Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients

Abstract

All great truths begin as blasphemies.-George Bernard Shaw W e have observed a group of patients who do not display the typical carpal tunnel syndrome signs and symptoms. 1,2 Their main complaints are pain and allodynia, often not limited to the median nerve distribution, worsening at night, and above all, inability to make a full fist (Fig. 1, above and center). Despite the different presentation from the typical carpal tunnel syndrome patient, they respond equally well to carpal tunnel release (Fig. 1 , below).Apparently unrelated to the description above, or to a problem in the carpal canal, is the condition known as complex regional pain syndrome of the upper limb (also known as reflex sympathetic dystrophy, Sudeck disease, or algodystrophy). Its clinical picture is characterized by trophic and vasomotor changes and, above all, pain out of proportion, which may be constant, present at rest or with the slightest movement, and with varying severity of allodynia and hyperalgesia. Disturbed sleep is the norm. The hand appearance changes over time: initially red, warm, and swollen, it later becomes whiter, drier, cooler, and stiffer. [3][4][5][6][7][8][9][10] Despite the abundant literature and research, complex regional pain syndrome has an

Discussion: Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients

“…Although a potential connection between carpal tunnel syndrome and complex regional pain syndrome has already been reported, 3 the present study 4 strongly suggests that a subset of patients “labeled” with the diagnosis of complex regional pain syndrome have an underlying trigger of carpal tunnel syndrome, which is surgically correctable by simple carpal tunnel release; and this surgical intervention has been documented to relieve the patient’s intractable pain and improve their range of motion. This hypothesis may not be accepted either by pain management specialists who rely on complex regional pain syndrome for their fees or by surgeons who use this diagnosis to explain their complications.…”

“…Unlike other conditions or injuries affecting the hand where there are objective tests, such as radiologic imaging or nerve conduction studies to confirm the diagnosis, complex regional pain syndrome is unique in that, despite patients complaining of pain out of all proportion to their original injury or surgery, there is no definitive diagnostic test to confirm this diagnosis, and physicians have to rely on less objective signs or consensus criteria. 1,2 Although a potential connection between carpal tunnel syndrome and complex regional pain syndrome has already been reported, 3 the present study 4 strongly suggests that a subset of patients "labeled" with the diagnosis of complex regional pain syndrome have an underlying trigger of carpal tunnel syndrome, which is surgically correctable by simple carpal tunnel release; and this surgical intervention has been documented to relieve the patient's intractable pain and improve their range of motion. This hypothesis may not be accepted either by pain management specialists who rely on complex regional pain syndrome for their fees or by surgeons who use this diagnosis to explain their complications.…”

Treatment of recurrent carpal tunnel syndrome with fat grafting as an adjunct

“…The suspected mechanism of action is the differentiation of adipocyte-derived stem cells into Schwann cells and the release of trophic and anti-inflammatory factors [10][11][12][13][14][15] . These studies are based on work on animal models of nerve injury, yet there is no study correlating these hypotheses to the actual improvement in clinical studies.…”

“…Adipose-derived stem cells are the most practical as they can be harvested easily from patients with a high yield of stem cells, about one million stem cells per gram of fat [8,9] . The mechanisms proposed in which adipose-derived stem cells aid in peripheral nerve injuries are: in situ differentiation to Schwann cells and secretion of trophic and anti-inflammatory factors [10][11][12][13][14][15][16][17][18][19][20] . The studies demonstrate that the positive effects of adipose-derived stem cells on peripheral nerve regeneration are mostly limited to animal models [21] .…”

Diagnosis and Outcomes of 225 Consecutive Cases of CRPS of the Hand.

“…In this respect, recently, carpal tunnel release (CTR) has been found curative in a group of patients who were diagnosed with CRPS. 18,19…”