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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 1181-1187
Extended open-carpal tunnel release in renal dialysis patients


1 Department of Plastic Surgery, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
2 Sheffield Kidney Institute, Sheffield Teaching Hospitals, Sheffield, United Kingdom

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Date of Web Publication17-Nov-2012
 

   Abstract 

Chronic hemodialysis patients are susceptible to median nerve compression. The clinical symptoms, surgical results and prognosis of chronic hemodialysis-related carpal tunnel syndrome have different results from those of idiopathic carpal tunnel syndrome. The aim of this study was to evaluate the clinical results of extended open carpal tunnel release in chronic hemodialysis-related carpal tunnel syndrome. A review of 31 open-extended carpal tunnel decompressions in 27 chronic dialysis patients was performed. The surgical technique is detailed and the clinical results analyzed. There was an improvement in symptoms and strength in all patients. There were no instances of recurrence of nerve compression during the one year follow-up period. Extended open carpal tunnel decompression improves symptoms and enhances hand function in patients receiving chronic hemodialysis.

How to cite this article:
Al-Benna S, Nano P, El-Enin H. Extended open-carpal tunnel release in renal dialysis patients. Saudi J Kidney Dis Transpl 2012;23:1181-7

How to cite this URL:
Al-Benna S, Nano P, El-Enin H. Extended open-carpal tunnel release in renal dialysis patients. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Aug 3];23:1181-7. Available from: http://www.sjkdt.org/text.asp?2012/23/6/1181/103557

   Introduction Top


Carpal tunnel syndrome is the most common compressive neuropathy in the upper extremity. [1],[2] The syndrome is usually related to compression of the median nerve, resulting in progressive sensory and motor disturbances. [1],[2] It is characterized clinically by pain, paresthesia and numbness in the median nerve distribution; clumsiness and weakness of the hand may also be present. [1],[2] Carpal tunnel syndrome is present in 2-4% of adults, and women are more frequently affected than men. [3],[4],[5],[6] The incidence of carpal tunnel syndrome is approximately 1-5 per 1000 people per year, and has been reported to occur more frequently in the dominant hand. [3],[7] The diagnosis of carpal tunnel syndrome is usually based on the clinical findings. [2] Nerve conduction studies are helpful in confirming the diagnosis and, in less-typical cases, in differentiating other conditions; however, it should be noted that abnormalities in nerve conduction velocity studies are not always correlated with clinical signs and symptoms. [8]

Most patients have idiopathic carpal tunnel syndrome, but some patients have predisposing factors. [9] Many of the underlying diseases or factors that contribute to the development of carpal tunnel syndrome are also associated with a more severe case of carpal tunnel syndrome. [10] These include rheumatoid arthritis, diabetes mellitus, gout, acromegaly, pregnancy, thyroid disease, amyloidosis, the use of corticosteroids and estrogens and fracture around the wrist. [9],[10],[11],[12],[13],[14],[15] Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist. [16]

Chronic renal dialysis has become a well-known cause of carpal tunnel syndrome. [10] Although numerous studies have been done since the first report of carpal tunnel syndrome developing in patients undergoing hemodialysis, the incidence of carpal tunnel syndrome in patients undergoing hemodialysis is variable. [17] The incidence of symptomatic carpal tunnel syndrome in patients receiving chronic hemodialysis varies from 2% to 32%. [18],[19],[20],[21],[22],[23],[24],[25],[26] The frequency of carpal tunnel syndrome increases gradually with hemodialysis duration, and the pathogenesis of the compression of the median nerve in the wrist is not yet clearly understood. [17],[25]

Carpal tunnel syndrome occurring against a background of chronic renal dialysis is often severe and unremitting, diminishing hand function and interfering with home dialysis and independent living. [9],[17],[18],[19],[25] This is in contrast to the clinical presentation of idiopathic cases arising in the population. [9],[25] Approximately 5% of hemodialysis patients have reported a history of carpal tunnel syndrome surgery. [26]

The aim of this study was to evaluate the clinical results of extended open carpal tunnel release in chronic hemodialysis-related carpal tunnel syndrome.


   Materials and Methods Top


From January 2008 to June 2009, extended open carpal tunnel release was performed on 27 patients (31 hands) with carpal tunnel syndrome resulting from chronic hemodialysis. Carpal tunnel syndrome secondary to other systemic diseases or trauma was excluded in this study.

All patients underwent detailed examination of both hands for symptoms and signs of carpal tunnel syndrome (Phalen's test and Tinel's sign). Thenar muscle hypotrophy was examined visually based on the bulk and contour of the thenar eminence. Grip and pinch strength were measured using a Jamar dynamometer and a Jamar pinchmeter (JA Preston Corp., Jackson, MI, USA), respectively. The diagnosis of carpal tunnel syndrome was established by the characteristic signs and symptoms, and electro-diagnostic confirmation was made in every patient before surgery.

Patients were asked to express their satisfaction with the surgery on a visual analogue scale after surgery. The visual analogue scale was a 10 cm line with one end labeled complete dissatisfaction and the other labeled complete satisfaction. The visual analogue satisfaction score represented a mark on the line that corresponded to the patient's mean satisfaction level.

The surgical technique of extended open carpal tunnel release was performed as follows. The operation was carried out under a local anesthetic. Exsanguination with an upper arm tourniquet was not used. The tourniquet was used only in case of an upper limb without a fistula. Full decompression of the median nerve was performed, including release of deep fascia in the distal forearm (a frequent site of nerve compression in recurrent cases) [Figure 1]. The synovium around the flexor tendons was inspected and flexor tendon synovectomy wasperformed only when the synovium was of abnormal appearance, with a specimen of tissue sent for histology.
Figure 1: Extended surgical incision. A flattened median nerve is clearly visible

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   Statistical Analysis Top


All analysis was carried out using Minitab Statistical Software version 13.1 (Minitab Inc., State College, PA, USA). Pair-wise comparisons were made using paired Student's t-tests. Unless otherwise indicated, results were shown as mean ± SD, and P <0.05 was considered significant.


   Results Top


The study population included 18 male (67%) and nine female (33%) patients, with a mean age of 53 ± 7 years. The duration of regular dialysis was 15 ± 4 years. Since 2007, all the patients had undergone high-flux hemodialysis three times per week. The duration of symptoms was 4 ± 3 months. Thirty-one extended open carpal tunnel decompression procedures were performed in all the patients. Carpal tunnel syndrome affected both hands in four (15%) patients. Of the patients with unilateral carpal tunnel syndrome, it was on the vascular access side in 56.5% and on the non-fistula side in 43.5%. Hand pain was present in 80.6% of the hands. Hand numbness was present in 80.6% hands. Nocturnal paraesthesias were present in 87.1% hands. Thenar wasting was noted in 64.5% hands; Phalen's test was positive in 90.3% hands; Tinel's sign over the median nerve at the wrist was positive in 74.2% hands; the average grip strength for the patients was 9.1 ± 2.7 kg; the average pinch strength was 2.4 ± 0.9 kg; and 19% patients reported aggravation of symptoms during hemodialysis, [Table 1]. The mean nerve conduction velocity was 19.1 ± 5.7 m/s and the mean distal motor latency was 5.3 ± 2.2 m/s.
Table 1: Pre-operative versus post-operative results at last follow-up.

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Intraoperative findings included an obvious constriction or flattening of the median nerve in 74.2% of the hands. In the remaining 25.8% of hands, the nerve appeared grossly normal. In the four bilateral cases, the median nerve appeared normal on both sides in one case, bilaterally compressed in another case and compressed on one side only in two cases. Flexor tendon synovectomy of macroscopically abnormal synovium was undertaken to permanently reduce the volume of the carpal tunnel contents of the carpal canal in all the cases, and specimens stained positive for β-2 amyloid. Synovectomy was not carried out in four cases when synovium was of normal appearance. All of the patients were followed-up for a mean of 12 ± 3 months. The mean post-operative satisfaction score was 8.3.

Wound-related complications were found in 18.5% patients. There were four patients with partial wound breakdown, and all recovered with conservative therapy and one patient with wound infection that was treated with oral antibiotics. There were no instances of recurrence of nerve compression during the follow-up period.


   Discussion Top


Extended open carpal tunnel release is successful in providing long-lasting relief from the symptoms of carpal tunnel syndrome in chronic renal dialysis patients. In this study, all patients with carpal tunnel syndrome also had electrodiagnostic evidence of peripheral neuropathy. Despite the high complication rate, these patients were generally satisfied with the improvement of symptoms and function.

The high frequency of carpal tunnel syndrome in renal dialysis patients raises the issue of whether screening for carpal tunnel syndrome is worth while in this population. [22],[24] There is no known association between carpal tunnel syndrome and the underlying renal diagnosis. [24],[26] There is controversy regarding the association between the duration of hemodialysis and the incidence of carpal tunnel syndrome. [23],[24],[25],[26] Studies have demonstrated an association between carpal tunnel syndrome and renal dialysis longer than four years, [23],[24],[25] while other studies have found no association. [26],[27],[28]

Similar to other studies, the present study found no relationship between side of fistula and carpal tunnel symptoms. [24],[25],[26],[27],[29] A previously or currently active forearm access was found in 81.5% of the hands with carpal tunnel syndrome and in 18.5% of the hands without carpal tunnel syndrome; 11.1% of patients with carpal tunnel syndrome had increased symptoms in the hand with the AV fistula while being dialyzed, and 12.9% of the involved extremities had never had vascular access. This is in contrast to other studies, in which all patients had vascular access in the involved arm. The presence of a fistula cannot be the sole explanation in the four bilateral patient cases in the present study. [24]

One must then question his contention that the etiology of "dialysis carpal tunnel syndrome" is directly related to altered vascular hemodynamics in the arm with carpal tunnel syndrome. It is probable that compressed nerves are abnormally sensitive to any additional ischemic insult. Renal dialysis patients have an increased potential for ischemia not only because of multiple access procedures but also because of accelerated atherosclerosis.

Several different etiologies for nerve compression in chronic renal dialysis patients have been proposed. These etiologies can be classified as volume-, pressure- and vascular-related. Nerve compression may simply be related to an increased volume in the limb, seen as part of a generalized edema in renal patients, edema around the nerve, increased synovial volume, amyloid deposition or due to altered local hemodynamics related to the fistula. [17],[26],[29],[30],[31],[32],[33],[34],[35],[36] Ischemia due to "steal" from a dialysis fistula or shunt can cause distal limb ischemia and symptoms similar to nerve compression. [31],[32],[33]

Segmental demyelination, axonal degeneration and segmental remyelination observed in patients with chronic renal failure cause distal motor and sensory polyneuropathy. [37] In addition, nerve conduction studies in patients with uremic neuropathy caused by chronic renal failure have shown nerve conduction abnormality of the median nerve in 36% of the cases. [38] Moreover, reduction in sensory and motor nerve conduction velocities is suggestive of the presence of central-peripheral axonopathy. [39] Therefore, electrodiagnostic tests may not be dependable positive predictor tests in these patients. Because of the rising number of patients undergoing hemodialysis, we must broaden our goal from simply lengthening patients' lives to also including long-term continuation of hemodialysis to prevent or minimize complications that compromise quality of life. In this regard, carpal tunnel syndrome is considered to be the main complication that may threaten the continuity of treatment. As most of the patients pay more attention to their wrist and the fistula, the diagnosis of carpal tunnel syndrome may be delayed. Thus, the possibility of carpal tunnel syndrome should always be kept in mind in hemodialysis patients with the presence of symptoms and clinical signs.

The presence of a fistula on the affected side normally precludes the use of an intra-operative tourniquet. Carpal tunnel release with a tourniquet on a fistula arm has been demonstrated in small case series both without and with complications (e.g., fistula thrombosis requiring surgical correction). [22],[23] Carpal tunnel release without a tourniquet is straight-forward as long as suitable hemostatic dissection techniques are used. [24]

Successful treatment of the renal patient with hand pain requires accurate diagnosis, as there is a differential diagnosis in these cases. In particular, the presence of peripheral neuropathy needs to be established as this will suggest incomplete resolution of symptoms from surgery. [22],[25],[26],[28],[40] Pre-operative neuro-physiological investigation by nerve conduction study is recommended to diagnose carpal tunnel syndrome and neuropathy, and to distinguish the two diagnoses in the symptomatic renal dialysis patient.

There is no specific treatment for β-2 amyloidosis. To date, although many treatments have been tested, only kidney transplantation will lower β-2 amyloid levels and may slow or halt progression of amyloidosis and ease symptoms of carpal tunnel syndrome, but is not readily available to most hemodialysis patients. [41],[42],[43] Unfortunately, no modality of hemodialysis can remove more β-2 amyloid levels than is generated, although removal is greater with biocompatible membranes and with hemofiltration and hemodiafiltration. [43],[44],[45],[46] Several studies offer evidence that when hemodialysis is performed with synthetic membranes that have large pores and/or with ultrapure dialysate, the amyloidosis may be delayed if not prevented. [43],[44],[45],[46]

All patients in this study noted an improvement in symptoms. This has been the experience of other authors. [21],[23],[26],[47],[48] There were no instances of recurrence of nerve compression during the follow-up period. Studies with longer follow-up periods than the present study suggest that symptoms begin to recur approximately 1.5 years after the operation, and these symptoms tended to rapidly worsen in about half of the patients who received hemodialysis continuously. [9],[22]

In conclusion, chronic hemodialysis patients are susceptible to developing carpal tunnel syndrome. Extended open carpal tunnel decompression enhances hand function and quality of life in patients receiving long-term hemodialysis with clinical and electrodiagnostic signs of carpal tunnel syndrome.

 
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Correspondence Address:
Sammy Al-Benna
Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, North Rhine-Westphalia, Germany

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DOI: 10.4103/1319-2442.103557

PMID: 23168846

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