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Sindrom zapestnega prehoda - ocenjevanje izida kirurškega zdravljenja v odvisnosti od stopnje prizadetosti medianega živca
Avtor: Valentina Otja Giacomelli, Andrej Repež
Mentor: prof. dr. Zoran M. Arnež, dr.med
Izhodišca. Sindrom zapestnega prehoda spremlja skupek klinicnih simptomov in znakov, ki nastanejo zaradi utesnitve medianega živca pod precno zapestno vezjo. Dolgotrajna in huda utesnitev vodi v trajno poškodbo medianega živca z motnjo obcutljivosti in funkcije mišic. Opisani poskusi ugotavljanja povezanosti trajanja bolezni pred operacijo in izhodišcnega elektrofiziološkega izvida s stopnjo okrevanja po operaciji, niso nedvoumno potrdili ali ovrgli napovednost teh dveh kazalcev, morda tudi zaradi omejene uporabe preiskavnih metod. V naši raziskavi smo s celostnim pristopom poskušali natancneje ugotoviti napovedno vrednost trajanja bolezni in izhodišcnega elektrofiziološkega izvida. Zanesljivi prognosticni kazalci bi pomenili pomembno orodje v obravnavi bolnika s sindromom zapestnega prehoda. Hipoteza 1. Kratka anamneza simptomov pred operacijo omogoca boljše in hitrejše okrevanje senzoricnih in motoricnih funkcij roke. Hipoteza 2. Izhodišcni elektrofiziološki izvid pred operacijo, ki pokaže manjšo prizadetost, omogoca boljše in hitrejše okrevanje senzoricnih in motoricnih funkcij roke.
Bolniki in metode. V raziskavi je sodelovalo 30 bolnikov z znacilnimi klinicnimi simptomi in znaki ter elektrofiziološko potrjeno diagnozo, in 10 zdravih prostovoljcev. Velikost vzorca bolnikov je kompromis statisticnih zahtev in velikega obsega preiskav (klinicni pregled, kvantitativna senzorimetrija in elektrofiziološke preiskave). Bolnike smo pregledali tik pred operacijo in 3 ter 6 mesecev po njej. Zdrave preiskovance smo pregledali le enkrat.
Rezultati. V skupni oceni nevroloških motenj smo zajeli rezultate pregleda motoricnih funkcij in kvantitativne senzorimetrije pred operacijo in 3 ter 6 mesecev po njej. Preskus povezanosti skupne ocene pred operacijo s casom trajanja simptomov ni pokazal znacilne povezave v nobenem kontrolnem obdobju (p<0,01). Skupna ocena je z izvidom izhodne elektrofiziološke preiskave v pozitivni povezavi v vseh treh kontrolnih obdobjih (r = 0,63, r = 0,6 in r = 0,59, p<0,01). Bolnike smo razdelili v 3 skupine po stopnjah prizadetosti glede na izsledke izhodišcnega elektrofiziološkega izvida. Analiza prognosticne vrednosti izhodiscnega elektrofiziološkega izvida je pokazala naslednje deleže bolnikov, ki so bili brez nevroloških motenj po 3 oziroma 6 mesecih: v skupini s hudo prizadetostjo 0 oziroma 40 %, skupina z zmerno prizadetostjo 17 oziroma 83 % in skupina z blago prizadetostjo 36 oziroma 92 %. Delež zdravih preiskovancev znacilno narašca in se razlikuje po skupinah (p<0,05).
Zakljucki. Cas trajanja bolezni pred operacijo ni v zvezi s stopnjo in hitrostjo okrevanja senzoricnih in motoricnih funkcij po operaciji. Poleg trajanje bolezni obstojijo še drugi pomembni dejavniki v razvoju kronicne utesnitve. Dejavnika, ki imata morda pomembnejšo vlogo pri nastanku okvare živca sta velikost pritiska v zapestnem prehodu in patološka preobcutljivost živcnih vlaken zaradi notranjih in zunanjih vzrokov. Izhodišcni izvid elektrofiziološke preiskave je jasno povezan s pooperativnim okrevanjem v vseh kontrolnih obdobjih. Izvid kaže na stopnjo bolezenskega procesa pred operacijo in omogoca napoved izida zdravljenja
[Abstract / English version]
Carpal tunnel syndrome - prognosis of surgical treatment outcome based on severity of entrapment of median nerve
Author: Valentina Otja Giacomelli, Andrej Repež
Mentor: prof. dr. Zoran M. Arnež, dr.med
Background. Carpal tunnel syndrome is an entrapment neuropathy of median nerve under the transverse ligament of the wrist and a defined clinical entity. Long-term and intense compression leads to permanent damage of median nerve with loss of sensoric and motoric functions in hand. Previous attempts failed to establish a certain correlation between duration of illness or results of electrophysiologic examination before the operation and pooperative recovery, possibly caused by limited methodological aproach. Our research was designed to ascertain the correlation and to establish the prognostic value of either of these two preoperative indices. Reliable prognostic factors would provide an important tool in management of patients with carpal tunnel syndrome. Hypothesis 1. Short history of clinical symptoms before operation leads to better and faster recooperation of sensoric and motoric functions in hand. Hypothesis 2. Less pathological preoperative electrophysiological results yields better and faster recooperation of sensoric and motoric functions in hand.
Patients and methods. 30 patients with definite clinical diagnosis and electrophysiological conformation of median entrapment neuropathy, and 10 healthy volunteers took part in our study. The size of patient sample is a compromise of stathistical demands and the ampleness of examinations (clinical examination, quantitative sensorimetry, electrophysiology). Patients were examined just before the operation and after 3 and 6 months. Volunteers were examined only once.
Results. Common index of neurological deficits was introduced and calculated for each follow-up period. It comprizes the results of motor function examination and quantitative sensorimetry. Correlation of common index of neurological deficits and duration of illness failed to be significant in any of the follow-up periods (p < 0,01). Common index of neurological deficits correlates positively with the results of the preoperative electrophysiological examination before operation and after 3 and 6 months (r = 0,63, r = 0,6, r = 0,59, respectively, p < 0,01). Patients were divided into three groups according to the results of the preoperative electrophysiological examination. Analysis of the prognostic value of the preoperative electrophysiological results showed the following percentages of patients with no neurological deficit in the 3rd and the 6th pooperative month: in group with severe results 0 and 40% respectively, in group with moderate results 17 and 83 % respectively, in group with mild results 36 and 93 % respectively. Percentage of healthy patients significantly differs among the groups (p < 0,05).
Conclusions. Duration of illness before operation is not related with the pooperative recovery of sensoric and motoric functions in hand. Results of the preoperative electrophysiological examination is clearly correlated with the pooperative recovery throughout the follow-up period of six months. Results reflect the pathological stage of disease before operation and provide certain prognosis of pooperative course.