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Muscle belly in the tunnel: an unusual cause of carpal tunnel syndrome in a patient with spinal cord injury.

ABSTRACT: Introduction:Carpal tunnel syndrome, entrapment of median nerve at the wrist, is one of the most commonly encountered peripheral neuropathies in the upper extremity. It is also common in individuals with spinal cord injury due to repetitive movements during wheelchair use. Although it is well known that prevalence of carpal tunnel syndrome is high in individuals with spinal cord injury, no previous study identified aberrant muscle as the cause. Case presentation:A 43-year-old man with T10 incomplete, ASIA Impairment Scale (AIS) C, patient with paraplegia who is a wheelchair basketball player presented to our electrodiagnostic laboratory with complaints of bilateral hand numbness after intensive training for a local veteran wheelchair basketball tournament. Nerve conduction studies showed carpal tunnel syndrome. Ultrasonographic assessment of carpal tunnel revealed the presence of abnormal muscle in the carpal tunnel encroaching the median nerve dynamically. Discussion:It is important to identify the underlying cause of carpal tunnel syndrome, which is a common cause of upper extremity impairment in individuals with spinal cord injury because individuals with spinal cord injury who use wheelchair depend on their arms for mobility, transfers, and most activities of daily life.

SUBMITTER: Giray E

PROVIDER: S-EPMC6786366 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Muscle belly in the tunnel: an unusual cause of carpal tunnel syndrome in a patient with spinal cord injury.

Giray Esra E Gencer Atalay Kardelen K Kurt Sefa S Yağcı İlker İ

Spinal cord series and cases 20190603

<h4>Introduction</h4>Carpal tunnel syndrome, entrapment of median nerve at the wrist, is one of the most commonly encountered peripheral neuropathies in the upper extremity. It is also common in individuals with spinal cord injury due to repetitive movements during wheelchair use. Although it is well known that prevalence of carpal tunnel syndrome is high in individuals with spinal cord injury, no previous study identified aberrant muscle as the cause.<h4>Case presentation</h4>A 43-year-old man ...[more]

PMID: 31632712

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Project description:BackgroundCarpal tunnel syndrome (CTS) is by far the most common entrapment neuropathy (Adams et al. Am J Ind Med 25:527-536, 1994; Cheadle et al. Am J Public Health 84:190-196, 1994; Stevens et al. Neurology 38:134-138, 1988). A combination of described symptoms, clinical findings and electrophysiological testing is used to confirm the diagnosis. Several studies have suggested that in patients with a clinical diagnosis of CTS, the accuracy of nerve sonography is similar to that for electromyography (Chen et al. BMC Med Imaging 11:22, 2011; Guan et al. Neurol Res 33:970-953, 2011; Kele et al. Neurology 61:389-391, 2003; Tai et al. Ultrasound Med Biol 38:1121-1128, 2012). In special cases though, the nerve sonography can reveal the cause of the median entrapment neuropathy (Fumière et al. JBR-BTR 85:1-3, 2002; Kele et al. J Neurosurg 97:471-473, 2002; Kele et al. Neurology 61:389-391, 2003; Zamora et al. J Clin Ultrasound 39:44-47, 2011).MethodsA 43-year-old farmer was admitted to our department with 1 year of intermittent pain in the left hand and numbness of the thumb, index and middle finger. The pain and the numbness could be reproduced by extension of the wrist and fingers. The electrophysiological testing revealed signs of an entrapment median neuropathy in carpal tunnel.ResultsThe high-resolution sonography (18 MHz) revealed signs of entrapment neuropathy with increased cross-sectional area, disturbed echostructure of the nerve and pathological wrist-to-forearm ratio, confirming the results from a similar study (Kele et al. Neurology 61:389-391, 2003). In addition, an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel could be identified. During the extension of the wrist and fingers, a greater protrusion of the muscle belly could be demonstrated causing compression of the median nerve.ConclusionsWe present a video case report of the sonographic findings of a patient diagnosed with carpal tunnel syndrome due to an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel. Our case highlights the importance of nerve sonography in the differential diagnosis of the cause of a carpal tunnel syndrome. With the aid of ultrasonography, it is possible to obtain very important information concerning different aspects of this case. First, in showing the presence of the elongated muscle belly of the flexor digitorum superficialis, the cause of the symptoms could be explained. Second, it was possible through the ultrasound study to explain the atypical clinical appearance in this case, demonstrating the compression neuropathy only after extension of the wrist and fingers. There have been no previous reports in which authors described an elongated muscle belly as cause of a CTS. Third, and perhaps most important, ultrasonography had a direct influence on our selection of therapeutical strategy and approach. As a result, we recommended in this patient a surgical therapy to completely solve the problem, but the patient declined this option and preferred a conservative therapy with a hand orthosis to prevent wrist extension. In conclusion we recommend ultrasonography as a very useful method in the diagnostic evaluation of carpal tunnel syndrome. We have clearly demonstrated that ultrasonography can be used to discover the cause of median nerve compression, especially in cases with an atypical clinical presentation.

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Muscle belly in the tunnel: an unusual cause of carpal tunnel syndrome in a patient with spinal cord injury.

Publications

Muscle belly in the tunnel: an unusual cause of carpal tunnel syndrome in a patient with spinal cord injury.

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