Carpal Tunnel Syndrome Caused by the Persistence of the Median Artery* W. Mauersberger, W. Meese Department of Neurosurgery, Klinikum Chariottenburg, Free University of Berlin (Head: Prof. Dr. Dr. R. Wüllenweber)
Summary As another cause for a symptomatic carpal tunnel syndrome the persistence of the median artery is postulated. This was observed by the authors in three cases all of whom presented a typical carpal tunnel syndrome. As the only cause in all three cases a persistent median artery was observed. The embryological facts and the possible pathogenetic causes are discussed.
tunnel carpien illustré par la présentation malades qui en sont atteints et chez qui persistance était la seule cause du mal. Les embryologiques et les causes pathogéniques sibles sont discutés.
de 3 cette faits pos-
Syndrome du tunnel du carpe lors de la persistance d'une artère médiane.
T h e carpal t u n n e l s y n d r o m e is one of the most frequent causes of a lesion in the median nerve. T h i s results from a chronic compression of the nerve in the so-called carpal tunnel, which c o r r e s p o n d s t o t h e space between the bones of t h e wrist a n d the transverse carpal ligament. In a great n u m b e r of cases, a direct reason for this compression is n o t evident. O n the other h a n d , n u m e r o u s pathological processes are k n o w n which can lead t o a compression of the m e d i a n nerve in the carpal tunnel. A m o n g t h e possible causes for a s y m p t o matic carpal tunnel s y n d r o m e , unspecific and specific inflammations of t h e digital flexor t e n d o n sheaths can be s h o w n (2, 3, 7 , 1 2 , 1 7 , 18, 19), as well as fractures a n d dislocations of t h e wrist (3, 7, 12, 17), deposits of substances in the carpal tunnel, for e x a m p l e in gouty arthritis (7, 8, 17, 20), p l a s m o c y t o m a (17), amyloidosis (7, 8, 9, 17), leukemia (17),
La persistance d'une artère médiane peut être invoquée comme autre cause du syndrome du
* Dedicated to Prof. Dr. P. Röttgen on his 65th birthday.
Key words: carpal tunnel syndrome genesis - median artery
patho-
Zusammenfassung Als eine weitere Ursache für ein symptomatisches Karpaltunnelsyndrom wird die Persistenz der A. mediana angeführt. Insgesamt wurden von den Autoren drei Fälle beobachtet, bei denen als alleinige Ursache eine persistierende Arteria mediana beobachtet wurde. Bei allen drei Patienten handelte es sich um ein typisches Karpaltunnelsyndrom. Die embryologischen Grundlagen dieser Fälle, sowie die möglichen pathogenetischen Faktoren werden diskutiert.
Résumé
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Neurochirurgia 18 (1975), 15-19 © Georg Thieme Verlag Stuttgart
W. Mauersberger, W. Meese
sarcoidosis (7), stenosing synovitis of the flexor t e n d o n s , t h e so-called "Trigger-finger" (7), o e d e m a d u r i n g p r e g n a n c y or t h e premenstrual p e r i o d (3, 10, 12, 1 3 , 21), acromegaly (3, 7, 12, 22) a n d h y p o t h y r o i d i s m (3, 7, 12), compression of t h e median nerve by synovial cysts (19).
tance oí 2 cm this vessel showed an aneurysmal dilatation and had compressed the median nerve. This segment of the vessel was removed (Fig. 1 and 2). The postoperative course was uneventful. At a control examination 11 months after the operation the patient did not have any complaints concerning her hands.
In spite of the great n u m b e r of possible causes for a carpal t u n n e l s y n d r o m e , there exists a constant p a t t e r n of s y m p t o m s caused by these lesions. T h e m o s t frequent sympt o m s are n o c t u r n a l p a i n and the n u m b ness a n d paraesthesia in the area of distribution of t h e distal m e d i a n nerve, especially in the tips of t h e first four digits. Besides, an atrophy of t h e t h e n a r eminence and a paresis of the t h e n a r muscles, involving the m. o p p o nens and short a b d u c t o r muscle of the t h u m b , may occur. A n o t h e r reason for this s y n d r o m e is the persistence of the median artery, which has been observed by t h e a u t h o r s in three cases.
Case 1 P. E., 67 years, female. History: For 2V» years she had noted nocturnal pain, beginning on the right side, but later more marked on the left. Subsequently a numbness of the index, middle and ring finger developed, as well as paraesthesiae in both hands corresponding to the distribution of the median nerve. Short time prior to admission a slight weakness of both hands, clearly left-accentuated, was noted. Physical examination: hypaesthesia, hypalgesia and thermo-hypaesthesia involving the ips of the index, the middle and ring fingers of both hands. Slight thenar atrophy and mild paresis of the opponens and short abductor muscle. Also, a tenderness on pressure over the volar aspect of the wrist exists. In the EMG, the median nerve conduction velocity on the right side was 45 m/sec, on the left side 56 m/sec. The distal motor latency was prolonged on both sides (right = 5,45 msec, left = 6,5 msec). The distal sensory latency could not be detetmined on either side, because a potential after stet stimulation was not obtainable. Operation: Cutting of the normal looking transverse carpal ligament, identification of the median nerve, which was covered by a strongly pulsating vessel under the ligament. Over a dis-
Fig. 1: Aneurysmal dilatation of the median artery {/) in the carpal tunnel, which covers almost completely the median nerve and caused a severe compression.
Fig. 2: Operative specimen of our patient P. E.
Case 2 J. E., 53 years, female. History: Since IV2 years nocturnal pain in the right hand, few months later also in the left
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16
hand. Conservative treatment with local hydrocortisone injections in the carpal tunnel was started. After each injection a improvement of her complaints for some weeks was observed. Six months before her admission an increase of the symptoms was observed and additional sensory disturbances appeared. Physical examination: On admission the volar aspect of the wrist showed a tenderness on pressure, with irradiation of the pain along the distribution of the median nerve in the hand. On the right side slight distally pronounced hypesthesia and hypalgesia of the median fingers was observed. On the left side no sensory disturbances could be demonstrated. Thenar atrophy and paresis was not observed. In the EMG the nerve conduction velocity of the median nerve was normal on both sides. The distal motor latency on the right side was 5,4 msec, on the left side 4,7 msec. The distal sensory latency in the thumb was 5,3 msec in a distance of 10,5 cm; in the index 5,4 msec at a distance of 15 cm. The latency was not determinable on the right middle finger, because after stimulation no potentials could be recorded. The distal motor and sensory latencies on the left side were normal. Operation: After cutting the transverse carpal ligament, one can see a pulsating vessel with a diameter of a knitting needle. The median nerve is lying medially under this vessel. In the region of the carpal tunnel, the nerve shows a considerable compression by this vessel, whereby some arterial branches cross the nerve. Obviously it is a question of anastomoses between the median and the ulnar artery. The vessel is extensively dissected from the nerve. As during the
Fig. 3: Tortuous vessel (/), which crosses under the transcerse carpal ligament and compresses the median nerve. Regard the almost identical diameter of nerve and vessel. 2 Neurochirurgia 18,1
17
operation it is not possible to determine if this artery plays a role in the blood supply of the hand, it was not removed in order to avoid trophic disturbances of the hand (Fig. 3). During the first days after operation the patient did not have any complaints, but a few days later, paresthesia in the thumb, index and middle finger of the right hand, as well as a hypesthesia of the tips of these fingers appeared, but nocturnal pain was not observed. The postoperative EMG showed on both sides normal conduction velocity of the median nerve. The distal motor latency on the right side was normal (4,7 msec). The sensory latency in the thumb was also normal (3,95 msec), in the middle finger it was pathological (5,25 msec), but in contrast with the preoperative examination, this value now was determinable. The motor and sensory latency were normal on the left side.
Case 3 K. M., 62 years, female. History: For 2 years severe nocturnal pain in the right hand. One year later she observed a hypesthesia of the thumb, index and middle finger of the right hand. Physical examination: On admission a hypesthesia, hypalgesia and thermohypesthesia of the tips of the thumb, index and middle finger of the right hand was observed. She had slight, but definite thenar atrophy and a paresis of the short abductor muscle. The nerve conduction velocity from the median nerve was, on the right side 47 m/sec, on
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Carpal Tunnel Syndrome Caused by the Persistence of the Median Artery
Fig. 4: Persistent median artery (MA) and vein (MV), which compresses the median nerve (MN'j in the carpal tunnel. the left side 56 m/sec. The distal motor latency was on the left side 3,65 msec, on the right side 8,05 msec, both values were measured at a distance of 5 cm. The distal sensory latency was on the left side 3,55 msec at a distance of 14,5 cm, on the right side no potentials were obtained. During the operation an artery and a vein, which cover the strikingly thin median nerve, were found (Fig. 4). After cutting the normal looking transverse carpal ligament the vessels were resected, after confirmation of a sufficient blood supply of the hand by the radial and ulnar artery. The postoperative course was uneventful. After the second day, the patient had no more complaints referable to her hands. Discussion During the first two months of the embryonal period the arterial supply of the forearm and the hand is carried by the interosseous artery, which is the direct prolongation of the brachial artery, and by the median artery, which is the first branch appearing from the brachial artery. The radial and ulnar artery appear later and take over the blood supply of the distal parts of the upper extremity. Simultaneously, an involution of the median artery occurs, which normaly accompanies the median nerve as a thin arterial vessel. A carpal tunnel syndrome being referable
to a persistent median artery was found in the literature only in six cases (4, 5, 6, 10, 14, 16). Since the year 1962 we have operated on 118 patients with a carpal tunnel syndrome. The three operated cases represent 2,5 % of the total number of patients. As McCormack et al. showed in a study of 750 extremities it is possible to find a prominent median artery in 4,43 °/o of cases. Comparing the frequency of a persistent median artery with the small number of cases observed, up to the present, in which this anomaly leads to a compression of the median nerve, one can suppose that a persistent median artery does not necessarily lead to a carpal tunnel syndrome. In the cases of Burnham; Jackson and Campbell; Maxwell et al.; the symptoms appeared acutely, after a thrombosis of the median artery, in contrast to our cases, in which the symptoms appear slowly. The vessels, except in our first case, do not show any pathological change. Other pathological facts, which frequently are found in the carpal tunnel syndrome, as for example thickening of the transverse carpal ligament, inflammatory changes of the flexor tendon sheaths, changes of the bones in the wrist, deposit of strange substances in the carpal tunnel, could be ex-
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W. Mauersberger, W. Meese
18
eluded by the intraoperative findings. It is possible, that a norrow carpal tunnel favours the compression of the median nerve. Mumenthaler and Schliack have postulated, that the symptoms in this cases are not only due to a compression of the median nerve, but that circulatory disturbances also play a role in these cases. This idea is especially applicable to our second case, in which in spite of the fact, that the transverse carpal ligament was sectioned, a short time after the operation slight symptoms of a carpal tunnel syndrome appeared again.
19
In the cases investigated by McCormack et al., the median artery participated in 2,1 % of the cases in the formation of the superficial volar arch and replaced completely the ulnar or radial artery. This fact must be kept in mind during the operation on these cases. A resection of the vessel is only possible, if before or during the operation a sufficient blood supply by the radial and ulnar artery for the hand can be assured, in order to prevent severe trophic disturbances. This was the reason, why in our second case the vessel was left in place.
References 1 Arey, L. B.: Anatomía del desarrollo. Edit. Vazquez, Buenos Aires. Embriología (1962) 304-305 2 Bailey, D., J. F. B. Carter: Median nerve palsy associated with acute infections of the hand. Lancet 1 (1955) 530-532 3 Beringer, V.: Das Karpaltunnelsyndrom. Analyse von 231 Fällen mit Hinweisen auf die operativen Behandlungsergebnisse. Schweiz, med. Wschr. 102 (1972) 52-58 4 Bralliar, F. P., zit. n. Maxwell, ]. A., J. ]. Kepes, L. D. Ketchum: Acute carpal tunnel syndrome secondary to thrombosis of a persistent median artery, case report. J. Neurosurg. 38 (1973) 774-777 5 Bunnel, S.: Diskussionsbeitrag in Phalen, G. S.: Spontaneous compression of median nerve at wrist. J. A. M. A. 145 (1951) 1128-1133 6 Burnham, P. J.: Acute carpal tunnel syndrome. Median artery thrombosis as cause. Arch. Surg. 87 (1963) 645-646 7 Cseuz, K. A., ]. E. Thomas, E. H. Lambert, G. L. Love, P. R. Lipscomb: Long term results of operation for carpal tunnel syndrome. Proc. Mayo Clin. 41 (1966) 232-241 8 Curtis, R. M., W. W. Eversmann: Internal neurolysis as an adjunct to the treatment of the carpal tunnel syndrome. J. Bone and Joint Surg. 55-A (1973) 733-740 9 Grokoest, A. W., F. E. Demartini: Systemic disease and carpal tunnel syndrome. J. A. M. A. 155 (1954) 635-637 10 Jackson, L T., J. C. Campbell: An unusual cause of carpal tunnel syndrome. A case of thrombosis of the median artery. J. Bone and Joint Surg. 52-B (1970) 330-333 11 Jartz, D.: Über das Karpaltunnelsyndrom als Grundlage von Schwangerschaftsparaesthesien. Dtsch. med. Wschr. 87 (1962) 1454-1547
12 Kaeser, H. E.: Diagnostische Probleme beim Karpaltunnelsyndrom. Dtsch. Z. Ncrvenheilk. 185 (1963) 453470 13 Kendall, D.: Aetiology, diagnosis and treatment of paraesthesiae in the hands. British Med. J. 2 (1960) 1633-1640 14 Maxwell, ]. A., ]. J. Kepes, L. D. Ketchum: Acute carpal tunnel syndrome secondary to thrombosis of a persistent median artery, case report. J. Neurosurg. 38 (1973) 774-777 15 McCormack, L. ]., E. W. Caldwell, B. J. Anson: Brachial and antebrachial arterial patterns. A study of 750 extremities. Surg. Gynec. Obstet. 96 (1953) 43-54 16 Mumenthaler, M., H. Schliack: Läsionen peripherer Nerven. Diagnostik und Therapie. 2. Aufl., Thieme, Stuttgart 1973, 24, 254 17 Phalen, G. S.: The carpal tunnel syndrome. (Seventeen years experience in diagnosis and treatment of six hundred and fifty four hands). J. Bone and Joint Surg, 48-A (1966) 211-228 18 Phalen, G. S., J. L. Kendrick: Compression of the median nerve in the carpal tunnel. J. A. M. A. 164 (1957) 524-530 19 Tänzer, R. C: The catpal tunnel syndrome. A clinical and anatomical study. J. Bone and Joint Surg. 41-A (1959) 626-634 20 Ward, L. £., W. H. Bickel, K. B. Corbin: Median neuritis (carpal tunnel syndrome) caused by gouty tophi. J. A. M. A. 167 (1958) 844-846 21 Wilkinson, M.: The carpal tunnel syndrome in pregnancy. Lancet 1 (1960) 453-454 22 Woltmann, H. W.: Neuritis associated with acromegaly. Neurol, and Psychiat. 45 (1941) 680-682
Dr. Wolfgang Mauersberger, Dr. Wolfgai
Meese, Neurochirurgische Klinik der Freien Universität Berlin, ikum Charlottenburg, D-1000 Berlin 19, Spandauer Damm 130
2*
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Carpal Tunnel Syndrome Caused by the Persistence of the Median Artery
Summary As another cause for a symptomatic carpal tunnel syndrome the persistence of the median artery is postulated. This was observed by the authors in three cases all of whom presented a typical carpal tunnel syndrome. As the only cause in all three cases a persistent median artery was observed. The embryological facts and the possible pathogenetic causes are discussed.
tunnel carpien illustré par la présentation malades qui en sont atteints et chez qui persistance était la seule cause du mal. Les embryologiques et les causes pathogéniques sibles sont discutés.
de 3 cette faits pos-
Syndrome du tunnel du carpe lors de la persistance d'une artère médiane.
T h e carpal t u n n e l s y n d r o m e is one of the most frequent causes of a lesion in the median nerve. T h i s results from a chronic compression of the nerve in the so-called carpal tunnel, which c o r r e s p o n d s t o t h e space between the bones of t h e wrist a n d the transverse carpal ligament. In a great n u m b e r of cases, a direct reason for this compression is n o t evident. O n the other h a n d , n u m e r o u s pathological processes are k n o w n which can lead t o a compression of the m e d i a n nerve in the carpal tunnel. A m o n g t h e possible causes for a s y m p t o matic carpal tunnel s y n d r o m e , unspecific and specific inflammations of t h e digital flexor t e n d o n sheaths can be s h o w n (2, 3, 7 , 1 2 , 1 7 , 18, 19), as well as fractures a n d dislocations of t h e wrist (3, 7, 12, 17), deposits of substances in the carpal tunnel, for e x a m p l e in gouty arthritis (7, 8, 17, 20), p l a s m o c y t o m a (17), amyloidosis (7, 8, 9, 17), leukemia (17),
La persistance d'une artère médiane peut être invoquée comme autre cause du syndrome du
* Dedicated to Prof. Dr. P. Röttgen on his 65th birthday.
Key words: carpal tunnel syndrome genesis - median artery
patho-
Zusammenfassung Als eine weitere Ursache für ein symptomatisches Karpaltunnelsyndrom wird die Persistenz der A. mediana angeführt. Insgesamt wurden von den Autoren drei Fälle beobachtet, bei denen als alleinige Ursache eine persistierende Arteria mediana beobachtet wurde. Bei allen drei Patienten handelte es sich um ein typisches Karpaltunnelsyndrom. Die embryologischen Grundlagen dieser Fälle, sowie die möglichen pathogenetischen Faktoren werden diskutiert.
Résumé
Downloaded by: University of British Columbia. Copyrighted material.
Neurochirurgia 18 (1975), 15-19 © Georg Thieme Verlag Stuttgart
W. Mauersberger, W. Meese
sarcoidosis (7), stenosing synovitis of the flexor t e n d o n s , t h e so-called "Trigger-finger" (7), o e d e m a d u r i n g p r e g n a n c y or t h e premenstrual p e r i o d (3, 10, 12, 1 3 , 21), acromegaly (3, 7, 12, 22) a n d h y p o t h y r o i d i s m (3, 7, 12), compression of t h e median nerve by synovial cysts (19).
tance oí 2 cm this vessel showed an aneurysmal dilatation and had compressed the median nerve. This segment of the vessel was removed (Fig. 1 and 2). The postoperative course was uneventful. At a control examination 11 months after the operation the patient did not have any complaints concerning her hands.
In spite of the great n u m b e r of possible causes for a carpal t u n n e l s y n d r o m e , there exists a constant p a t t e r n of s y m p t o m s caused by these lesions. T h e m o s t frequent sympt o m s are n o c t u r n a l p a i n and the n u m b ness a n d paraesthesia in the area of distribution of t h e distal m e d i a n nerve, especially in the tips of t h e first four digits. Besides, an atrophy of t h e t h e n a r eminence and a paresis of the t h e n a r muscles, involving the m. o p p o nens and short a b d u c t o r muscle of the t h u m b , may occur. A n o t h e r reason for this s y n d r o m e is the persistence of the median artery, which has been observed by t h e a u t h o r s in three cases.
Case 1 P. E., 67 years, female. History: For 2V» years she had noted nocturnal pain, beginning on the right side, but later more marked on the left. Subsequently a numbness of the index, middle and ring finger developed, as well as paraesthesiae in both hands corresponding to the distribution of the median nerve. Short time prior to admission a slight weakness of both hands, clearly left-accentuated, was noted. Physical examination: hypaesthesia, hypalgesia and thermo-hypaesthesia involving the ips of the index, the middle and ring fingers of both hands. Slight thenar atrophy and mild paresis of the opponens and short abductor muscle. Also, a tenderness on pressure over the volar aspect of the wrist exists. In the EMG, the median nerve conduction velocity on the right side was 45 m/sec, on the left side 56 m/sec. The distal motor latency was prolonged on both sides (right = 5,45 msec, left = 6,5 msec). The distal sensory latency could not be detetmined on either side, because a potential after stet stimulation was not obtainable. Operation: Cutting of the normal looking transverse carpal ligament, identification of the median nerve, which was covered by a strongly pulsating vessel under the ligament. Over a dis-
Fig. 1: Aneurysmal dilatation of the median artery {/) in the carpal tunnel, which covers almost completely the median nerve and caused a severe compression.
Fig. 2: Operative specimen of our patient P. E.
Case 2 J. E., 53 years, female. History: Since IV2 years nocturnal pain in the right hand, few months later also in the left
Downloaded by: University of British Columbia. Copyrighted material.
16
hand. Conservative treatment with local hydrocortisone injections in the carpal tunnel was started. After each injection a improvement of her complaints for some weeks was observed. Six months before her admission an increase of the symptoms was observed and additional sensory disturbances appeared. Physical examination: On admission the volar aspect of the wrist showed a tenderness on pressure, with irradiation of the pain along the distribution of the median nerve in the hand. On the right side slight distally pronounced hypesthesia and hypalgesia of the median fingers was observed. On the left side no sensory disturbances could be demonstrated. Thenar atrophy and paresis was not observed. In the EMG the nerve conduction velocity of the median nerve was normal on both sides. The distal motor latency on the right side was 5,4 msec, on the left side 4,7 msec. The distal sensory latency in the thumb was 5,3 msec in a distance of 10,5 cm; in the index 5,4 msec at a distance of 15 cm. The latency was not determinable on the right middle finger, because after stimulation no potentials could be recorded. The distal motor and sensory latencies on the left side were normal. Operation: After cutting the transverse carpal ligament, one can see a pulsating vessel with a diameter of a knitting needle. The median nerve is lying medially under this vessel. In the region of the carpal tunnel, the nerve shows a considerable compression by this vessel, whereby some arterial branches cross the nerve. Obviously it is a question of anastomoses between the median and the ulnar artery. The vessel is extensively dissected from the nerve. As during the
Fig. 3: Tortuous vessel (/), which crosses under the transcerse carpal ligament and compresses the median nerve. Regard the almost identical diameter of nerve and vessel. 2 Neurochirurgia 18,1
17
operation it is not possible to determine if this artery plays a role in the blood supply of the hand, it was not removed in order to avoid trophic disturbances of the hand (Fig. 3). During the first days after operation the patient did not have any complaints, but a few days later, paresthesia in the thumb, index and middle finger of the right hand, as well as a hypesthesia of the tips of these fingers appeared, but nocturnal pain was not observed. The postoperative EMG showed on both sides normal conduction velocity of the median nerve. The distal motor latency on the right side was normal (4,7 msec). The sensory latency in the thumb was also normal (3,95 msec), in the middle finger it was pathological (5,25 msec), but in contrast with the preoperative examination, this value now was determinable. The motor and sensory latency were normal on the left side.
Case 3 K. M., 62 years, female. History: For 2 years severe nocturnal pain in the right hand. One year later she observed a hypesthesia of the thumb, index and middle finger of the right hand. Physical examination: On admission a hypesthesia, hypalgesia and thermohypesthesia of the tips of the thumb, index and middle finger of the right hand was observed. She had slight, but definite thenar atrophy and a paresis of the short abductor muscle. The nerve conduction velocity from the median nerve was, on the right side 47 m/sec, on
Downloaded by: University of British Columbia. Copyrighted material.
Carpal Tunnel Syndrome Caused by the Persistence of the Median Artery
Fig. 4: Persistent median artery (MA) and vein (MV), which compresses the median nerve (MN'j in the carpal tunnel. the left side 56 m/sec. The distal motor latency was on the left side 3,65 msec, on the right side 8,05 msec, both values were measured at a distance of 5 cm. The distal sensory latency was on the left side 3,55 msec at a distance of 14,5 cm, on the right side no potentials were obtained. During the operation an artery and a vein, which cover the strikingly thin median nerve, were found (Fig. 4). After cutting the normal looking transverse carpal ligament the vessels were resected, after confirmation of a sufficient blood supply of the hand by the radial and ulnar artery. The postoperative course was uneventful. After the second day, the patient had no more complaints referable to her hands. Discussion During the first two months of the embryonal period the arterial supply of the forearm and the hand is carried by the interosseous artery, which is the direct prolongation of the brachial artery, and by the median artery, which is the first branch appearing from the brachial artery. The radial and ulnar artery appear later and take over the blood supply of the distal parts of the upper extremity. Simultaneously, an involution of the median artery occurs, which normaly accompanies the median nerve as a thin arterial vessel. A carpal tunnel syndrome being referable
to a persistent median artery was found in the literature only in six cases (4, 5, 6, 10, 14, 16). Since the year 1962 we have operated on 118 patients with a carpal tunnel syndrome. The three operated cases represent 2,5 % of the total number of patients. As McCormack et al. showed in a study of 750 extremities it is possible to find a prominent median artery in 4,43 °/o of cases. Comparing the frequency of a persistent median artery with the small number of cases observed, up to the present, in which this anomaly leads to a compression of the median nerve, one can suppose that a persistent median artery does not necessarily lead to a carpal tunnel syndrome. In the cases of Burnham; Jackson and Campbell; Maxwell et al.; the symptoms appeared acutely, after a thrombosis of the median artery, in contrast to our cases, in which the symptoms appear slowly. The vessels, except in our first case, do not show any pathological change. Other pathological facts, which frequently are found in the carpal tunnel syndrome, as for example thickening of the transverse carpal ligament, inflammatory changes of the flexor tendon sheaths, changes of the bones in the wrist, deposit of strange substances in the carpal tunnel, could be ex-
Downloaded by: University of British Columbia. Copyrighted material.
W. Mauersberger, W. Meese
18
eluded by the intraoperative findings. It is possible, that a norrow carpal tunnel favours the compression of the median nerve. Mumenthaler and Schliack have postulated, that the symptoms in this cases are not only due to a compression of the median nerve, but that circulatory disturbances also play a role in these cases. This idea is especially applicable to our second case, in which in spite of the fact, that the transverse carpal ligament was sectioned, a short time after the operation slight symptoms of a carpal tunnel syndrome appeared again.
19
In the cases investigated by McCormack et al., the median artery participated in 2,1 % of the cases in the formation of the superficial volar arch and replaced completely the ulnar or radial artery. This fact must be kept in mind during the operation on these cases. A resection of the vessel is only possible, if before or during the operation a sufficient blood supply by the radial and ulnar artery for the hand can be assured, in order to prevent severe trophic disturbances. This was the reason, why in our second case the vessel was left in place.
References 1 Arey, L. B.: Anatomía del desarrollo. Edit. Vazquez, Buenos Aires. Embriología (1962) 304-305 2 Bailey, D., J. F. B. Carter: Median nerve palsy associated with acute infections of the hand. Lancet 1 (1955) 530-532 3 Beringer, V.: Das Karpaltunnelsyndrom. Analyse von 231 Fällen mit Hinweisen auf die operativen Behandlungsergebnisse. Schweiz, med. Wschr. 102 (1972) 52-58 4 Bralliar, F. P., zit. n. Maxwell, ]. A., J. ]. Kepes, L. D. Ketchum: Acute carpal tunnel syndrome secondary to thrombosis of a persistent median artery, case report. J. Neurosurg. 38 (1973) 774-777 5 Bunnel, S.: Diskussionsbeitrag in Phalen, G. S.: Spontaneous compression of median nerve at wrist. J. A. M. A. 145 (1951) 1128-1133 6 Burnham, P. J.: Acute carpal tunnel syndrome. Median artery thrombosis as cause. Arch. Surg. 87 (1963) 645-646 7 Cseuz, K. A., ]. E. Thomas, E. H. Lambert, G. L. Love, P. R. Lipscomb: Long term results of operation for carpal tunnel syndrome. Proc. Mayo Clin. 41 (1966) 232-241 8 Curtis, R. M., W. W. Eversmann: Internal neurolysis as an adjunct to the treatment of the carpal tunnel syndrome. J. Bone and Joint Surg. 55-A (1973) 733-740 9 Grokoest, A. W., F. E. Demartini: Systemic disease and carpal tunnel syndrome. J. A. M. A. 155 (1954) 635-637 10 Jackson, L T., J. C. Campbell: An unusual cause of carpal tunnel syndrome. A case of thrombosis of the median artery. J. Bone and Joint Surg. 52-B (1970) 330-333 11 Jartz, D.: Über das Karpaltunnelsyndrom als Grundlage von Schwangerschaftsparaesthesien. Dtsch. med. Wschr. 87 (1962) 1454-1547
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Dr. Wolfgang Mauersberger, Dr. Wolfgai
Meese, Neurochirurgische Klinik der Freien Universität Berlin, ikum Charlottenburg, D-1000 Berlin 19, Spandauer Damm 130
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Carpal Tunnel Syndrome Caused by the Persistence of the Median Artery
