Tunnel Syndrome Following Vascular Shunts for Hemodialysis
Carpal
Barbel Holtmann, MD, Charles B. Anderson, MD \s=b\ Carpal tunnel syndrome developed in the hands of two patients five to six months after Quinton-Scribner vascular shunts for hemodialysis were removed from the forearm of the symptomatic upper extremity. Thickened flexor tendon synovium within the carpal tunnel in all three cases suggests that the
cause
is
an
increase in the volume of the contents within the
rigid confines of the carpal canal. Division of the transverse carpal ligament and synovectomy resulted in complete relief of symptoms 4, 14, and 23 months after operation. Carpal tunnel syndrome should be considered an additional new complication of vascular shunt procedures in patients treated by hemodialysis for renal failure.
(Arch Surg 112:65-66, 1977) one case of carpal tunnel syndrome associated with a functioning internal Brescia-Cimino arteriovenous fistula in the same forearm has been reported,1 to our knowledge there are no reports of this syndrome occurring as a late complication of external QuintonScribner vascular shunts for hemodialysis. We describe three cases of carpal tunnel syndrome in two patients with onset of symptoms several months after removal of Quinton-Scribner shunts from the forearms of the symptomatic upper extremities.
Although ,
REPORT OF CASES Case l.-An 18-year-old man with end-stage renal disease due to congenital hypoplastic kidneys with superimposed chronic glomerulonephritis was started on long-term hemodialysis therapy in 1969 via a side-to-side cephalic vein-radial artery arteriovenous
fistula in the distal left forearm. One year later, the fistula ceased to function adequately for hemodialysis and a Quinton-Scribner shunt using the radial artery and cephalic -ein was inserted in the distal right forearm. During the next four years a total of eight surgical procedures involving the right forearm were required to revise the shunt to maintain adequacy of function for hemodialy¬ sis. In early 1973, spontaneous functional recovery of the left forearm arteriovenous fistula occurred. Long-term hemodialysis was continued using this fistula and the right forearm shunt was removed. Six months after removal of the right forearm shunt, the patient noted the onset of pain and paresthesias involving the right thumb and index finger. The symptoms were exacerbated when he started a new job that required grasping a knife in his right (dominant) hand to whittle artificial limbs. He was unable to maintain a sustained grip on the knife because this activity caused severe pain and paresthesias in the thumb and index finger. These symptoms also awakened him at night. Examination showed for publication Sept 20, 1976. From the Division of Plastic Surgery (Dr
Accepted of Surgery Louis.
Holtmann) and the Department (Dr Anderson), Washington University School of Medicine, St
Reprint requests to Division of Plastic Surgery, Washington University School of Medicine, 4960 Audubon Ave, St Louis, MO 63110 (Dr Holt-
the distal right forearm and wrist (Fig 1). ischemie changes and no objective signs of sensory or motor loss along the median nerve distribution in the right hand. A nerve conduction study demonstrated increased terminal latency of median nerve conduction that was compatible with compression of the right median nerve within the carpal tunnel. On Oct 14, 1974, under axillary block anesthesia and with tourniquet control, the right transverse carpal ligament was completely divided. In addition to swelling of the median nerve proximal and distal to the site of compression (Fig 2), marked thickening of the synovium of the flexor tendons within the carpal tunnel was noted. A synovectomy was also performed. The patient had immediate and complete relief of symptoms postoperatively. He underwent successful cadaver kidney trans¬ plant May 1, 1975, and has had no recurrent symptoms of median nerve compression for the past 23 months. Case 2.-A 43-year-old woman underwent elective cholecystec¬ tomy for cholelithiasis. Postoperatively she required surgical drainage of an intra-abdominal abscess and acute tubular necrosis developed. She was transferred to this hospital on March 13, 1974, to undergo short-term hemodialysis. A Quinton-Scribner shunt using the radial artery and cephalic vein was immediately placed in the distal right forearm and hemodialysis was started. Surgical revision of this shunt was performed ten days later. Because of recurrent clotting of the right forearm shunt, a second shunt using the radial artery and cephalic vein was placed in the distal left forearm. The left forearm shunt was surgically revised on one occasion. Because neither forearm shunt remained functional, both were removed on March 26,1974. Hemodialysis was continued via external shunts in both lower extremities utilizing the poste¬ rior tibial arteries and greater saphenous veins. Spontaneous recovery of renal function occurred and the patient was discharged on April 10, 1974. Five months after removal of both forearm shunts the patient had the onset of pain and paresthesias in both thumbs, index, and long fingers when holding a magazine or newspaper. Bilateral symptoms gradually worsened, especially in the right (dominant) hand and awakened her at night. Examination showed multiple scars along both distal forearms. There were no ischemie changes or objective signs of sensory or motor loss along the median nerve distribution in either hand. Nerve conduction studies demon¬ strated increased terminal latency of both median nerves that was compatible with bilateral median nerve compression within the carpal tunnel. On July 17, 1975, under general anesthesia and with tourniquet control, the right transverse carpal ligament was completely divided and synovectomy of the flexor tendons within the carpal tunnel performed. Findings included a constricted segment of median nerve within the carpal tunnel and marked thickening of the synovium of the flexor tendons. While the right hand was bandaged, the patient experienced increased symptoms in the left hand. She had complete relief of symptoms in the right hand postoperatively and a relative decrease in left hand symptoms when the right hand could be used. Because of a generalized reluctance on her part for any type of surgical procedure, she failed to return for release of the left carpal tunnel until ten months later, when symptoms in the left
multiple There
scars over
were no
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/04/2015
Fig 1.—Patient 1. Multiple scars of distal volar forearm secondary to multiple vascular shunt procedures.
and wrist
hand were again awakening her at night and she could no longer hold a telephone with her left hand. On May 20,1976, the left transverse carpal ligament was divided and synovectomy was performed in similar fashion to the right side. Findings again included a constricted segment of the median nerve and thickening of the flexor tendon synovium. Postopera¬ tively, the patient had complete relief of symptoms. The right and left hands have remained asymptomatic for 14 and 4 months,
respectively.
Fig 2.—Patient 1. Complete division of transverse carpal ligament exposing constricted segment of median nerve with proximal and distal bulging of the nerve.
COMMENT
The carpal tunnel syndrome has been defined as compression of the median nerve within the carpal tunnel due to a variety of etiologic factors.-4 Compression of the nerve occurs when there is an alteration in the relationship between the capacity of the canal and the volume of its contents. A decrease in capacity of the unyielding canal or an increase in the volume of its contents can produce median nerve compression. Because the space within the canal varies with position of the wrist, symptoms of compression (pain, paresthesias) are often sporadic. Long¬ standing compression of the nerve can cause sensory and motor deficits along the median nerve distribution in the
hand. In our patients the cause of median nerve compression is most likely related to an increase in the volume of the contents of the carpal tunnel. Visible thickening of the flexor tendon synovium within the carpal canal was present in all three instances, although none showed abnormalities on histologie examination. The previously reported case of carpal tunnel syndrome was associated with a functioning internal side-to-side arteriovenous fistula and was thought to be caused by venous stasis and congestion due to altered hemodynamics distal to the fistula. These findings were grossly and microscopically absent in our patients. The diagnosis of carpal tunnel syndrome in patients who are undergoing or have undergone hemodialysis may be difficult. Symptoms of pain and paresthesias in the hand may be attributed to ischemia or the peripheral neuropathy associated with uremia. Physical examination should readily determine the presence or absence of ischemie changes. Symptoms of uremie peripheral neuropathy are fairly symmetrical, usually begin as the "burning-foot syndrome" with progressive involvement of the legs, and reportedly only involve the upper extremities in the presence of severe lower extremity involvement. There is generalized slowing of peripheral nerve conduction veloci¬ ty in uremie patients." In patients with carpal tunnel syndrome this decrease in nerve conduction velocity is limited to slowing across the wrist, which is expressed as '
increase in terminal latency of the median nerve.7 It is to make an early diagnosis of carpal tunnel because delay in identifying this entity can result in a loss of sensory or motor function or both that may be irreversible.4 Surgical release of the transverse carpal ligament for relief of symptoms resulting from median nerve compression results in a greater than 95% incidence of success.4-8 As the number of hemodialysis patients and the duration of hemodialysis increase, the incidence of associated carpal tunnel syndrome should also increase. Although a variety of complications have been associated with arteriovenous shunts and fistulas for hemodialysis," carpal tunnel syndrome has not previously been reported as a complica¬ tion, except as noted.1 It is apparent that symptoms of median nerve compression at the wrist can occur in the presence of a functioning internal arteriovenous fistula or as a late complication after removal of an external shunt. Carpal tunnel syndrome should be considered in the differ¬ ential diagnosis of patients with pain or paresthesias or both in the hand following vascular access procedures. an
important syndrome
References 1. Mancusi-Ungaro A, Corres JJ, DiSpaltro F: Median carpal tunnel syndrome following a vascular shunt procedure in the forearm. Plast Reconstr Surg 57:96-97, 1976. 2. Entin MA: Carpal tunnel syndrome and its variants. Surg Clin North
Am 48:1097-1112, 1968. 3. Milford L: Carpal tunnel and ulnar tunnel syndromes and stenosing tenosynovitis, in The Hand. St Louis, CV Mosby Co, 1971, pp 230-236. 4. Tanzer RC: Compression neuropathies, in Flynn JE (ed): Hand Surgery. Baltimore, Williams & Wilkins Co, 1975, pp 317-321. 5. Tyler HR: Neurologic disorders in renal failure. Am J Med 44:734-748, 1968. 6. Dinapoli RP, Johnson WJ, Lambert EH: Experience with a combined hemodialysis-renal transplantation program: Neurologic aspects. Mayo Clin Proc 41:809-820, 1966. 7. Simpson JA: Electrical signs in the diagnosis of carpal tunnel and related syndromes. J Neurol Neurosurg Psychiatry 19:275-280, 1956. 8. Phalen GS: The carpal-tunnel syndrome: 17 years' experience in diagnosis and treatment of 654 hands. J Bone Joint Surg 48A:211-228, 1966. 9. Kuruvila KC, Beven EG: Arteriovenous shunts and fistulas for hemodialysis. Surg Clin North Am 51:1219-1234, 1971.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/04/2015
Carpal
Barbel Holtmann, MD, Charles B. Anderson, MD \s=b\ Carpal tunnel syndrome developed in the hands of two patients five to six months after Quinton-Scribner vascular shunts for hemodialysis were removed from the forearm of the symptomatic upper extremity. Thickened flexor tendon synovium within the carpal tunnel in all three cases suggests that the
cause
is
an
increase in the volume of the contents within the
rigid confines of the carpal canal. Division of the transverse carpal ligament and synovectomy resulted in complete relief of symptoms 4, 14, and 23 months after operation. Carpal tunnel syndrome should be considered an additional new complication of vascular shunt procedures in patients treated by hemodialysis for renal failure.
(Arch Surg 112:65-66, 1977) one case of carpal tunnel syndrome associated with a functioning internal Brescia-Cimino arteriovenous fistula in the same forearm has been reported,1 to our knowledge there are no reports of this syndrome occurring as a late complication of external QuintonScribner vascular shunts for hemodialysis. We describe three cases of carpal tunnel syndrome in two patients with onset of symptoms several months after removal of Quinton-Scribner shunts from the forearms of the symptomatic upper extremities.
Although ,
REPORT OF CASES Case l.-An 18-year-old man with end-stage renal disease due to congenital hypoplastic kidneys with superimposed chronic glomerulonephritis was started on long-term hemodialysis therapy in 1969 via a side-to-side cephalic vein-radial artery arteriovenous
fistula in the distal left forearm. One year later, the fistula ceased to function adequately for hemodialysis and a Quinton-Scribner shunt using the radial artery and cephalic -ein was inserted in the distal right forearm. During the next four years a total of eight surgical procedures involving the right forearm were required to revise the shunt to maintain adequacy of function for hemodialy¬ sis. In early 1973, spontaneous functional recovery of the left forearm arteriovenous fistula occurred. Long-term hemodialysis was continued using this fistula and the right forearm shunt was removed. Six months after removal of the right forearm shunt, the patient noted the onset of pain and paresthesias involving the right thumb and index finger. The symptoms were exacerbated when he started a new job that required grasping a knife in his right (dominant) hand to whittle artificial limbs. He was unable to maintain a sustained grip on the knife because this activity caused severe pain and paresthesias in the thumb and index finger. These symptoms also awakened him at night. Examination showed for publication Sept 20, 1976. From the Division of Plastic Surgery (Dr
Accepted of Surgery Louis.
Holtmann) and the Department (Dr Anderson), Washington University School of Medicine, St
Reprint requests to Division of Plastic Surgery, Washington University School of Medicine, 4960 Audubon Ave, St Louis, MO 63110 (Dr Holt-
the distal right forearm and wrist (Fig 1). ischemie changes and no objective signs of sensory or motor loss along the median nerve distribution in the right hand. A nerve conduction study demonstrated increased terminal latency of median nerve conduction that was compatible with compression of the right median nerve within the carpal tunnel. On Oct 14, 1974, under axillary block anesthesia and with tourniquet control, the right transverse carpal ligament was completely divided. In addition to swelling of the median nerve proximal and distal to the site of compression (Fig 2), marked thickening of the synovium of the flexor tendons within the carpal tunnel was noted. A synovectomy was also performed. The patient had immediate and complete relief of symptoms postoperatively. He underwent successful cadaver kidney trans¬ plant May 1, 1975, and has had no recurrent symptoms of median nerve compression for the past 23 months. Case 2.-A 43-year-old woman underwent elective cholecystec¬ tomy for cholelithiasis. Postoperatively she required surgical drainage of an intra-abdominal abscess and acute tubular necrosis developed. She was transferred to this hospital on March 13, 1974, to undergo short-term hemodialysis. A Quinton-Scribner shunt using the radial artery and cephalic vein was immediately placed in the distal right forearm and hemodialysis was started. Surgical revision of this shunt was performed ten days later. Because of recurrent clotting of the right forearm shunt, a second shunt using the radial artery and cephalic vein was placed in the distal left forearm. The left forearm shunt was surgically revised on one occasion. Because neither forearm shunt remained functional, both were removed on March 26,1974. Hemodialysis was continued via external shunts in both lower extremities utilizing the poste¬ rior tibial arteries and greater saphenous veins. Spontaneous recovery of renal function occurred and the patient was discharged on April 10, 1974. Five months after removal of both forearm shunts the patient had the onset of pain and paresthesias in both thumbs, index, and long fingers when holding a magazine or newspaper. Bilateral symptoms gradually worsened, especially in the right (dominant) hand and awakened her at night. Examination showed multiple scars along both distal forearms. There were no ischemie changes or objective signs of sensory or motor loss along the median nerve distribution in either hand. Nerve conduction studies demon¬ strated increased terminal latency of both median nerves that was compatible with bilateral median nerve compression within the carpal tunnel. On July 17, 1975, under general anesthesia and with tourniquet control, the right transverse carpal ligament was completely divided and synovectomy of the flexor tendons within the carpal tunnel performed. Findings included a constricted segment of median nerve within the carpal tunnel and marked thickening of the synovium of the flexor tendons. While the right hand was bandaged, the patient experienced increased symptoms in the left hand. She had complete relief of symptoms in the right hand postoperatively and a relative decrease in left hand symptoms when the right hand could be used. Because of a generalized reluctance on her part for any type of surgical procedure, she failed to return for release of the left carpal tunnel until ten months later, when symptoms in the left
multiple There
scars over
were no
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/04/2015
Fig 1.—Patient 1. Multiple scars of distal volar forearm secondary to multiple vascular shunt procedures.
and wrist
hand were again awakening her at night and she could no longer hold a telephone with her left hand. On May 20,1976, the left transverse carpal ligament was divided and synovectomy was performed in similar fashion to the right side. Findings again included a constricted segment of the median nerve and thickening of the flexor tendon synovium. Postopera¬ tively, the patient had complete relief of symptoms. The right and left hands have remained asymptomatic for 14 and 4 months,
respectively.
Fig 2.—Patient 1. Complete division of transverse carpal ligament exposing constricted segment of median nerve with proximal and distal bulging of the nerve.
COMMENT
The carpal tunnel syndrome has been defined as compression of the median nerve within the carpal tunnel due to a variety of etiologic factors.-4 Compression of the nerve occurs when there is an alteration in the relationship between the capacity of the canal and the volume of its contents. A decrease in capacity of the unyielding canal or an increase in the volume of its contents can produce median nerve compression. Because the space within the canal varies with position of the wrist, symptoms of compression (pain, paresthesias) are often sporadic. Long¬ standing compression of the nerve can cause sensory and motor deficits along the median nerve distribution in the
hand. In our patients the cause of median nerve compression is most likely related to an increase in the volume of the contents of the carpal tunnel. Visible thickening of the flexor tendon synovium within the carpal canal was present in all three instances, although none showed abnormalities on histologie examination. The previously reported case of carpal tunnel syndrome was associated with a functioning internal side-to-side arteriovenous fistula and was thought to be caused by venous stasis and congestion due to altered hemodynamics distal to the fistula. These findings were grossly and microscopically absent in our patients. The diagnosis of carpal tunnel syndrome in patients who are undergoing or have undergone hemodialysis may be difficult. Symptoms of pain and paresthesias in the hand may be attributed to ischemia or the peripheral neuropathy associated with uremia. Physical examination should readily determine the presence or absence of ischemie changes. Symptoms of uremie peripheral neuropathy are fairly symmetrical, usually begin as the "burning-foot syndrome" with progressive involvement of the legs, and reportedly only involve the upper extremities in the presence of severe lower extremity involvement. There is generalized slowing of peripheral nerve conduction veloci¬ ty in uremie patients." In patients with carpal tunnel syndrome this decrease in nerve conduction velocity is limited to slowing across the wrist, which is expressed as '
increase in terminal latency of the median nerve.7 It is to make an early diagnosis of carpal tunnel because delay in identifying this entity can result in a loss of sensory or motor function or both that may be irreversible.4 Surgical release of the transverse carpal ligament for relief of symptoms resulting from median nerve compression results in a greater than 95% incidence of success.4-8 As the number of hemodialysis patients and the duration of hemodialysis increase, the incidence of associated carpal tunnel syndrome should also increase. Although a variety of complications have been associated with arteriovenous shunts and fistulas for hemodialysis," carpal tunnel syndrome has not previously been reported as a complica¬ tion, except as noted.1 It is apparent that symptoms of median nerve compression at the wrist can occur in the presence of a functioning internal arteriovenous fistula or as a late complication after removal of an external shunt. Carpal tunnel syndrome should be considered in the differ¬ ential diagnosis of patients with pain or paresthesias or both in the hand following vascular access procedures. an
important syndrome
References 1. Mancusi-Ungaro A, Corres JJ, DiSpaltro F: Median carpal tunnel syndrome following a vascular shunt procedure in the forearm. Plast Reconstr Surg 57:96-97, 1976. 2. Entin MA: Carpal tunnel syndrome and its variants. Surg Clin North
Am 48:1097-1112, 1968. 3. Milford L: Carpal tunnel and ulnar tunnel syndromes and stenosing tenosynovitis, in The Hand. St Louis, CV Mosby Co, 1971, pp 230-236. 4. Tanzer RC: Compression neuropathies, in Flynn JE (ed): Hand Surgery. Baltimore, Williams & Wilkins Co, 1975, pp 317-321. 5. Tyler HR: Neurologic disorders in renal failure. Am J Med 44:734-748, 1968. 6. Dinapoli RP, Johnson WJ, Lambert EH: Experience with a combined hemodialysis-renal transplantation program: Neurologic aspects. Mayo Clin Proc 41:809-820, 1966. 7. Simpson JA: Electrical signs in the diagnosis of carpal tunnel and related syndromes. J Neurol Neurosurg Psychiatry 19:275-280, 1956. 8. Phalen GS: The carpal-tunnel syndrome: 17 years' experience in diagnosis and treatment of 654 hands. J Bone Joint Surg 48A:211-228, 1966. 9. Kuruvila KC, Beven EG: Arteriovenous shunts and fistulas for hemodialysis. Surg Clin North Am 51:1219-1234, 1971.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/04/2015
