DVT

Hand Surgery, Vol. 10, No. 1 ( July 2005) 1–5

© World Scientific Publishing Company

ORIGINAL ARTICLES

IS SYMPTOMATOLOGY USEFUL IN DISTINGUISHING BETWEEN CARPAL TUNNEL SYNDROME AND

CERVICAL SPONDYLOSIS?

C. S. Chow, L. K. Hung, C. P. Chiu,* K. L. Lai,* L. N. Lam,* M. L. Ng,* K. C. Tam,* K. C. Wong* and P. C. Ho

Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong Prince of Wales Hospital, Hong Kong S.A.R., China

Received 22 March 2004; Accepted 25 January 2005

ABSTRACT Hand paraesthesia is a common symptom found in patients either with carpal tunnel syndrome or cervical spondylosis. To differentiate between the two conditions, it is important to identify additional diagnostic symptoms. Ninety-two patients with operated carpal tunnel syndrome and 138 patients with spinal surgery for cervical spondylosis were reviewed. After exclusion of cases co-morbid with both cervical spondylosis and carpal tunnel syndrome or other neurological disorders, 44 patients with carpal tunnel syndrome and 41 patients with cervical spondylosis were compared. There were significant differences in the symptomatology between the two groups. In carpal tunnel syndrome, 84% had nocturnal paraesthesia, 82% hand paraesthesia were aggravated by hand activity, and hand pain occurred in 64%. The incidences were only 10%, 7% and 10%, respectively in cervical spondylosis. Neck pain was present in 76% of cervical spondylosis but only in 14% of carpal tunnel syndrome, and lower limb symptoms were present in 44% of cervical spondylosis and only 9% in carpal tunnel syndrome.

Keywords: Hand Paraesthesia; Hand Pain; Nocturnal Hand Pain.

INTRODUCTION

Hand paraesthesia is defined as tingling, pins-and-needles sen- sation and numbness. This symptom has a point prevalence of 33% as estimated by a British survey.1 It is commonly caused by impingement of one or more nerve roots in the neck as a consequence of cervical spondylosis (CS), or by periph- eral nerve entrapment, particularly in carpal tunnel syndrome (CTS).2 Theoretically, the anatomic distribution of paraesthe- sia may provide a useful clue to the underlying pathology. In clinical practice, the difference is frequently indistinct and it is difficult for patients to recall the exact distribution of the sensory

Correspondence to: Professor L. K. Hung, Room 74038, 5/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, N. T., Hong Kong S. A. R., China. Tel: (+852) 2632-2724, Fax: (+852) 2637-7889, E-mail: [email protected] ∗Medical students of CUHK, Hong Kong.

symptoms. The classical physical signs, such as the Phalen test, Tinel sign or direct compression over the nerve were commonly used for CTS. However, the reliability of these well-known clini- cal signs has been questioned due to their poor sensitivity, which ranged only from 42% to 58%.3 The nerve conduction study has a sensitivity of 90% for CTS3 but is unreliable for CS. It is expen- sive and time-consuming and is not cost efficient for screening purpose. The use of magnetic resonance imaging (MRI) for the diagnosis of CS is also not cost-effective.

The authors therefore compared and analysed the role of different clinical symptoms, including hand pain, neck pain,

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neck stiffness, hand weakness, arm/shoulder pain, lower limb and sphincter symptoms. These symptoms occur with certain frequency and regularity in either CTS or CS and can act as a useful tool in the clinical setting to help in differentiating between the conditions.

MATERIAL AND METHODS

The case records of 92 patients who had surgical release for CTS between January 2001 to May 2003 were reviewed. All these patients had pre-operative nerve conduction studies which demonstrated a conduction block at the carpal tunnel. They all had symptomatic improvement after surgical release. Another 138 patients with spinal surgery for CS were also reviewed. These patients had MRI confirmation of cervical pathology and had either anterior spinal fusion, posterior spinal fusion or lamino- plasty performed during the period from May 1999 to May 2003. They also had improvement in their conditions after surgery.

A proforma was designed for the analysis of the clinical symp- toms of each patient at the initial presentation. The proforma analysed the pattern of hand paraesthesia exacerbation, hand pain, neck pain, hand weakness, lower limb symptoms, sphinc- ter disturbance, neck stiffness, arm pain and shoulder pain (Table 1). The proforma was completed by review of the record and a phone interview was carried out whenever necessary. Several categories of patients were excluded from the analysis. These included patients who were lost to follow-up or who had died prior to the review, mentally ill, physically frail with multi- ple other medical problems, presented with both symptoms and signs of CS and CTS or were co-morbid with other neurological disorders, and could be classified as having a “double crush” syndrome. After exclusion, 44 patients (37 females; six males; mean age 51) with CTS and 41 patients (12 females; 29 males, mean age 48) with CS were recruited.

Results were analysed statistically with Fisher-exact test using the SPSS version 11.0 software; p values <0.05 were considered statistically significant.

RESULTS

The results are summarised in Table 1 and Figs. 1 to 4.

Hand Paraesthesia

The occurrence of hand paraesthesia alone is not useful for differentiating between CTS and CS. Bilateral hand paraesthesia

Table 1 Incidence of Different Symptoms.

Carpal Tunnel Cervical Syndrome Spondylosis

Symptoms n = 44 n = 41 p Hand paraesthesia (bilateral) 27 61% 19 46% 0.195

Nocturnal exacerbation 37 84% 4 10% 0.000

Hand activity exacerbation 36 82% 3 7% 0.000

Neck activity exacerbation 2 5% 8 20% 0.082

Hand pain 28 64% 4 10% 0.000

Both hands 19 43% 1 2% 0.000

Nocturnal exacerbation 23 52% 1 2% 0.000

Hand activity exacerbation 20 61% 2 5% 0.000

Neck activity exacerbation 0 0% 2 5% 0.230

Neck pain 4 9% 31 76% 0.000

Nocturnal exacerbation 1 2% 8 20% 0.013

Hand activity exacerbation 0 0% 2 5% 0.230

Neck activity exacerbation 0 0% 14 34% 0.000

Hand weakness 35 80% 21 51% 0.004

Lower limb symptoms 4 9% 18 44% 0.000

Sphincter disturbance 1 2% 3 7% 0.102

Neck stiffness 5 11% 10 24% 0.157

Arm pain 10 23% 9 22% 1.000

Shoulder pain 11 25% 14 34% 0.475

∗Fischer-exact.

occurred in 61% of CTS patients and 46% of CS patients. The difference was not statistically significant. However, the associa- tion of hand paraesthesia with nocturnal exacerbation and hand activity is much more common in CTS. The difference was more than 70% and was statistically highly significant. Surprisingly neck movements only aggravated paraesthesia in 20% of CS.

Hand Pain

Hand pain occurred more frequently in CTS and is a useful symptom for differentiating the two conditions. This was also fre- quently aggravated by activities or at night. Again, exacerbation by neck movements was not common, even for CS.

Neck Pain

Neck pain is distinctly more common for CS, and showed noc- turnal exacerbation and exacerbation by neck movements. Neck

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Symptomatology for Distinguishing Between CTS and CS 3

Fig. 1 Comparison of hand paraesthesia between the two conditions. CTS: Carpal tunnel syndrome; CS: cervical spondylosis.

Fig. 2 Comparison of hand pain between the two conditions. CTS: Carpal tunnel syndrome; CS: cervical spondylosis.

pain occurred in 9% of CTS patients, therefore on the basis of neck pain alone it does not help to differentiate between the two conditions.

Hand Weakness

Hand weakness occurred in 80% of patients with CTS. It is more often than CS. But there is also weakness in 51% of CS patients.

Lower Limb Symptoms

There are symptoms of paraesthesia and spasticity. These occurred in 44% of CS patients, which was much more than the incidence of 9% in CTS patients.

Others

Sphincter dysfunction, neck stiffness, arm pain, shoulder pain were also compared. These symptoms occurred in variable

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4 C. S. Chow et al.

Fig. 3 Comparison of neck pain between the two conditions. CTS: Carpal tunnel syndrome; CS: cervical spondylosis.

Fig. 4 Comparison of different symptoms between the two conditions. CTS: Carpal tunnel syndrome; CS: cervical spondylosis.

extent in either conditions (Table 1) but did not demonstrate a statistically significant difference between the two conditions.

DISCUSSION

The result of our study demonstrated that there is a certain overlap of the symptomatology between CS and CTS. Some symptoms are distinctly different, and when all symptoms are analysed together, the two conditions can be differentiated quite confidently.

Hand Paraesthesia

Although hand paraesthesia occurs in almost 100% of CTS patients,4 and is often the first presentation, in a Cochrane review for cervical spondylotic radiculomyelopathy, 98% of patients also had hand paraesthesia at presentation.5 In another prospective study for CTS, the sensitivity and specificity for hand paraesthesia is 97% and 4%, respectively.3 In the same study, nocturnal exacerbation was shown to have a sensitivity of 91% and specificity of 14%. In the present study, the mere occurrence

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Symptomatology for Distinguishing Between CTS and CS 5

of bilateral hand paraesthesia cannot be relied to differentiate the two conditions. When hand paraesthesia is associated with nocturnal exacerbation and hand activity exacerbation, these are reliable symptoms to diagnose CTS.

Hand Pain

Hand pain has been found in previous studies to be a com- mon feature in CTS. In Buch-Jaeger’s study of CTS, hand pain has a sensitivity of 80% and a specificity of 27%;3 nocturnal exacerbation of hand pain also has a sensitivity of 91% and specificity of 14%. In another study by Katz et al., hand pain has a sensitivity of 61% and specificity of 71% for CTS.6 Our study has confirmed that hand pain was a very distinctive feature in CTS and occurred in 64%. There was a high incidence of exacer- bation by activity or at night. It was postulated that compression within the carpal tunnel causes decreased blood supply to nerve fibres. The C-fibres, which are the pain and temperature afferent fibres, are most sensitive to ischaemia. Therefore, when these fibres are affected hand pain becomes a distinctive feature.3

Neck Pain

Neck pain is very common among the general population. It is non-specific and can be caused by a number of conditions.7

An epidemiological study showed that the prevalence of neck pain in asymptomatic patients (23.7%) is similar to those with median nerve sensory symptoms (24.0%).2 In patients with non- median hand numbness, the prevalence of neck pain is much higher (33.6%–40.7%) and was thought to be caused by CS.2,8

In CS with radiculopathy, the neck pain is frequently aggra- vated by neck movements because of foraminal narrowing with movements.7,9 Similar observations were made in our study.

Hand Weakness

The presence of hand weakness is quite controversial. In our study, the incidence of hand weakness is significantly higher in the CTS group. However, other studies indicated that motor weakness in the hand is commonly seen in patients with CS.8,9

This could be due to the more advanced presentation of our patients. Therefore, the occurrence of hand weakness alone is not reliable for an accurate diagnosis and other symptoms need to be considered together.

Lower Limb Symptoms

The presence of lower limb symptoms indicates the occurrence of cervical myelopathy and is a late symptom.10 Since the CS cases in this study are all operated cases, they tend to have more advanced diseases, therefore the incidence of lower limb symptoms was high. For an average case of CS, this may not be a reliable symptom to differentiate it from CTS.

CONCLUSION

Clinical symptoms can be safely and accurately relied for dif- ferentiating between CTS and CS. As a result, an early diagnosis can be made which lead to early effective therapy. This could reduce the need to use nerve conduction studies or MRI scans which are expensive procedures. They can be reserved for the ambiguous cases or for more advanced cases which are being planned for surgery.

References 1. Ferry S, Silman AJ, Pritchard T, Keenan J, Croft P, The association between

different patterns of hand symptoms and objective evidence of median nerve compression, Arthritis Rheum 41:720–724, 1998.

2. Reading I, Walker-Bone K, Palmer KT, Cooper C, Coggon D, Anatomic distribution of sensory symptoms in the hand and their relation to neck pain, psychosocial variables, and occupational activities, J Epidemiol 157A:524–530, 2002.

3. Buch-Jaeger N, Foucher G, Correlation of clinical signs with nerve con- duction tests in the diagnosis of carpal tunnel syndrome, J Hand Surg 19B(6):720–724, 1994.

4. Thomsen JF, Mikkelsen S, Interview data versus questionnaire data in the diagnosis of carpal tunnel syndrome in epidemiological studies, Occup Med 53:56–63, 2003.

5. Fouyas IP, Statham P, Sandercock P, Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy, Spine 27:736–747, 2002.

6. Katz JN, Larson MG, Sabra A, Krarup C, Stirrat CR, Sethi R, Eaton HM, Fossel AN, Liang M, The carpal tunnel syndrome: diagnositc utility of the history and physical examination findings, Ann Inter Med 112:321–327, 1990.

7. Narayan P, Haid RW, Treatment of degenerative cervical disc disease, Neurol Clin 1:217–229, 2001.

8. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S, Reli- ability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy, Spine 28:52–62, 2003.

9. Malanga GA, The diagnosis and treatment of cervical radiculopathy, Med Sci Sports Exerc 7(Suppl):S236–245, 1997.

10. Rao R, Neck pain, cervical radiculopathy, and cervical myelopathy, JBJS 84A:1872–1881, 2002.

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