A 35-year-old right-handed woman comes to the physician because of a 2-month history of right wrist pain that radiates into her forearm. She also describes a sensation of pins and needles as well as numbness in her right thumb and index finger. She states that her symptoms are worse at night, causing her to wake up in the middle of the night. She has also been inadvertently dropping objects from her right hand. She denies any recent trauma to her right upper extremity, or weakness or numbness involving any of her other limbs. She also denies neck pain. She has no other medical problems. She works as a medical transcriptionist.
Examination shows some atrophy over the right thenar eminence. The sensory examination reveals reduced pinprick sensation along the first, second, and lateral half of the third digit with sparing of the thenar eminence.
An outpatient EMG study is consistent with median neuropathy at the wrist with axonal loss and prolonged motor and sensory latencies.
Which of the following is the next best step in this patient's management?

Question

A 35-year-old right-handed woman comes to the physician because of a 2-month history of right wrist pain that radiates into her forearm.  She also describes a sensation of pins and needles as well as numbness in her right thumb and index finger.  She states that her symptoms are worse at night, causing her to wake up in the middle of the night.  She has also been inadvertently dropping objects from her right hand.  She denies any recent trauma to her right upper extremity, or weakness or numbness involving any of her other limbs.  She also denies neck pain.  She has no other medical problems.  She works as a medical transcriptionist.
Examination shows some atrophy over the right thenar eminence.  The sensory examination reveals reduced pinprick sensation along the first, second, and lateral half of the third digit with sparing of the thenar eminence.
An outpatient EMG study is consistent with median neuropathy at the wrist with axonal loss and prolonged motor and sensory latencies.
Which of the following is the next best step in this patient's management?

Quizplus · Accepted Answer

11ec193a_987a_ba55_853d_211e0ae60a04_MD0002_00 This patient's presentation is consistent with carpal tunnel syndrome (CTS) with severe right median neuropathy across the wrist. Mild to moderate CTS typically presents with intense wrist pain without hand muscle weakness, atrophy, or obvious EMG evidence of median nerve axonal injury. Most patients with mild to moderate CTS respond to conservative therapy (e.g., wrist splint, steroid injections). Nocturnal wrist splinting keeps the wrist in a neutral position to improve flexion and extension, and is preferred initially in most patients. Patients who do not respond to wrist splinting may be treated with wrist glucocorticoid injections. Patients who refuse injections can be treated with a short course of oral steroids. It is important to remember that steroid injections provide only short-term symptomatic relief (1 to 3 months). median neuropathy Surgical median nerve decompression is recommended for patients with severe symptoms (or evidence of axonal injury on EMG) or mild to moderate symptoms refractory to conservative therapy. This patient has severe symptoms with evidence of axonal injury and would benefit most from surgery (Choices A and C). (Choice B) Naproxen and other NSAIDs are not effective for CTS and are not recommended. (Choice D) Physical therapy with carpal bone immobilization limits movement at the wrist bones and joints and can improve paresthesias in some patients; however, studies have not shown significant improvement in short-term pain or hand function. Educational objective: Carpal tunnel syndrome usually affects the dominant hand and is due to compression of the median nerve by the flexor retinaculum. Mild to moderate symptoms are treated with conservative therapy (e.g., wrist splint, steroid injections). Surgical decompression is reserved for patients with severe symptoms (or evidence of axonal injury on EMG) or mild to moderate symptoms refractory to conservative therapy. __________ References: Management of extreme carpal tunnel syndrome: evidence from a long-term follow-up study. (http://www.ncbi.nlm.nih.gov/pubmed/19367639) Carpal tunnel syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21435163)

A 35-Year-Old Right-Handed Woman Comes to the Physician Because of a 2-Month