陳泊儒 1 呂岳謙 2 王培銘 3 黃志芳 4 前言與流行病學 4.9% [1] [2] [4] (idiopathic) [4] ( 1) 臨床表徵和診斷 病生理機轉 (flexor retinaculum) ( 1) (microcirculation) 1 高雄長庚醫院家庭醫學科住院醫師 2 高雄長庚醫院家庭醫學科住院醫師 3 高雄長庚醫院家庭醫學科主治醫師 4 高雄長庚醫院家庭醫學科主任 Carpal tunnel syndrome (paraesthesias) (dysesthesia) [5] 214 家庭醫學與基層醫療 第八期
圖 1 腕隧道內包含正中神經及九條屈肌肌腱, 周圍由腕骨和屈肌支持帶所環繞形成的空間 資料來源 : 參考資料 7 表 1 腕隧道症候群相關成因 不明原因 機轉 相關疾病 佔據空間病灶 (space-occupying lesion) 代謝或生理性因素 神經病變 腫瘤 滑液膜組織肥大 骨折 ( 如 Colle's fracture) 血腫 結節 懷孕 甲狀腺功能低下 類風濕性關節炎 肥胖 糖尿病 酗酒 感染 遺傳 資料來源 : 參考資料 4 6mm [6] Flick sign 93% 96% [7] 家庭醫學與基層醫療 第八期 215
Phalen's test, Tinel sign, Durkan compression test 90 60 Phalen's test Tinel sign Durkan compression test 30 2 56% 85% 94 99% [6] (nerve conduction studies) (delayed distal latencies) (needle electromyography) (polyneuropathy) (radiculopathy) (American Academy of Orthopaedic Surgeons) (British Society for Surgery of the Hand) (British Orthopaedic association) (Royal College of Surgeons) [4] (<1 mm) ( ) 表 2 各項理學檢查之敏感度及特異度 敏感度 (%) 特異度 (%) Flick sign 93 96 Phalen's test 陽性 57~68 58~73 Tinel sign 陽性 36~50 77 Durkan compression test 陽性 64 83 Durkan compression test 及 Phalen's test 皆陽性 80 92 拇指對掌無力 29~65 65~80 魚際肌萎縮 12~16 90~94 資料來源 : 參考資料 6 216 家庭醫學與基層醫療 第八期
77.6% 86.8% [8] X 腕隧道症候群治療 [5] [9] 2 6 3 6 ( ) ( ) 2 (3 ) (2 ) [19] 副木 (neutral position 0 ) 8 [10] [11] 雷射 [12] (Transcutaneous electrical nerve stimulation, TENS) [13] 局部類固醇注射 家庭醫學與基層醫療 第八期 217
(palmaris longus) ( ) ( ) [14] 1 1 3 8 6 [15] 6 口服藥物 prednisone 20mg 10 14 8 B6 [16] 神經滑動術 手術治療 70% 90% [18] (denervation) 8 (major complication) (minor complication) ( ) ( ) [17] 2 1 218 家庭醫學與基層醫療 第八期
(abductor pollicis brevis muscle) [18] 新治療 (platelet-rich plasma, PRP) 3 [20] 6 [21] 5% (D5W) (arachidonic acid) D5W D5W [22] (visual analog scale, VAS) (Boston Carpal Tunnel Syndrome Questionnaire) [23] (hydrodissection) (transverse carpal ligament) 40 80mg methylprednisolone [24] 結語 5% 家庭醫學與基層醫療 第八期 219
參考資料 1. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I: Prevalence of carpal tunnel syndrome in a general population. JAMA 1999; 282: 153-8. 2. Bongers FJ, Schallevis FG, van den Bosch WJ, van der ZeeJ: Carpal tunnel syndrome in general practice (1981 and 2001): incidence and role of occupational and non occupational factors. Br J Gen Pract 2007; 57: 36-9. 3. Aboonq MS: Pathophysiology of carpal tunnel syndrome. Neurosciences 2015; 20: 4-9. 4. Middleton SD, Anakwe RE: Carpal tunnel syndrome. BMJ 2014; 349: g6437. 5. Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, Caliandro P, Hobson-Webb LD: Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol 2016; 15: 1273-84. 6. Wipperman J, Goerl K: Carpal tunnel syndrome: diagnosis and management. Am Fam Physician 2016; 94: 993-9. 7. D`Arcy CA, McGee S: The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA 2000; 283: 3110-7. 8. Fowler JR, Gaughan JP, Ilyas AM: The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a metaanalysis. Clin Orhtop Relat Res 2011; 469:1089-94. 9. O`Connor D, Page MJ, Marshall SC, Massy- Westropp N: Ergonomic positioning or equipment for treating carpal tunnel syndrome. Cochrane Database Syst Rev 2012; 1: 1-38. 10. Hall B, Lee HC, Fitzgerald H, Byrne B, Barton A, Lee AH: Investigating the effectiveness of full-time first splinting and education in the treatment of carpal tunnel syndrome: a randomized controlled trial. Am J Occup Ther 2013; 67: 448-59. 11. Page MJ, Massy-Westropp N, O`Connor D, Pitt V: Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev 2012; 7: 1-159. 12. Lazovic M, Ilic-Stojanovic O, Kocic M, Zivkovic V, Hrkovic M, Radosavljevic N: Placebo-controlled investigation of low-level laser therapy to treat carpal tunnel syndrome. Photomed Laser Surg 2014; 32: 336-44. 13. Casale R, Damiani C, Maestri R, Wells CD: Pain and electrophysiological parameters are improved by combined 830-1064 high-intensity LASER in symptomatic carpal tunnel syndrome versus Transcutaneous Electrical Nerve Stimulation. A randomized controlled study. Eur J Phys Rehabil Med 2013; 49: 205-11. 14. Kaman A, Bezgincan M, Kaya A: Comparison of local steroid injection into carpal tunnel via proximal and distal approach in patients with carpal tunnel syndrome. Bratisl Lek Listy 2011; 112: 337-41. 15. Marshall S, Tardif G, Ashworth N: Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2007; 18. 16. Hulsstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelkoop M, Koes BW: Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments a systematic review. Arch Phys Med Rehabil 2010; 91: 981-1004. 17. Vasiliadis HS, Georgoulas P, Shrier I, Salanti G, Scholten RJ: Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev 2014; 1. 18. Turner A, Kimble F, Gulyás K, Ball J: Can the outcome of open carpal tunnel release be predicted?: a review of the literature. ANZ J Surg 2010; 80: 50-4. 19. Ly-Pen D, Andréu JL, Millán I, de Blas G, Sánchez-Olaso A: Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial. Rheumatology 2012; 51: 1447-54. 220 家庭醫學與基層醫療 第八期
20. Malahias MA, Johnson EO, Babis GC, Nikolaou VS: Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome. Neural Regen Res 2015; 10: 1856-9. 21. Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Huang GS, Chen LC: Six-month efficacy of plateletrich plasma for carpal tunnel syndrome: a prospective randomized, single-blind controlled trial. Sci Rep 2017; 7: 94. 22. Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Tsai CK, Chen LC: Six-month efficacy of perineural dextrose for carpal tunnel syndrome: a prospective, randomized, double-blind, controlled trial. Mayo Clin Proc 2017; 92: 1179-89. 23. Wu YT, Ke, MJ, Chou YC, Chang CY, Lin CY, Li TY, Shih FM, Chen LC: Effect of radial shock wave therapy for carpal tunnel syndrome: a prospective randomized, double-blind, placebocontrolled trial. J Orthop Res 2016; 34: 977-84. 24. Bilge A, Ulusoy RG, Ozturk O, Ozturk IA, Aykut S: Carpal tunnel syndrome surgery antiadhesion gel is effective? Acta Chir Orthop Traumatol Cech 2017; 84: 391-5. 家庭醫學與基層醫療 第八期 221