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手根管症候群の治療アルゴリズム

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手根管の解剖

手根管の横断面

手根管症候群典型例の感覚障害範囲

手根管症候群で障害される感覚障害の範囲。手指の神経支配にはバリエーションがあることが報告されており、図に示したのは典型例の障害範囲である。

Tinel様徴候、Phalen test

Tinel様徴候は正中神経上を検者の中指で軽く叩打する(a)。手根管入口近位(手首皮線近位)と出口(浅掌動脈弓あたり)で陽性となることが多い。Phalen testは1分間手関節最大掌屈位保持、オリジナル手技はテーブルに肘をつき肘屈曲位で行う方法(b)。手根管症候群における神経症状誘発テストはほかにいくつか提唱されているが、診断確立例における頻度の高い誘発検査はTinel様徴候とPhalen testであるとの報告がある。
出典
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1: The value of diagnostic testing in carpal tunnel syndrome.
著者: R M Szabo, R R Slater, T B Farver, D B Stanton, W K Sharman
雑誌名: J Hand Surg Am. 1999 Jul;24(4):704-14.
Abstract/Text: The purpose of this study was to determine the validity of tests or a combination of tests for the diagnosis of carpal tunnel syndrome. Three groups of 50 subjects each were studied: group 1 had definite carpal tunnel syndrome as defined by history, clinical presentation, and improvement of symptoms following carpal tunnel release; group 2 had a variety of nontraumatic upper extremity disorders other than carpal tunnel syndrome; and group 3 subjects were asymptomatic healthy volunteers. Subjects submitted a self-administered hand diagram, and were queried about night pain, symptom duration, and coexistent medical conditions. Phalen's test, Tinel's sign, Durkan's compression test, and Semmes-Weinstein monofilament testing both before and after a Phalen's maneuver for 5 minutes were performed on each subject. Grip and pinch strengths were measured. Univariate analysis of groups 1 and 2 showed that the tests with the highest sensitivity were Durkan's compression test (89%), Semmes-Weinstein testing after Phalen's maneuver (83%), and hand diagram scores (76%). Night pain was a sensitive symptom predictor (96%). The most specific tests were the hand diagram (76%) and Tinel's sign (71%). Analysis of groups 1 and 3 without group 2 increased the specificity and predictive value of a positive test. A regression model was used to develop a multivariate equation with 4 variables. If a patient has an abnormal hand diagram, abnormal sensibility by Semmes-Weinstein testing in wrist-neutral position, a positive Durkan's test, and night pain, the probability that carpal tunnel syndrome will be correctly diagnosed is 0.86. If all 4 of these conditions are normal, the probability that the patient has carpal tunnel syndrome is 0.0068. We found that the addition of electrodiagnostic tests did not increase the diagnostic power of the combination of 4 clinical tests.
J Hand Surg Am. 1999 Jul;24(4):704-14.
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2: The carpal-tunnel syndrome. Seventeen years' experience in diagnosis and treatment of six hundred fifty-four hands.
J Bone Joint Surg Am. 1966 Mar;48(2):211-28.

手根管のMRI画像

45歳男性、屈筋腱滑膜増殖(点線部分)による手根管症候群と考えられた症例のMRI画像。手根管の横断像T2強調画像(矢印は正中神経)。
出典
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母指球萎縮

罹患側(右)の母指球の筋萎縮がある。
出典
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Semmes-Weinstein monofilament test用フィラメント(左)と2点識別覚計(右)

定量的感覚検査に用いる感覚検査計
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正中神経伝導速度ルーチン検査

a:運動神経伝導速度検査。遠位潜時(丸印)は10.06 msで明らかな遅延がある。
b:感覚神経伝導速度検査。手関節部で記録されたSNAPはdispersionを認める。示指―手関節間の伝導速度は19.1 msecと明らかに遅延。
出典
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手根管症候群に対する超音波診断

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手掌内皮切

靱帯切離範囲

Single portal法の模式図

母指対立再建術

手根管症候群の治療アルゴリズム

出典
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1: 著者提供

手根管の解剖

手根管の横断面