Carpal tunnel syndroma - Dijagnostika i hirurško lečenje -
naša iskustva

Igor Maljković, Miodrag Jovanović, Dragoslav Božilović, Danijela Ivanović
ZDRAVSTVENI CENTAR BOR, ODELJENJE ORTOPEDIJE I TRAUMATOLOGIJE SA PLASTIČNOM HIRURGIJOM

UVOD

Daleko najčešća kompresivna neuropatija gornjeg ekstremiteta je niska kompresija n.medianusa u predelu karpalnog tunela, koja je u suštini mehanička kompresija uzrokovana idiopatskim sinovitom fleksornih tetiva koje sa nervom prolaze rigidnim karpalnim tunelom. Drugi čest uzrok kompresije je hernijacija gangliona karpusa.
Karpal tunel sindrom (CTS) češći je kod žena i sreće se u oko 70% slučajeva. Tipična manifestacija bolesti je utrnulost kažiprsta i srednjeg prsta koja se uz jak bol javlja noću i budi iz sna. U ranoj fazi bolesti lake vežbe dovode do nestanka simptoma. Sa progresijom bolesti utrnulost se prenosi i na palac, i bol postje konstantan. Značajno je da senzibilitet kože baze dlana nije izmenjen, jer ga oživčava površna grana n. medianusa koja ne prolazi kroz sam tunel.
Phalenov test, kada se RC zglob pasivno flektira i meri vreme do pojave simptoma nije apsolutni, ali je pouzdan pokazatelj CTS. Atrofija tenara viđa se kao kasni znak bolesti. Bolest često prati i dijabetes, giht, hypotiroidizam, bubrežnu insuficijenciju i gojaznost.
 

MATERIJAL I METOD RADA

Tokom 2006. i 2007. na odeljenju ortopedije sa plastičnom hirurgijom ZC Bor uradjeno je 19 dekompresija n. medianusa kod 12 bolesnika, i to kod 8 žena i 4 muškarca. Prosečna starost bila je 44 godine. Od tog broja 1 operacija bila je zbog rekurentne bolesti i urađena je 12 meseci po prvoj dekompresiji, urađenoj u drugoj zdravstvenoj ustanovi. Svi bolesnici su lečeni najpre od strane fizijatra, a pregledani i elektromiografski sagledani, kako pre, tako i posle otvorene dekompresije. Dužina stacionarnog lečenja postoperativno je jedan do dva dana, a odsustvovanje sa posla je oko šest nedelja.
Cilj rada je da prikažemo rezultate hirurškog lečenja CTS kod 1 dvanaest pacijenata (bolesnika).
 

REZULTATI RADA

Poboljšanje simptoma ispitivali smo anamnestički i došli do sledećih rezultata:

• Ukupan broj operacija: 19
• Potpuni nestanak simptoma u toku 6 nedelja: 16
• Delimični nestanak simptoma (povremena utrnulost): 3

Elektromiografski došlo je do skraćenja latence za senzorne i motorne potencijale i do nestanka znakova hronične iritacije nerva u roku od 12 nedelja. Za to vreme bolesnici su obavljali fizikalnu terapiju, od toga 14–21 dan u stacionarnim uslovima.
 

DISKUSIJA

Lečenje CTS može biti neoperativno i operativno.
Lečenje – steroidne injekcije i ortoze nemaju dobar efekat kod žena mlađih od 40 godina, dok bolesnici koji pate duže od tri godine imaju manje šanse za izlečenje. Rezidualni simptomi, produženo bolovanje i promene radnog mesta češće su kod radnika sa očekivanjem kompenzacije.
Konzervativno lečenje nije opcija za srednje teške i teške oblike bolesti, naročito kod pacijenata sa znacima atrofije mičića ili težim senzornim očtećenjima, i obuhvata imobilizaciju, kortiko preparate, vežbe, jontoforezu , kineziterapiju i promenu radnog mesta. Imobilizacija je jevtina metoda, i u početku bolesti, efikasna. Farmakoterapija obuhvata NSAIL, steroide, vitamine B kompleksa.
Injekcije steroida ponekad dovode do nestanka simptoma, naročito ako se kombinuju sa imobilizacijom. Na žalost vreme trajanja dejstva je ograničeno, i obično prestaje za 12-18 meseci.


Slika 4. Imobilizacija kao metoda lečenja
 

HIRURŠKO LEČENJE

Indikacija za hirurško lečenje je perzistencija simptoma i pored ordinirane konzervativne terapije. Relativna indikacija je elektromiografska denerva¬cija muskulature inervisane n. medianusom, kada se i postoperativni oporavak nerva dovodi u pitanje.
Robert Galoway 1924 uradio je prvu dekompresiju n. medianusa, sekcijom transverzalnog karpalnog ligamenta. Ovom tehnikom se zapremina karpalnog tunela povećava za oko 24%, što omogućuje nestanak kompresije i oporavak nerva. Obzirom na velike anatomske varijacije struktura u samom tunelu otvorena metoda je i danas metod izbora mnogih hirurga, naročito zato što omogućuje punu inspekciju TCL i sadržaja karpalnog kanala.
Anestezija može biti lokalna, regionalna ili opšta. Kod nas se najčešće koristi regionalna intravenska anestezija uz korišćenje nadlakatnog turnikea.
Palmarna incizija izvodi se ulnarno od ulegnuća izmedju tenara i hipotenara da bi se smanjila šansa za povredu palmarne kožne grane nerva.
Proksimalno incizija se pruža do radijalne kožne brazde. Superficijalna palmarna fascija se preseca incizijom, a TCL se preseca duž ulnarnog aspekta. Na distalnom delu incizije potrebno je identifikovati površni dlanski luk i sačuvati ga Proksimalno je potrebno ligament preseći do antebrahijalne fascije, a ponekad je i nju potrebno otvoriti, naročito ako je zadebljala i rigidna. Rutinski se radi inspekcija karpalnog tunela, dok se sinoviektomija radi samo u izuzetnim slučajevima. Neuroliza se ne radi , i trenutno se ne smatra neophodnom. Po he¬mostazi i irigaciji rana se zatvara u jednom sloju, pojedinačnim šavovima.
Otvorena dekompresija je izdržala test vremena sa pouzdanim ishodom, smanjenjem simptoma bolesti. Studije dokumentuju uspešnost od 81 do 98%, i simptom koji prvi nestaje je noćni bol, dok se u roku od 6 nedelja povlače i ostali simptomi.

ZAKLJUČAK

Otvorena metoda lečenja kompresivne neuropatije je relativno jednostavna i visoko efikasna metoda koja u kratkom vremenskom periodu dovodi do smirivanja simptoma bolesti, povratka uobičajenim aktivnostima i može se izvesti u uslovima regionalne bolnice.

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