The objective of this study was prospective comparative determination of both clinical and neurophysiological characteristics of a new pathological reflex in CTS. The authors investigated 300 patients with severe carpal tunnel syndrome undergoing surgery. The 134 patients who showed the sign were allocated as the reflex group. The remaining 166 cases with no sign were named the control group. Two blinded neurology specialists eva luated all patients prior to and after the surgery. Their clinical data, the reflex sign and the electrophysiological results were recorded. The ligament thicknesses during surgery and postoperative changes were also recorded. The reflex group showed exaggerated symptoms with worse electrophysiological results. The reflex group also had thicker median carpal ligament in operative measurements. The difference was significant. The reflex does not disappear easily after surgery and persists up to three months. In the author’s opinion , this sign may present a new pathological reflex indicating severe long-lasting nerve compression with the requirement of surgical de compression of the median nerve in CTS subjects.
The neurological signs and symptoms of CTS are well known in the daily practice of hand surgeons and neurosurgeons. There is no diagnostic difficulty in the majority of the CTS cases in the preoperative period but confirming of the severity may sometimes be difficult in complicated cases [
In this study, the authors sought to identify this new NS by evaluating patients in a prospective manner using both electrophysiological and intraoperative findings. The increased chronic pressure of the thickened carpal ligament may exaggerate NS positivity. Ligament measurements from the operated cases were used to confirm the condition.
After the first discovery of the NS during the neurological examination of severe carpal tunnel syndrome patients between 1998 and 2000, this prospective study was planned and performed. The study was initially reviewed by the hospital human studies ethical committee and accepted. At the time of the examination of the patients, the NS was carefully investigated and observed by two blinded neurology specialists. The duration of the symptoms, the dominant hand and all accompanying diseases were queried. Patients with diabetes or other neurological diseases such as cervical spinal stenosis or disc disease were excluded from study. Electrophysiological studies of the subjects were performed at the other centers before the investigation.
The thickness of the ligament and postoperative clinical recovery duration were also recorded. The results of surgery were evaluated. There were 300 consecutive patients enrolled in the study between 2000 and 2008. All patients underwent x-rays and MRI to rule out bony or other soft tissue abnormality (
The NS appears when the examiner gently taps on the flexor retinaculum with a reflex hammer. A positive result is sudden flexion of the distal interphalangeal joints with flexion of the elbow and shoulder (occasionally) in severe cases (
Statistical analyses were performed using the t test. Values for P < 0.05 were considered statistically significant. Results are presented as means ± standard error.
A total of 300 patients consisting of 268 women and 32 men were investigated for the presence and severity of the neurological sign. The demographic data and clinical presentation of the patients are displayed in
Postoperatively, the NS did not disappear quickly and generally persisted up to the third postoperative month.
The CTS is a nerve entrapment pathology caused by the chronic compression of the median nerve at the wrist. The reason for this compression is a hypertrophied median carpal ligament [2,3]. One percent of the general population is affected by CTS [4,5]. After its first description by Sir James Paget in 1854, the underlying pathology and physical compressive elements became clear with time. Although Pierre Marie and Charles Foix both recommended sectioning the transverse carpal ligament to relieve symptoms in CTS, the first operation was performed by Herbert Galloway and Andrew McKinnon in 1929 [
The test for NS in our observations differs from the previous examination maneuvers. The combination of
*Significantly higher than other group (P < 0.05).
*Significantly higher than the other group (P < 0.05).
*Significantly higher than the other group (P < 0.05).
flexion of the shoulder, elbow and fingers emphasizes some degree of hyper excitation and irritability of the spinal cord secondary to chronic median nerve compression.
Various authors have investigated the results of chronic nerve compression from different aspects. The chronic compression in peripheral neuropathies may induce severe irreversible changes in both the spinal cord and peripheral nerves. Girlanda et al. showed the hyper-excitability of the motor neuronal pool in the spinal cord of cubital tunnel patients in 2000. The authors concluded that a peripheral nerve injury might induce pathological rearrangement of nerve circuits at the spinal cord level [
The proposed reflex arc consists of both afferent and efferent pathways with several neural interconnections in the spinal cord. To the author’s opinion the main afferent way should be sensory, conveying fibers of the median nerve. The motor jerk response mainly affects the biceps with the elbow flexors, finger flexors and interosseous muscles of the hand. Therefore the possible efferents for this NS may be the median and ulnar nerves of the forearm. The spinal interconnections seem more complex and questionable but have a serious influence on the excitation of C4, C5, C6 and C7 radixes.
Minority of our patients showed NS without Tinel’s sign. This condition may be explained by severe nerve dysfunction, inactivity of pain fibers or central ignorance to pain after chronic compression of the nerve.
A single study has previously mentioned a similar response as a motor Tinel’s sign in entrapment neuropathies of the cubital tunnel and CTS. This observation included a limited patient size of 30 CTS patients and no surgical results. A muscle jerk with percussion of the median nerve was not visually observed but corresponding myoclonic bursts were demonstrated on electromyographic (EMG) records of the effected muscles in 15 patients [