「腕管综合征」是很多人对周围神经系统问题最初的印象,根据 1854 年 Paget 描述,腕管综合征(Carpal Tunnel Syndrome)是由正中神经在腕管内受压而表现出的一组症状和体征,是引起上肢神经受压最常见的原因。 应用解剖
拇长屈肌腱被桡侧滑膜囊包裹,其他肌腱为尺侧滑膜囊包裹,当腕关节掌屈时,正中神经受压,同时用力握拳,则受压更剧。 易患因素 2、生活习惯: 生活中过度使用电脑、键盘,特别是手腕部位置,在腕管的发展中起着重要作用。 3、职业因素: 如木工、厨工等长期过度用力使用腕部,腕管内压力反复出现急剧变化:
这种压力变化也易引起慢性正中神经损伤。 病因 2、管腔本身变小: 腕部骨折、脱位、腕横韧带增厚等。 3、腕管内容物增多: 临床表现 2、腕管综合征最常见的症状为正中神经感觉分布区的感觉异常,即病人首先感到桡侧三个手指端麻木或疼痛,持物无力,以中指为甚。 腕管综合征查体:拇、示、中指有感觉过敏或迟钝。 大鱼际肌萎缩,拇指对掌无力。 3、病人疼痛夜间或清晨症状最重,适当抖动手腕可以减轻。有时疼痛可牵涉到前臂。(夜间痛是 CTS 的一个较恒定的症状) 4、测试拇指外展强度: 要求患者将手放在桌子上,手掌朝上,拇指外展(指向天花板)。 检查者触诊大鱼际、拇短展肌的肌肉体积、主动收缩和收缩强度的证据,同时为患者的主动拇指外展提供阻力。并与对侧进行比较。 5、腕管综合症的刺激性试验 ① Tinel 征(叩击实验): 将患者手腕平放在桌子上,检查者用食指或中指从近端到远端轻叩患者正中神经。 如患者出现拇指、食指和中指有「放电」样麻木感,即为阳性(敏感性 60%,特异性 67%)。 ② Phalen’s 实验(屈腕实验): 屈肘、前臂上举,双腕同时屈曲 90°,持续 60 秒。 如患者 60 秒内出现桡侧半手指有麻木感或刺痛感,即为阳性(敏感性 75%,特异性 47%)。 ③ Reverse Phalen 实验: 屈肘、前臂上举,双腕同时背伸 90°,持续 60 秒。 如患者 60 秒内出现桡侧半手指有麻木感或刺痛感,即为阳性。 ④ Durkan 实验(腕管压迫实验) —— 这是考虑诊断腕管综合征最敏感和特异性的刺激试验(敏感性 87%,特异性 90%)。 将患者手腕平放在桌子上,检查者将三个手指放在腕管上,并压缩这个区域 30 秒。 辅助检查 1、X 线及 CT 非手术治疗
③持续的感觉异常; ④狭窄性屈肌腱鞘炎; ⑤ 30s 之内 Phalen 试验阳性。
手术治疗
总结 腕管综合征是最常见的压迫性神经病变。对于轻度或近期出现症状的病例,应进行保守治疗。手术治疗对中重度 CTS 病例是有效的。 作者:孙小六 排版:景胜杰 图源:文末文献 参考文献(特别特别多) 1.Ng, Alex Wing Hung; Griffith, James Francis; Tsai, Chris Siu Chun; Tse, Wing Lim; Mak, Michael; Ho, Pak Cheong (2020). MRI of the Carpal Tunnel 3 and 12 Months After Endoscopic Carpal Tunnel Release. American Journal of Roentgenology, (), 1–7. doi:10.2214/AJR.20.23066 2.Kamel, Sarah I; Freid, Bradley; Pomeranz, Corbin; Halpern, Ethan J; Nazarian, Levon N (2020). Minimally Invasive Ultrasound-Guided Carpal Tunnel Release Improves Long-Term Clinical Outcomes in Carpal Tunnel Syndrome. American Journal of Roentgenology, (), AJR.20.24383–. doi:10.2214/ajr.20.24383 3.Atroshi, Isam; Tadjerbashi, Kamelia; McCabe, Steven J.; Ranstam, Jonas (2019). Treatment of carpal tunnel syndrome with wrist splinting: study protocol for a randomized placebo-controlled trial. Trials, 20(1), 531–. doi:10.1186/s13063-019-3635-6 4.Ting BL, Blazar PE, Collins JE, et al. 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