t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e3
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Audit
Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome M. Vashishtha*, B. Varghese, F. Mosley, A. Kadakia, W. de Jager Department of Trauma and Orthopaedic Surgery, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, United Kingdom
article info
abstract
Article history:
Background: Current literature demonstrates that patients with carpal tunnel syndrome
Received 29 June 2014
(CTS) have a higher prevalence of hypothyroidism and diabetes. The British Society for
Received in revised form
Surgery of the Hand (BSSH) advises screening CTS patients for thyroid and glucose
24 September 2014
dysfunction before surgery. This study aimed to analyze the current departmental practice
Accepted 12 November 2014
for patients listed for carpal tunnel decompression (CTD) with respect to preoperative
Available online xxx
assessment of diabetic and thyroid status. Method: A retrospective review of all patients who underwent surgery for CTS under one
Keywords:
team over a 3 year period (2009e2011) in a UK teaching hospital was performed. Patients'
Carpal tunnel
medical records and pathology results were reviewed.
Diabetes
Results: A total of 103 procedures were performed in 100 patients. Preoperative thyroid
Hypothyroidism
function was checked in 63/100 patients with an abnormal result in 3/63 patients. Two of
Decompression
these patients were subsequently diagnosed with hypothyroidism. Similarly blood glucose
Median nerve
was checked in 67/100 patients. This resulted in the new diagnosis of three patients with
Glucose
diabetes. Conclusion: The results are consistent with the view that CTS is associated with thyroid dysfunction and diabetes and screening helps in diagnosing new cases of these conditions in this select group. The cost of diagnosing new cases of hypothyroidism and diabetes can be considered as money well spent. © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Carpal tunnel syndrome (CTS) is a common condition often necessitating surgery. In various studies, it has been shown that patients with carpal tunnel syndrome demonstrated a higher prevalence of hypothyroidism and diabetes
mellitus.1e3 It is well accepted that non-surgical treatment of CTS has limited effect4e6 and that surgical treatment results are better.7 The British Society for Surgery of the Hand (BSSH) advises that screening CTS patients for thyroid and glucose dysfunction before surgery may sometimes be required.8 The primary presentation with CTS offers an opportunity to screen and diagnose these two important disorders. This could help
* Corresponding author. Bradford Royal Infirmary, Bradford BD9 6RJ, United Kingdom. E-mail address: [email protected] (M. Vashishtha). http://dx.doi.org/10.1016/j.surge.2014.11.003 1479-666X/© 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Vashishtha M, et al., Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.11.003
2
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e3
counsel the patients better and may occasionally, by itself obviate the need for surgery by better management of the underlying disorder.
Methods The aim of the study was to analyse the work up for thyroid dysfunction and glucose intolerance in patients presenting with carpal tunnel syndrome in relation to the local referral pathway at a UK teaching hospital. We have a locally agreed pathway for referral of patients presenting to primary care with CTS which advocates screening for diabetes mellitus and hypothyroidism. This study is a retrospective review of the clinical activity performed during the period from January 2009 to December 2011 by a single surgical team led by a consultant. Patient care records and pathology results were analysed to assess the work up of patients who were referred with median nerve symptoms suggestive of carpal tunnel syndrome.
Results A total of one hundred patients presented for surgery. They had 103 procedures performed on them (3 bilateral). The male to female ratio was 19:81. The mean age was 54.8 (range 25e90). Thyroid function tests (TFTs) were checked in 63 out of 100 patients. There was a known thyroid abnormality in 7 patients. The TSH was normal in 60 out of 63 patients. The TSH was abnormal in 3 out of 63. One patient had a previous thyroidectomy. The two patients were not previously known to be hypothyroid and were referred back to the general practitioner, to be investigated further. The blood glucose was checked in 67 out of 100 patients. 18 out of 100 patients were known to have diabetes mellitus. Abnormal glucose levels were detected in 25 out of the 100 patients. 16 of these were previously known to be diabetic. 9 of these 25 patients were not previously known to have diabetes mellitus. On follow up investigations, 3 of the 9 were diagnosed to have diabetes mellitus. A cost analysis showed the additional total cost for screening was £10.86 per patient. This is the rate charged by our regional laboratory service to the primary care for blood glucose and thyroid function tests. Our series yielded five newly diagnosed patients with either glucose or thyroid intolerance. The effective cost for a new diagnosis was £145.2 per patient diagnosed. It is debatable whether this burden can be borne and is cost effective. This can however be considered as money well spent in the treatment of not just the carpal tunnel syndrome but in the overall health of patients diagnosed with the underlying conditions, leading to the presentation of CTS.
Discussion It is well accepted and reported that CTS is commoner in diabetes and hypothroidism.1e3
A review9 has reported that as only one study10 specifically addressed the issue of the prevalence of non-manifest cases of the concurrent conditions, there was insufficient evidence for routine laboratory screening for concurrent conditions in all newly diagnosed CTS patients. Another study with a yield of 2 diabetics and 2 hypothyroid patients in a group of 516 patients with electromyography diagnosed CTS, advocated against systematic screening for incident diabetes mellitus, hypothyroidism and connective tissue disease through additional blood tests.11 CTS has been highlighted as risk factor for later manifestation of diabetes mellitus, as patients with newly diagnosed diabetes showed CTS manifestation 1.4-fold more often than the age-matched reference population.12 The Freemantle longitudinal observational study highlighted a fourfold increase in incidence of CTD in diabetic patients compared to the general population. A large case control study in the UK in the general practice domain revealed risk factors for CTS which include wrist fractures, rheumatoid arthritis, osteoarthritis of wrist and carpus, obesity, diabetes and use of insulin, sulphonylureas, metformin and thyroxine.3 There is some controversy about how diabetic patients respond to surgery in CTS with some studies reporting a detrimental effect13,14 and some that do not report any difference.15e18 The diagnosis of underlying diabetes would help a more informed discussion and enable a balanced prognosis. In published literature, some studies report a high prevalence of thyroid disorders in patients presenting with CTS.19,20 Studies suggest that hypothyroidism contributes to carpal tunnel symptoms by inducing changes to the nerve and its conductivity21 as well as the changes in the muscle tendon unit.22,23 The evidence suggests that CTS symptoms may improve following management of the thyroid disorder. This emphasises the need to diagnose these disorders early. It has been considered expensive to screen for thyroid disorders20 but this has changed over time. It is possible to make a case for this to be made routine. In summary, we understand that these endocrine disorders can cause carpal tunnel symptoms due to changes in the nerves as well as the tissues surrounding these nerves. They do also have a bearing on the overall prognosis and the modalities of management. It is hence an opportunity to diagnose these in a patient presenting with CTS.
Conclusions In our study, work up of patients presenting with CTS resulted in identification of 3 new cases of diabetes and 2 new cases of hypothyroidism. Our retrospective study however had a select population of patients who failed to respond to non-operative treatment or who had motor or sensory impairment in the median nerve. This may explain the higher yield of new cases of diabetes and thyroid dysfunction in our study compared to previous studies. There is debate about cost effectiveness of screening. In our opinion, it can be considered as money well spent in the treatment of not just the carpal tunnel symptoms but in the overall health of patients diagnosed with underlying conditions, leading to the presentation of CTS. These disorders are easily screened and diagnosed and can have
Please cite this article in press as: Vashishtha M, et al., Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.11.003
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e3
implications if not detected and treated early. The costs can also be put in better perspective by considering the costs of complications arising from the non-diagnosis of these conditions. There is considerable scope for improvement in achieving 100% compliance with our own local guidelines. Good communication between primary and secondary care providers would enhance the quality of work up of these patients thus ensuring accurate diagnosis leading to optimum treatment choice. The study aims at highlighting the two important differential diagnoses to be considered in a patient presenting with carpal tunnel symptoms in both the primary and secondary care setting.
Sources of financial support None.
Acknowledgements We are thankful our laboratory sciences department for information on the testing and costs involved.
references
1. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome. Ann Plast Surg 2002;48(3):269e73. 2. Boulton AJ, Malik RA, Arezzo JC, Sosenko JM. Diabetic somatic neuropathies. Diabetes Care 2004;27(6):1458e86. 3. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hubbard R. Risk factors in carpal tunnel syndrome. J Hand Surg Br 2004;29(4):315e20. 4. Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev 2012;6. Cd009899. 5. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2007;2. Cd001554. 6. Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev 2012;7. Cd010003. 7. Verdugo RJ, Salinas RA, Castillo JL, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev 2008;4. Cd001552.
3
8. Reese T. Carpal_tunnel_syndrome. BSSH; 2010. http://www. bssh.ac.uk/education/guidelines/carpal_tunnel_syndrome. pdf. 9. van Dijk MA, Reitsma JB, Fischer JC, Sanders GT. Indications for requesting laboratory tests for concurrent diseases in patients with carpal tunnel syndrome: a systematic review. Clin Chem 2003;49(9):1437e44. 10. Atcheson SG, Ward JR, Lowe W. Concurrent medical disease in work-related carpal tunnel syndrome. Arch Intern Med 1998;158(14):1506e12. 11. de Rijk MC, Vermeij FH, Suntjens M, van Doorn PA. Does a carpal tunnel syndrome predict an underlying disease? J Neurol Neurosurg Psychiatr 2007;78(6):635e7. 12. Bahrmann A, Zieschang T, Neumann T, Hein G, Oster P. Carpal tunnel syndrome in diabetes mellitus. Med Klin Munich 2010;105(3):150e4. 13. Ozer K, Malay S, Toker S, Chung KC. Minimal clinically important difference of carpal tunnel release in diabetic and nondiabetic patients. Plast Reconstr Surg 2013;131(6):1279e85. 14. Ozkul Y, Sabuncu T, Kocabey Y, Nazligul Y. Outcomes of carpal tunnel release in diabetic and non-diabetic patients. Acta Neurol Scand 2002;106(3):168e72. 15. Mondelli M, Padua L, Reale F, Signorini AM, Romano C. Outcome of surgical release among diabetics with carpal tunnel syndrome. Arch Phys Med Rehabil 2004;85(1):7e13. 16. British Journal of General PracticeBrown E, Genoway KA. Impact of diabetes on outcomes in hand surgery. J Hand Surg Am 2011;36(12):2067e72. 17. Jenkins PJ, Duckworth AD, Watts AC, McEachan JE. The outcome of carpal tunnel decompression in patients with diabetes mellitus. J Bone Jt Surg Br 2012;94(6):811e4. 18. Kiylioglu N, Bicerol B, Ozkul A, Akyol A. Natural course and treatment efficacy: one-year observation in diabetic and idiopathic carpal tunnel syndrome. J Clin Neurophysiol 2009;26(6):446e53. 19. Palumbo CF, Szabo RM, Olmsted SL. The effects of hypothyroidism and thyroid replacement on the development of carpal tunnel syndrome. J Hand Surg Am 2000;25(4):734e9. 20. Mistry N, Wass J, Turner MR. When to consider thyroid dysfunction in the neurology clinic. Pract Neurol 2009;9(3):145e56. 21. Yerdelen D, Ertorer E, Koc¸ F. The effects of hypothyroidism on strengtheduration properties of peripheral nerve. J Neurol Sci 2010;294(1):89e91. 22. Oliva F, Berardi AC, Misiti S, Verga Falzacappa C, Iacone A, Maffulli N. Thyroid hormones enhance growth and counteract apoptosis in human tenocytes isolated from rotator cuff tendons. Cell Death Dis 2013;4:e705. http:// dx.doi.org/10.1038/cddis.2013.229. 23. Oliva F, Berardi AC, Misiti S, Maffulli N. Thyroid hormones and tendon: current views and future perspectives. Concise review. Muscles Ligaments Tendons J 2013 Aug 11;3(3):201e3.
Please cite this article in press as: Vashishtha M, et al., Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.11.003
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Audit
Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome M. Vashishtha*, B. Varghese, F. Mosley, A. Kadakia, W. de Jager Department of Trauma and Orthopaedic Surgery, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, United Kingdom
article info
abstract
Article history:
Background: Current literature demonstrates that patients with carpal tunnel syndrome
Received 29 June 2014
(CTS) have a higher prevalence of hypothyroidism and diabetes. The British Society for
Received in revised form
Surgery of the Hand (BSSH) advises screening CTS patients for thyroid and glucose
24 September 2014
dysfunction before surgery. This study aimed to analyze the current departmental practice
Accepted 12 November 2014
for patients listed for carpal tunnel decompression (CTD) with respect to preoperative
Available online xxx
assessment of diabetic and thyroid status. Method: A retrospective review of all patients who underwent surgery for CTS under one
Keywords:
team over a 3 year period (2009e2011) in a UK teaching hospital was performed. Patients'
Carpal tunnel
medical records and pathology results were reviewed.
Diabetes
Results: A total of 103 procedures were performed in 100 patients. Preoperative thyroid
Hypothyroidism
function was checked in 63/100 patients with an abnormal result in 3/63 patients. Two of
Decompression
these patients were subsequently diagnosed with hypothyroidism. Similarly blood glucose
Median nerve
was checked in 67/100 patients. This resulted in the new diagnosis of three patients with
Glucose
diabetes. Conclusion: The results are consistent with the view that CTS is associated with thyroid dysfunction and diabetes and screening helps in diagnosing new cases of these conditions in this select group. The cost of diagnosing new cases of hypothyroidism and diabetes can be considered as money well spent. © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Carpal tunnel syndrome (CTS) is a common condition often necessitating surgery. In various studies, it has been shown that patients with carpal tunnel syndrome demonstrated a higher prevalence of hypothyroidism and diabetes
mellitus.1e3 It is well accepted that non-surgical treatment of CTS has limited effect4e6 and that surgical treatment results are better.7 The British Society for Surgery of the Hand (BSSH) advises that screening CTS patients for thyroid and glucose dysfunction before surgery may sometimes be required.8 The primary presentation with CTS offers an opportunity to screen and diagnose these two important disorders. This could help
* Corresponding author. Bradford Royal Infirmary, Bradford BD9 6RJ, United Kingdom. E-mail address: [email protected] (M. Vashishtha). http://dx.doi.org/10.1016/j.surge.2014.11.003 1479-666X/© 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Vashishtha M, et al., Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.11.003
2
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e3
counsel the patients better and may occasionally, by itself obviate the need for surgery by better management of the underlying disorder.
Methods The aim of the study was to analyse the work up for thyroid dysfunction and glucose intolerance in patients presenting with carpal tunnel syndrome in relation to the local referral pathway at a UK teaching hospital. We have a locally agreed pathway for referral of patients presenting to primary care with CTS which advocates screening for diabetes mellitus and hypothyroidism. This study is a retrospective review of the clinical activity performed during the period from January 2009 to December 2011 by a single surgical team led by a consultant. Patient care records and pathology results were analysed to assess the work up of patients who were referred with median nerve symptoms suggestive of carpal tunnel syndrome.
Results A total of one hundred patients presented for surgery. They had 103 procedures performed on them (3 bilateral). The male to female ratio was 19:81. The mean age was 54.8 (range 25e90). Thyroid function tests (TFTs) were checked in 63 out of 100 patients. There was a known thyroid abnormality in 7 patients. The TSH was normal in 60 out of 63 patients. The TSH was abnormal in 3 out of 63. One patient had a previous thyroidectomy. The two patients were not previously known to be hypothyroid and were referred back to the general practitioner, to be investigated further. The blood glucose was checked in 67 out of 100 patients. 18 out of 100 patients were known to have diabetes mellitus. Abnormal glucose levels were detected in 25 out of the 100 patients. 16 of these were previously known to be diabetic. 9 of these 25 patients were not previously known to have diabetes mellitus. On follow up investigations, 3 of the 9 were diagnosed to have diabetes mellitus. A cost analysis showed the additional total cost for screening was £10.86 per patient. This is the rate charged by our regional laboratory service to the primary care for blood glucose and thyroid function tests. Our series yielded five newly diagnosed patients with either glucose or thyroid intolerance. The effective cost for a new diagnosis was £145.2 per patient diagnosed. It is debatable whether this burden can be borne and is cost effective. This can however be considered as money well spent in the treatment of not just the carpal tunnel syndrome but in the overall health of patients diagnosed with the underlying conditions, leading to the presentation of CTS.
Discussion It is well accepted and reported that CTS is commoner in diabetes and hypothroidism.1e3
A review9 has reported that as only one study10 specifically addressed the issue of the prevalence of non-manifest cases of the concurrent conditions, there was insufficient evidence for routine laboratory screening for concurrent conditions in all newly diagnosed CTS patients. Another study with a yield of 2 diabetics and 2 hypothyroid patients in a group of 516 patients with electromyography diagnosed CTS, advocated against systematic screening for incident diabetes mellitus, hypothyroidism and connective tissue disease through additional blood tests.11 CTS has been highlighted as risk factor for later manifestation of diabetes mellitus, as patients with newly diagnosed diabetes showed CTS manifestation 1.4-fold more often than the age-matched reference population.12 The Freemantle longitudinal observational study highlighted a fourfold increase in incidence of CTD in diabetic patients compared to the general population. A large case control study in the UK in the general practice domain revealed risk factors for CTS which include wrist fractures, rheumatoid arthritis, osteoarthritis of wrist and carpus, obesity, diabetes and use of insulin, sulphonylureas, metformin and thyroxine.3 There is some controversy about how diabetic patients respond to surgery in CTS with some studies reporting a detrimental effect13,14 and some that do not report any difference.15e18 The diagnosis of underlying diabetes would help a more informed discussion and enable a balanced prognosis. In published literature, some studies report a high prevalence of thyroid disorders in patients presenting with CTS.19,20 Studies suggest that hypothyroidism contributes to carpal tunnel symptoms by inducing changes to the nerve and its conductivity21 as well as the changes in the muscle tendon unit.22,23 The evidence suggests that CTS symptoms may improve following management of the thyroid disorder. This emphasises the need to diagnose these disorders early. It has been considered expensive to screen for thyroid disorders20 but this has changed over time. It is possible to make a case for this to be made routine. In summary, we understand that these endocrine disorders can cause carpal tunnel symptoms due to changes in the nerves as well as the tissues surrounding these nerves. They do also have a bearing on the overall prognosis and the modalities of management. It is hence an opportunity to diagnose these in a patient presenting with CTS.
Conclusions In our study, work up of patients presenting with CTS resulted in identification of 3 new cases of diabetes and 2 new cases of hypothyroidism. Our retrospective study however had a select population of patients who failed to respond to non-operative treatment or who had motor or sensory impairment in the median nerve. This may explain the higher yield of new cases of diabetes and thyroid dysfunction in our study compared to previous studies. There is debate about cost effectiveness of screening. In our opinion, it can be considered as money well spent in the treatment of not just the carpal tunnel symptoms but in the overall health of patients diagnosed with underlying conditions, leading to the presentation of CTS. These disorders are easily screened and diagnosed and can have
Please cite this article in press as: Vashishtha M, et al., Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.11.003
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e3
implications if not detected and treated early. The costs can also be put in better perspective by considering the costs of complications arising from the non-diagnosis of these conditions. There is considerable scope for improvement in achieving 100% compliance with our own local guidelines. Good communication between primary and secondary care providers would enhance the quality of work up of these patients thus ensuring accurate diagnosis leading to optimum treatment choice. The study aims at highlighting the two important differential diagnoses to be considered in a patient presenting with carpal tunnel symptoms in both the primary and secondary care setting.
Sources of financial support None.
Acknowledgements We are thankful our laboratory sciences department for information on the testing and costs involved.
references
1. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome. Ann Plast Surg 2002;48(3):269e73. 2. Boulton AJ, Malik RA, Arezzo JC, Sosenko JM. Diabetic somatic neuropathies. Diabetes Care 2004;27(6):1458e86. 3. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hubbard R. Risk factors in carpal tunnel syndrome. J Hand Surg Br 2004;29(4):315e20. 4. Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev 2012;6. Cd009899. 5. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2007;2. Cd001554. 6. Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev 2012;7. Cd010003. 7. Verdugo RJ, Salinas RA, Castillo JL, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev 2008;4. Cd001552.
3
8. Reese T. Carpal_tunnel_syndrome. BSSH; 2010. http://www. bssh.ac.uk/education/guidelines/carpal_tunnel_syndrome. pdf. 9. van Dijk MA, Reitsma JB, Fischer JC, Sanders GT. Indications for requesting laboratory tests for concurrent diseases in patients with carpal tunnel syndrome: a systematic review. Clin Chem 2003;49(9):1437e44. 10. Atcheson SG, Ward JR, Lowe W. Concurrent medical disease in work-related carpal tunnel syndrome. Arch Intern Med 1998;158(14):1506e12. 11. de Rijk MC, Vermeij FH, Suntjens M, van Doorn PA. Does a carpal tunnel syndrome predict an underlying disease? J Neurol Neurosurg Psychiatr 2007;78(6):635e7. 12. Bahrmann A, Zieschang T, Neumann T, Hein G, Oster P. Carpal tunnel syndrome in diabetes mellitus. Med Klin Munich 2010;105(3):150e4. 13. Ozer K, Malay S, Toker S, Chung KC. Minimal clinically important difference of carpal tunnel release in diabetic and nondiabetic patients. Plast Reconstr Surg 2013;131(6):1279e85. 14. Ozkul Y, Sabuncu T, Kocabey Y, Nazligul Y. Outcomes of carpal tunnel release in diabetic and non-diabetic patients. Acta Neurol Scand 2002;106(3):168e72. 15. Mondelli M, Padua L, Reale F, Signorini AM, Romano C. Outcome of surgical release among diabetics with carpal tunnel syndrome. Arch Phys Med Rehabil 2004;85(1):7e13. 16. British Journal of General PracticeBrown E, Genoway KA. Impact of diabetes on outcomes in hand surgery. J Hand Surg Am 2011;36(12):2067e72. 17. Jenkins PJ, Duckworth AD, Watts AC, McEachan JE. The outcome of carpal tunnel decompression in patients with diabetes mellitus. J Bone Jt Surg Br 2012;94(6):811e4. 18. Kiylioglu N, Bicerol B, Ozkul A, Akyol A. Natural course and treatment efficacy: one-year observation in diabetic and idiopathic carpal tunnel syndrome. J Clin Neurophysiol 2009;26(6):446e53. 19. Palumbo CF, Szabo RM, Olmsted SL. The effects of hypothyroidism and thyroid replacement on the development of carpal tunnel syndrome. J Hand Surg Am 2000;25(4):734e9. 20. Mistry N, Wass J, Turner MR. When to consider thyroid dysfunction in the neurology clinic. Pract Neurol 2009;9(3):145e56. 21. Yerdelen D, Ertorer E, Koc¸ F. The effects of hypothyroidism on strengtheduration properties of peripheral nerve. J Neurol Sci 2010;294(1):89e91. 22. Oliva F, Berardi AC, Misiti S, Verga Falzacappa C, Iacone A, Maffulli N. Thyroid hormones enhance growth and counteract apoptosis in human tenocytes isolated from rotator cuff tendons. Cell Death Dis 2013;4:e705. http:// dx.doi.org/10.1038/cddis.2013.229. 23. Oliva F, Berardi AC, Misiti S, Maffulli N. Thyroid hormones and tendon: current views and future perspectives. Concise review. Muscles Ligaments Tendons J 2013 Aug 11;3(3):201e3.
Please cite this article in press as: Vashishtha M, et al., Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.11.003
