A 65-year-old woman comes to the physician for mild pain, tingling, and numbness in her right hand. The symptoms started 2 weeks ago and are worse at night. She experiences neck pain occasionally but has no shooting or radiating pain. The patient has not had any recent head/neck trauma, headache, muscle weakness, or bowel/bladder incontinence. Her past medical history includes hypertension, hyperlipidemia, and cervical degenerative disk disease. The patient has a 30-pack-year smoking history. She is retired and knits frequently as a hobby.
Her blood pressure is 150/90 mm Hg and pulse is 88/min. Examination of the right hand reveals decreased sensation to pain and temperature along the ventral aspect of the first 3 digits and the radial half of the fourth digit. Sensation over the thenar eminence is preserved. There is no muscle weakness or atrophy.
Which of the following is the most appropriate next step in management of this patient?

Question

A 65-year-old woman comes to the physician for mild pain, tingling, and numbness in her right hand.  The symptoms started 2 weeks ago and are worse at night.  She experiences neck pain occasionally but has no shooting or radiating pain.  The patient has not had any recent head/neck trauma, headache, muscle weakness, or bowel/bladder incontinence.  Her past medical history includes hypertension, hyperlipidemia, and cervical degenerative disk disease.  The patient has a 30-pack-year smoking history.  She is retired and knits frequently as a hobby.
Her blood pressure is 150/90 mm Hg and pulse is 88/min.  Examination of the right hand reveals decreased sensation to pain and temperature along the ventral aspect of the first 3 digits and the radial half of the fourth digit.  Sensation over the thenar eminence is preserved.  There is no muscle weakness or atrophy.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation is consistent with carpal tunnel syndrome (CTS) as she has subjective pain/paresthesias in the median nerve distribution. Symptoms of CTS are frequently worse at night and can be exacerbated by repetitive/sustained hand movements (eg, knitting). Preservation of sensation over the thenar eminence is highly indicative as the palmar sensory cutaneous branch of the median nerve goes over, not through, the carpal tunnel. Provocative maneuvers such as the Phalen and Tinel tests have limited sensitivity (~60%) and specificity (~70%). median nerve Phalen and Tinel tests CTS is primarily a clinical diagnosis. Nerve conduction studies (NCS) are usually performed during atypical presentations, to evaluate disease severity, and prior to considering surgery (sensitivity 56%-85%, specificity 94%). Electromyography is often done with NCS to differentiate neurogenic versus myopathic weakness. Neither of these studies is necessary in this patient as her symptoms are mild and her presentation is typical of CTS (Choice C). Patients with mild-to-moderate disease can have short-term symptom relief with conservative measures (20%-93% success rate) such as wrist splinting and injectable corticosteroids. Decompressive surgery might result in long-term improvement (75% success rate) and should be considered in patients with severe disease or in those who have failed conservative measures (Choice D). (Choice A) Although this patient has risk factors for stroke (eg, hypertension, hyperlipidemia, smoking), a brain MRI will not likely be useful as her focal sensory deficits follow a median nerve distribution. Patients with lacunar stroke of the thalamus can present with pure sensory loss; however, symptoms/signs typically occur on one side of the body (eg, face, arm, and leg). (Choice B) Cervical radiculopathy can present with pain and paresthesias in the hand; however, symptoms would follow a dermatomal pattern as opposed to a median nerve pattern. dermatomal pattern Educational objective: Carpal tunnel syndrome is primarily a clinical diagnosis. Electrodiagnostic studies are usually performed during atypical presentations, to evaluate disease severity, and prior to considering surgery. Mild-to-moderate cases can be treated conservatively (eg, wrist splinting, injectable corticosteroids). __________ References: Optimal management of carpal tunnel syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20830201) Carpal tunnel syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21524035)

A 65-Year-Old Woman Comes to the Physician for Mild Pain