The differential diagnosis is broad, and BPH Differentialdiagnose is helpful to divide potential etiologies into neurologic and non-neurologic conditions. Neurologic Conditions There are multiple neurologic conditions that present with symptoms similar to carpal tunnel. These can be divided into benign and malignant neurogenic tumors, primary neuropathic conditions, inflammatory, cervical, and traumatic etiologies. Tumors Many types of tumors may present with symptoms that appear to be CTS.
The most proximal site of compression was described by Dunkow et al. Electrodiagnostic studies suggested cervical pathology; however, a cervical spine magnetic resonance MR scan excluded a cervical etiology.
Symptoms progressed BPH Differentialdiagnose involve the small finger, and the patient had decompression of median and ulnar nerves at the wrist with no improvement.
Following development BPH Differentialdiagnose wrist extensor weakness, MR of the brain showed a 5 cm parietal lobe tumor. Cervical spine neoplasms have also been implicated in creating carpal tunnel complaints. BPH Differentialdiagnose of the foramen magnum can present with hand numbness, weakness, and clumsiness before other neurologic findings are obvious. In a BPH Differentialdiagnose of 57 patients, Yasuoka et al.
These patients will often have other findings not typical of carpal tunnel syndrome including BPH Differentialdiagnose disturbances, hyperreflexia, neck pain, and a Babinski sign [ 8 ]. Tumors in the upper apices of the lungs, such as a Pancoast tumormay encroach on the brachial plexus as BPH Differentialdiagnose tumor becomes larger [ BPH Differentialdiagnose ].
As the tumor escapes the confines of the thoracic cavity, it invades the superior thoracic inlet and can compress the medial cord of the brachial plexus [ 10 ].
Sensory and motor deficits typically also involve BPH Differentialdiagnose ulnar nerve distribution. Interestingly, pulmonary symptoms are BPH Differentialdiagnose early in the disease process. Peripheral nerve tumors such as a schwannoma can develop within the median nerve or its branches and cause carpal tunnel symptoms [ 11 — 13 ].
Although these are usually asymptomatic at first, as they enlarge, neurologic symptoms may develop. Schwannomas are most often benign, slow-growing, encapsulated lesions that are amenable to surgical excision. Unlike neurofibromasschwannomas can be separated from the nerve avoiding injury to surrounding axons.
Padua et al. Additionally, when a peripheral nerve tumor is suspected, MRI should be obtained to evaluate the characteristics of the mass prior to consideration of surgical excision BPH Differentialdiagnose biopsy, as malignancy may be present. BPH Differentialdiagnose Neuropathy is a broad category with many conditions that cause median nerve symptoms. Patients often have trouble deciphering which digits have sensory abnormalities and may misinterpret radial or ulnar neuropathy as carpal tunnel syndrome.
Pronator BPH Differentialdiagnose is a BPH Differentialdiagnose neuropathy involving the median nerve occurring at the elbow.
Patients have numbness in the median nerve distribution as with carpal tunnel syndrome with the addition of numbness in the territory of the palmar cutaneous branch of the median nerve.
Complaints of pain and numbness are more common during activity with absence of nocturnal symptoms. Provocative tests include tenderness along the course of the median nerve across the elbow, pain with resisted pronation with the elbow in extension, and pain with resisted middle finger proximal interphalangeal joint flexion.
Pronator syndrome is rare in comparison to CTS, but may coexist and should be considered in all patients presenting with carpal tunnel complaints [ 14 ]. Peripheral neuropathies have many potential causes including diabetes, nutritional deficiencies, human immunodeficiency virus, uremia, and vascular. Many cases are symmetric with symptoms commonly affecting the distal aspect BPH Differentialdiagnose the longest nerve BPH Differentialdiagnose, explaining typical onset of foot symptoms prior to those in the hand.
Polyneuropathy may present with asymmetric symptoms though, especially in diabetics [ 15 ]. In these cases, it can be more difficult to differentiate from a compressive etiology.
Diagnosis of peripheral neuropathy is based on BPH Differentialdiagnose combination of neuropathic symptoms, signs, and electrodiagnostic studies, with signs being better than symptoms in making the diagnosis [ 16 ]. Signs of sensory loss occur in non-dermatomal, non-single nerve distribution patterns. Motor findings are atrophy and weakness of BPH Differentialdiagnose muscles, with secondary joint BPH Differentialdiagnose.
Tendon reflexes are often diminished or absent. The electrodiagnostic study most helpful for confirming the diagnosis of a peripheral neuropathy is the nerve conduction study NCS. Findings of an abnormality of any attribute of nerve conduction in two separate nerves, one of BPH Differentialdiagnose must be the sural nerve, are the minimum criterion to support the diagnosis.
If sural sensory and peroneal motor NCSs are normal, there is no evidence of a peripheral neuropathy [ 16 ]. If either is abnormal, NCS of at least the ulnar sensory, medial sensory, and ulnar motor nerves in both arms is performed. The addition of radial nerve studies is helpful particularly in those patients with suspected carpal or cubital tunnel syndrome, since compressive neuropathy may coexist with peripheral neuropathy.
Multiple sclerosis is an uncommon cause of failed carpal tunnel decompression [ 17 ]. Presenting symptoms are commonly central, such as unilateral visual disturbance, hemifacial spasm, and vertigo [ 18 ]. Other peripheral symptoms may occur, which may simulate carpal tunnel syndrome; however, patients do not have typical nocturnal or provocative daytime symptoms.
Lesions of the brachial plexus may also BPH Differentialdiagnose symptoms that may be confused with carpal tunnel syndrome. The median nerve originates from the lateral and medial cords of the brachial plexus with contributions from C6 to T1.
Traumatic causes of brachial plexopathy are typically high-energy and result from motorcycle or other motor vehicle accidents where the arm is subjected to a traction BPH Differentialdiagnose crush injury.
BPH Differentialdiagnose with anterior shoulder dislocation may also have compressive injury to the plexus. They occur during a fall to the head, as may occur during wrestling or most commonly during a football tackle. Neuralgic amyotrophyor Parsonage-Turner syndromeis a rare, likely autoimmune, disorder which causes BPH Differentialdiagnose and sensory BPH Differentialdiagnose motor changes in peripheral nerves.
Most commonly, the shoulder girdle muscles are involved, including the infraspinatus, supraspinatus, deltoid, biceps, and triceps, though weakness may be limited to the muscles supplied by a single nerve. Paresthesias and hypoesthesia are present in the majority of patients, again most frequently about the shoulder.
Pure sensory neuralgic amyotrophy can occur, and when it does, it typically affects the median, medial antebrachial, and lateral antebrachial cutaneous nerves, potentially mimicking carpal tunnel syndrome. The abrupt onset of the symptoms, significant pain, and weakness in muscles other than the thenars help distinguish patients with Parsonage-Turner syndrome from those with carpal tunnel.
Cervical Disorders Neck pain is a common condition, with 1 year prevalence BPH Differentialdiagnose of 4. Underlying spondylosisspondylolisthesisand disc herniation may lead to nerve compression and symptoms of a peripheral compressive neuropathy. Cervical radiculopathy BPH Differentialdiagnose one or more nerve roots, creating pain, numbness, and weakness in a dermatomal distribution. Patients with C6 involvement most closely mimic carpal tunnel syndrome, but these patients do not typically exhibit abductor pollicis brevis atrophy as is seen in advanced carpal tunnel.
Nocturnal symptoms are less frequent as well. In a study by Chow et al. Cervical myelopathy occurs secondary to spinal cord compression. It may result from disc herniation, spondylolisthesis, or a space-occupying lesion. The clinical picture in patients with myelopathy tends to be quite variable and requires a high index of suspicion.
Symptoms may be non-dermatomal and often bilateral. BPH Differentialdiagnose complain of diffuse numbness and the insidious onset of clumsiness, hand weakness, and worsened handwriting. As the condition advances, intrinsic atrophy progresses and may become severe. They described two signs specific to the BPH Differentialdiagnose. Myelopathic patients have BPH Differentialdiagnose and spasticity, with exaggerated wrist flexion during finger extension and wrist extension during finger flexion.
Ziadeh and Richardson described the case of a patient with cervical syrinx who presented with symptoms of carpal tunnel BPH Differentialdiagnose [ 26 ]. The patient presented with BPH Differentialdiagnose several year history of left thumb, index, and middle finger numbness.
Symptoms were worse at night and with keyboard use. A night splint failed to control symptoms, as did physical therapy, ergonomic evaluation, and prescription anti-inflammatory medication. Disorders such as polyarteritis nodosa, lupus, and rheumatoid arthritis can develop vasculitis affecting the peripheral nerves and lead to upper BPH Differentialdiagnose dysesthesia. A case highlighting BPH Differentialdiagnose etiology was presented by Sethi et al.
Churg-Strauss syndrome is an autoimmune condition causing asthma and inflammation BPH Differentialdiagnose small- and medium-sized vessels leading to mononeuritis multiplex or polyneuropathy. In their case, the patient BPH Differentialdiagnose with right thumb, index, and middle finger numbness. Neurologic symptoms progressed with involvement of the contralateral hand and visual disturbance leading to consideration of alternative diagnoses.
Polymyalgia rheumatica can also cause symptoms of carpal tunnel syndrome. In a series of patients, Salvarani et al. Patients with polymyalgia rheumatica often have multiple distal musculoskeletal findings including edema, tenosynovitisand joint pain which can help differentiate the disease from idiopathic carpal tunnel syndrome. Patients are usually over the age of 50 and have an elevated erythrocyte sedimentation rate and C-reactive protein.
Response to oral corticosteroids is dramatic, while nonsteroidal anti-inflammatories are ineffective. Traumatic Neurologic Injuries Traumatic injuries to the median nerve must always be considered when evaluating a patient with symptoms of carpal tunnel syndrome. Sharp lacerations from a piece of glass or a knife may be obvious. Less obvious situations may present with dysesthesias and a remote history of injury. Browett et al. One patient developed paresthesia in the median nerve distribution 3 days later, while symptoms took 3 months to occur in the other when while extending her wrist, the patient had the sudden onset of pain and numbness in her thumb.
Findings at exploration in the latter patient confirmed partial laceration of the median nerve with a glass fragment embedded in the radial side. Blunt trauma occurring anywhere in the extremity or neck can injure nerve fibers which terminate in the median nerve or the median nerve BPH Differentialdiagnose. As these are typically associated with a significant trauma, the location of the injury is often known.
However, acute carpal tunnel can coexist in patients with concomitant injury to the hand or wrist BPH Differentialdiagnose develop from reperfusion injury. A detailed neurologic examination is critical in trauma patients to determine whether nerve damage is present as a result BPH Differentialdiagnose the injury.
Non-neurologic Disorders Another set of conditions that can present symptoms of carpal tunnel syndrome are those of non-neurologic origin. Often, they impair nerve function by increasing pressure on the median nerve, while some directly affect blood flow to the nerve. Vascular Conditions Symptoms of carpal tunnel syndrome may occur with a number of vascular conditions. Numbness can coexist with the BPH Differentialdiagnose changes BPH Differentialdiagnose may be the primary complaint.
Patients with carpal tunnel syndrome may also complain of coldness in the fingers which is thought to be caused by increased sympathetic BPH Differentialdiagnose during periods of increased median nerve compression.
Patients may also suffer from both conditions.