RSD Puzzle #012

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD PUZZLE #12
Misdiagnosing Carpal Tunnel In Place Of RSD

"My doctor has diagnosed me as suffering from RSD due to right carpal tunnel syndrome. Because my job is am assembly line worker using scissors all working day long, and because my hand is getting weaker, EMG and nerve conduction times were done and I was diagnosed as suffering from carpal tunnel syndrome on the right side. My doctor says without getting rid of the source of the RSD (right carpal tunnel syndrome), there is no hope for me."

This puzzle is quite a common occurrence among RSD patients. This is especially true in "over use" lines of professions such as assembly line workers, court reporters, transcribers, employees who work with computer all day long, workers who do a lot of drilling metals (e.g., in aerospace industry drilling titanium against steel). Frequently one encounters such a puzzle outlined above.
Carpal tunnel syndrome is the most frequent entrapment neuropathy noted in the extremities in a neurologic practice. However, it is rarely accompanied by RSD (1.5%).

When carpal tunnel syndrome (CTS) is accompanied by RSD, it is usually the effect rather than the cause. This is especially true among the professionals mentioned above.

Because RSD is a disease of constant burning pain accompanied by constriction of blood vessels, muscle contraction, weakness of the muscles, insomnia, and inflammation of the soft tissues, it can easily cause carpal tunnel syndrome due to the inflammatory process at the carpal tunnel (wrist) as well as poor circulation to the nerve due to constriction of the blood vessels.

It is not at all difficult to diagnose the CTS cases that are caused by RSD. The following are the clues that differentiate the true CTS from RSD CTS.

1. The patient's profession (over use factor). In such a profession usually the patient is well adjusted with the repetitive use of the hand unless there is a rush in productivity (e.g., a court reporter having to transcribe a voluminous court proceeding over night) or, improper work station hygiene (position of the hand and wrist in relation to the computer keyboard) complicate the assembly job work.

2. In true somatic, run of the mill, CTS, only the point of entrance of the median nerve to the hand is tender and sore (the so-called Tinel's Sign). On the other hand in the CTS due to RSD, every part of the hand and wrist is sore, tender, and allodynic (hypersensitive to touch).

3. The non-sympathetic CTS causes weakness and atrophy limited to the first three fingers. The CTS causes weakness and atrophy involving the entire hand and causes a tendency for flexion spasm and contraction of all the fingers.

4. In somatic CTS, MRI of the hand and wrist is normal. In contrast, in sympathetic CTS the MRI may show fluid between the small bones of the wrist, osteoporosis, focal areas of loss of bone in the small bones of the wrist, and soft tissue inflammation around the wrist.

5. In the operating room, the surgeon notices swelling of the soft tissues at the wrist, dark bluish or blackish dead tissue, and brittle and fragile bones at the wrist in the case of sympathetic CTS. On the other hand in the case of RSD CTS, the surgeon notices simple pressure on the median nerve by the carpal tunnel ligament at the wrist.

6. In RSD CTS, the injection of steroids at the wrist causes aggravation and flare-up of RSD. In the somatic CTS, such injections improve the patient's condition.

7. In sympathetic CTS, the patient's symptoms and signs are quite dramatic and severe whereas the nerve conduction delay at the wrist is quite minimal. The reverse is true for the somatic CTS.

Of all the points of differentiation mentioned above, the most critical one is marked intolerance to simple touch over the entire hand and wrist in the sympathetic CTS patients. If this sign is present, surgical treatment is going to end up with disastrous results.

The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2006 H. Hooshmand, M.D.