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The initial symptoms are pain, burning, and tingling in the distribution of the median nerve (the palmar surfaces of the thumb, the index and long fingers, and the radial half of the ring finger) Aching pain may radiate proximally into the forearm and occasionally proximally to the shoulder and over the neck and chest Pain is exacerbated by manual activity, particularly by extremes of volar flexion or dorsiflexion of the wrist It is most bothersome at night Impairment of sensation in the median nerve distribution may or may not be demonstrable Subtle disparity between the affected and opposite sides can be shown by testing for two-point discrimination or by requiring the patient to identify different textures of cloth by rubbing them between the tips of the thumb and the index finger Tinel s or Phalen s sign may be positive (Tinel s sign is tingling or shock-like pain on volar wrist percussion; Phalen s sign is pain or paresthesia in the distribution of the median nerve when the patient flexes both wrists to 90 degrees for 60 seconds) The carpal compression test, in which numbness and tingling are induced by the direct application of pressure over the carpal tunnel, may be more sensitive and specific than the Tinel and Phalen tests Muscle weakness or atrophy, especially of the thenar eminence, appears later than sensory disturbances Specific examinations include electromyography and determinations of segmental sensory and motor conduction delay Sensory conduction delay is evident before motor delay
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This syndrome should be differentiated from other cervicobrachial pain syndromes, from compression syndromes of the median nerve in the forearm or arm, and from mononeuritis multiplex When left-sided, it may be confused with angina pectoris
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COMPLEX REGIONAL PAIN SYNDROME (REFLEX SYMPATHETIC DYSTROPHY)
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Complex regional pain syndrome is a rare disorder of the extremities characterized by autonomic and vasomotor instability The cardinal symptoms and signs are diffuse pain (characteristically localized to an arm or hand, leg or foot), swelling of the involved extremity, disturbances of color and temperature in the affected limb, dystrophic changes in the overlying skin and nails, and limited range of motion Use of the former name of this entity, reflex sympathetic dystrophy, is now discouraged because the precise role of the sympathetic nervous system is unclear and dystrophy is not an inevitable sequela of the syndrome Most cases are preceded by direct physical trauma, often of relatively minor nature, to the soft
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Treatment is directed toward relief of pressure on the median nerve When a causative lesion is discovered, it is treated appropriately Otherwise, patients in whom causative carpal tunnel syndrome is suspected should modify their hand activities and have the affected wrist splinted for 2 6 weeks NSAIDs can also be added Patients should be referred to a specialist for injection of corticosteroid into
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tissues, bone, or nerve Any extremity can be involved, but the syndrome most commonly occurs in the hand and is associated with ipsilateral restriction of shoulder motion (shoulderhand syndrome) The syndrome proceeds through phases: pain, swelling, and skin color and temperature changes develop early and, if untreated, lead to atrophy and dystrophy The swelling in complex regional pain syndrome is diffuse ( catcher s mitt hand ) and not restricted to joints Pain is often burning in quality, intense, and often greatly worsened by minimal stimuli such as light touch The shoulder-hand variant of this disorder sometimes complicates myocardial infarction or injuries to the neck or shoulder Complex regional pain syndrome may occur after a knee injury or after arthroscopic knee surgery There are no systemic symptoms In the early phases of the syndrome, bone scans are sensitive, showing diffuse increased uptake in the affected extremity Radiographs eventually reveal severe generalized osteopenia In the posttraumatic variant, this is known as Sudeck s atrophy Symptoms and findings are bilateral in some This syndrome should be differentiated from other cervicobrachial pain syndromes, rheumatoid arthritis, thoracic outlet obstruction, and scleroderma, among others Early mobilization after injury, surgery, or myocardial infarction reduces the likelihood of developing the syndrome In addition to addressing the underlying disorder, treatment is directed toward restoration of function Physical therapy is the cornerstone of treatment Many patients will also benefit from drug therapies, especially antidepressant agents (eg, nortriptyline initiated at a dosage of 10 mg orally at bedtime and gradually increased to 40 75 mg at bedtime) In resistant cases, prednisone, 30 40 mg/d orally for 2 weeks and then tapered over 2 weeks, may be effective Regional nerve blocks and dorsal-column stimulation have also been demonstrated to be helpful Patients who have restricted shoulder motion may benefit from the treatment described for scapulohumeral periarthritis The prognosis partly depends on the stage in which the lesions are encountered and the extent and severity of associated organic disease Early treatment offers the best prognosis for recovery
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Birklein F Complex regional pain syndrome J Neurol 2005 Feb;252(2):131 8 [PMID: 15729516]
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