There are further considerations of the reduction in waiting times, which are explored further within the analysis. Conclusion: Economic evaluation is complex due to the variety of pathways adopted by different orthopaedic departments. While the results of the Patient-complete version of the CTQ may not be as convincing as the clinician completed the study does provide validation for its use and expands the versatility of this useful adjunct to the assessment of CTS. Both versions could potentially confer significant cost savings and reduce demands on investigative services, reducing waiting times and improving the patient journey in suspected CTS.

Orientador: Humberto Santo Neto / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Biologia / Made available in DSpace on 2018-08-18T14:45:14Z (GMT). No. of bitstreams: 1 Luz_MarcusAlexandreMendes_D.pdf: 10387090 bytes, checksum: fb422b3999d7ad8433ea938ee8b28b9f (MD5) Previous issue date: 2011 / Resumo: A região carpal anterior apresenta dois túneis delimitados por tecido fibroso: o túnel do carpo e o túnel ulnar. A importância clínica e cirúrgica dessa região está diretamente ligada às síndromes de compressão nos túneis do carpo e ulnar, comprometendo a função motora. Contudo, a abordagem clínica, tanto para diagnóstico como para o tratamento dessas lesões baseia-se em dados anatômicos de indivíduos adultos, sendo escassas as descrições em crianças. Assim sendo, o presente trabalho tem por objetivo descrever anatomicamente e histologicamente o túnel do carpo e o túnel ulnar em crianças. Foram analisadas 33 mãos de crianças de 2 a 11 anos de idade sem identificação de sexo, provenientes do Laboratório de Anatomia Humana do Departamento de Anatomia, Biologia Celular e Fisiologia e Biofísica do Instituto de Biologia da UNICAMP. Uma amostra de sete peças foi submetida à técnica de ressonância magnética e dissecadas, 14 foram dissecadas e 12 destinadas à histologia. A análise histomorfométrica das estruturas em secção transversal revelou que 58,1% da área do túnel do carpo é ocupada pelos tendões dos músculos flexores superficial e profundo dos dedos, tendão do músculo flexor radial do carpo e tendão do músculo flexor longo do polegar, sendo que 12,1% dessa área é ocupada pelo nervo mediano. Nos dados obtidos das imagens por ressonância magnética, observou-se que o nervo mediano pode assumir duas posições no túnel do carpo: lateral (71,4%) e mediana (28,5%). O túnel ulnar revelou localização palmar, e em 93,8% dos casos observou-se que o limite inferior desse túnel se constitui do retináculo dos músculos flexores e do hâmulo do hamato. Em 16% das amostras analisadas observou-se a artéria acompanhante do nervo mediano persistente, ocupando 1,1% da área do canal do carpo. Em 41,6% das amostras, a densidade de volume de tecido conjuntivo não variou na área de túneis do carpo com maior e menor dimensão, independente do espaço ocupado pelos componentes tendinosos nesse compartimento. De acordo com os dados obtidos, podemos concluir que a anatomia dos componentes neurovasculares dos túneis do carpo e ulnar em crianças apresentam particularidades em relação aos descritos em adultos e devem ser consideradas nas intervenções cirúrgicas / Abstract: The anterior carpal region has two tunnels limited by fibrous tissue: the carpal tunnel and the ulnar tunnel. The clinical and surgical importance of this region is related to the carpal and ulnar tunnel syndromes, both able to impair motor and sensitive functions. The diagnosis and clinical approach to treat these syndromes are mainly based on anatomical features of the tunnels in adults. In children, little is known about the anatomy of these tunnels. In the present study, we describe the anatomy and histology of the carpal and ulnar tunnels in children. Thirty-three hands from children between ages 2 and 11 were studied. Seven samples were submitted to magnetic resonance and dissected; 14 samples were dissected and 12 processed to histology. The histomorphometric analysis in transversal sections showed 58.1% of the areas of the carpal tunnel are occupied by tendons of both superficial and deep flexor muscles of the fingers, by the tendon of the carpal radial flexor muscle and the tendon of the long flexor muscle of the thumb. The median nerve occupied 12.1% of the tunnel area. Magnetic resonance analysis showed that the median nerve was positioned either lateral (71,4%) or median (28,5%) in the carpal tunnel. The ulnar tunnel revealed a palmar location and 93.8% of the samples the inferior limit of the ulnar tunnel was made by the retinaculum of flexor muscles and of the hook of the hamate. In 16% of the samples, an accompanying artery of the median nerve persisted, occupying 1.1% of the area of the carpal tunnel. In 41,6% of the samples the density of the volume of the conjunctive tissue did not change in relation to the dimensions of the carpal tunnel or in relation to the space occupied by the tendons. According to these data, we concluded that the anatomy of the neurovascular components of carpal tunnel and ulnar tunnel in children have individual in relation to those described in adults and these differences may be of relevance to perform safer surgical approaches to the treatment of carpal and ulnar tunnel syndromes / Doutorado / Anatomia / Doutor em Biologia Celular e Estrutural

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As the incidence of diagnosed carpal tunnel syndrome continues to increase, an understanding of the mechanism(s) of insult to the median nerve which leads to its development becomes ever more imperative. Knowledge of the exact cause of CTS could lead to improved diagnostic and treatment methods, or more importantly, to better preventative measures. The goal of this study was to investigate movements and interactions of structures within the carpal tunnel during wrist flexion and hand loading in order to obtain information about a specific mechanism of insult to the median nerve. Symptomatic and normal subjects were compared to observe differences in the interactions of the median nerve and its surrounding structures. A new methodology was developed to facilitate the evaluation of these populations.

Carpal tunnel syndrome is a frequently encountered chronic peripheral nerve entrapment disorder caused by mechanical insult to the median nerve, which may occur from impingement by the surrounding digital flexor tendons and the tunnel boundaries. Anatomic finite element models of the carpal tunnel provide a method to evaluate the potential contact stresses that may develop on the median nerve between the digital flexor tendons and tunnel boundaries. Realistic finite element simulations are dependent upon the use of physiologically accurate material properties. The purpose of this work was to ascertain material properties for the digital flexor tendons, median nerve and transverse carpal ligament to inform finite element simulations. The compressive mechanical behavior of the digital flexor tendons, median nerve and transverse carpal ligament was characterized under functionally relevant axial tensile loads. These properties can now be implemented into full scale finite element models of the carpal tunnel to evaluate the mechanism of insult to the median nerve leading to the development of carpal tunnel syndrome.

<p>Neurography is the most objective and reliable measure of the peripheral nerve function, and it is used to diagnose both local and generalized neuropathies. Neurography can measure both motor and sensory nerve functions. The principle for sensory neurgraphy is to stimulate over the nerve and record proximal or distal from the stimulated electrode.</p><p>At the Department of Clinical Neurophysiology, University Hospital Uppsala, a problem has been identified, in that young adult patients tend to show unexpected abnormal neurography values in relation to the expected, indicated by the reference limits, without clinical correlates. This concerns foremost the sensory amplitudes in median and ulnar nerves. The hypothesis is that the requirement of young adults’ amplitudes is too high. A reference material better including more subjects in this age group may solve the problem.</p><p>Sensory nerve conduction studies were performed in 33 subjects, aged 15-30. The nerve functions were tested on median, ulnar and radial nerves. Surface electrodes were used for both recording and stimulation.</p><p>The result shows that the presently used reference material for some nerves indeed has too high requirement for young adults. After increasing the reference material for younger age groups, the new reference limits has been changed and this should cause fewer false positive findings.</p>