Neuropathic Pain in Carpal Tunnel syndrome

1. Prevalence of Neuropathic Pain (NP) in patients who underwent Carpal Tunnel Release (CTR) and outcomes of surgery on Neuropathic Pain Singapore Orthopaedic Association 41st Annual Scientific Meeting Date 3 November 2018 Presenter Tan Chin Hung Mark Rajaratnam Vaikunthan, Dexter Kuah Le Zhi

2. Background • Carpal tunnel syndrome (CTS) - commonest compressive neuropathy (up to 10% of general population) • Neuropathic pain defined as pain caused by a lesion or disease of the somatosensory nervous system • Prevalence of neuropathic pain in CTS reported to be 36%1 2 1Motoki s, The Effect of Carpal Tunnel Release on Neuropathic Pain in Carpal Tunnel Syndrome, Pain Res Manag. 2017:8098473. DOI:10.1155/2017/8098473

3. Purpose • Few studies to evaluate prevalence of Neuropathic Pain (NP) in Carpal Tunnel Syndrome (CTS) • Purpose of study is to evaluate: 1 ) Prevalence and risk factors of NP in CTS 2 ) Outcome of surgery on NP 3

4. Methodology • Retrospective study • Patients who underwent Carpal Tunnel Release for NCS proven CTS at a tertiary hospital in Singapore from January to July 2018 were recruited • 2- part data collection via phone interview and clinical notes • Neuropathic pain determined by Douleur Neuropathique 4 (DN4) questionnaire • Functional outcome determined by QUICKDASH questionnaire 4

5. Methodology 5

6. Methodology • DN4 has been validated as a screening tool for neuropathic pain in a number of studies1 2 • Sensitivity of 83%1 • Specificity of 90%1 1. Spallone V1, Morganti R, D'Amato C, Greco C, Cacciotti L, Marfia GA: Validation of DN4 as a screening tool for neuropathic pain in painful diabetic polyneuropathy. Diabet Med. 2012 May;29(5):578-85 2. Madani SP1, Fateh HR, Forogh B, Fereshtehnejad SM, Ahadi T, Ghaboussi P, Bouhassira D, Raissi GR : Validity and reliability of the persian (Farsi) version of the DN4 (Douleur Neuropathique 4 Questions) questionnaire for differential diagnosis of neuropathic from non-neuropathic pains.. Pain Pract. 2014 Jun;14(5):427-36

7. Results (Demographics) • 39 involved wrists in 37 patients • Average age 54 (± 13 years) • Average follow up period 5 months (± 2 months) 7 Mal e 26 %Fe mal e 7… Sex Rig ht 67 % Lef t 33 % Op Side Yes 8% No 92 % Steroid Injections

8. Results 8 Yes 72 % No 28 % Prevalence of Neuropathic Pain (Pre-Op) Yes 36 % No 64 % Prevalence of Neuropathic Pain (Post-Op) 74% 10% 15% QuickDASH Score Post Op Improved Worsened No Change3 (7.7%) patients developed Neuropathic pain post op

9. 9 50 30 0. 12.5 25. 37.5 50. 62.5 Pre-op Post-op QuickDASHScore Results (Functional Outcome)

10. Results • Pre-op NP associated with side of surgery (p=0.036) but not associated with age, race, gender or pre- existing diabetes • Pre-op corticosteroid injection associated with worsened QuickDASH score post op (p=0.032) • Post-op neuropathic pain associated with poorer QuickDASH score (47.7 vs 19.46) 10

11. Discussion • Neuropathic pain is more prevalent than what existing studies suggest • Even after surgery, 36% of patients still have neuropathic pain • More can be done for these patients (Multi- disciplinary: Pain team, hand therapists etc) 11

12. Discussion • No similar studies done in Singapore • Results of this study will be used in informed consent for carpal tunnel release • Short follow up; prospective trial with larger sample size in the pipeline

Editor's Notes

Purpose and background NP feature of CTS (no studies done in singapore) Definition of neuropathic pain Pain is classified into nociceptive pain and neuropathic pain (NP). Nociceptive pain is usually acute, develops in response to a specific situation. And tends to go away as the affected body part heals. Damage or dysfunction of the central or peripheral nervous system induces the development of NP It is different from nociceptive pain because it does not develop in response to any specific circumstance or outside stimulus.
Purpose and background NP feature of CTS (no studies done in singapore) Definition of neuropathic pain Pain is classified into nociceptive pain and neuropathic pain (NP). Damage or dysfunction of the central or peripheral nervous system induces the development of NP
QuickDASH score Is a 11 part questionnaire involving activities of daily living and patients had to give a score for each commonent depending on their function. Higher score indicates poorer functional status. It is a clinician-administered questionnaire consisting of 10 items. Seven items related to pain quality (i.e. sensory and pain descriptors) are based on an interview with the patient and 3 items based on the clinical examination. [1] The DN4 (which stands for Douleur Neuropathique 4) is one of the questionnaires that can be useful in diagnosing neuropathic pain. It has components of how the pain feels to the patient but also requires the examining health professional to assess whether there is reduced sensation (hypoaesthesia) to touch or pinprick and whether light brushing increases or causes pain (allodynia).[2] Questionnaire initially written in French but immediately translated into English by the same team. The scale has been widely used since 2005 because of its simplicity. It evaluates neuropathic pain following central and peripheral neurological lesions.It is also used for diagnostic purposes, allowing the clinician to determine if the pain is of neuropathic origin.[3] This questionnaire has been well validated in a number of studies.DN 4 Valid for a cut-off value ≥ 4 points [5] DN4 is valid for painful diabetic polyneuropathy which supports its usefulness as a screening tool for neuropathic pain in diabetes.[5] Sensitivity The DN4 questionnaire has very good sensitivity (83%) [5] Specificity It has specificity of (90%)
DN4 is a clinician administered questionnaire that has been widely used since 2005 a a screening tool for neuropathic pain due to its simplicity Sensitivity The DN4 questionnaire has very good sensitivity (83%) [5] Specificity It has specificity of (90%)
Include average f/u time Average age 53.76 Average pre-op DN4 score 4.76Average post op DN4 score 2.64 Average Preop QD score 49.8 Average postop QD score 29.6
Average age 53.76 Average pre-op DN4 score 4.76Average post op DN4 score 2.64 Average Preop QD score 49.8 Average postop QD score 29.6
Average age 53.76 Average pre-op DN4 score 4.76Average post op DN4 score 2.64 Average Preop QD score 49.8 Average postop QD score 29.6
Include p score
First study in Singapore ? Limitations next slide- short follow up, prospective trial with larger sample size required Results of this study will be used as evidence in informed consent for CTR
First study in Singapore ? Limitations next slide- short follow up, prospective trial with larger sample size required Results of this study will be used as evidence in informed consent for CTR Patient have to be properly counselled for regarding prevalence of neuropathic pain even after surgery However we do not that this study has a short follow up period, and hence a prospective trial with large sample size is in the pipeline

Neuropathic Pain in Carpal Tunnel syndrome

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Neuropathic Pain in Carpal Tunnel syndrome

Editor's Notes