Tinel's and Phalen's signs and two-point discrimination lack sensitivity and specificity for the diagnosis of CTS. Electrodiagnostic testing is the gold standard but is 90 to 95 sensitive and may be false negative if performed before 4 to 6 weeks of when symptoms begin. Nonsteroidal antiinflammatory drugs (NSAIDs) are not considered to be effective, whereas nocturnal splinting, work-site modification, and steroid injection may be of satisfactory benefit. In long-standing cases with abnormal sensation and motor weakness, carpal tunnel release is the preferred initial treatment. Nonoccupational causes must be considered including metabolic conditions causing peripheral neuropathy (diabetes, hypothyroid conditions, vitamin B12 deficiency, chronic alcoholism), arthritis, cervical radiculopathy, and myofascial pain conditions (47).
A variety of medications including analgesics (opioid and nonopioid), anticonvulsants, steroidal and nonsteroidal antiinflammatory agents, locally injected agents (e.g., anesthetics, steroids), topical agents (e.g., lidocaine patches, fentanyl patches), stimulants, antidepressants and antiparkinsonian agents have been all tried and have showed various degrees of efficacy. Table 17.4 lists some of the most commonly prescribed medications for LPB. As always, a thorough and creative approach to pain management is mandatory. The authors assert that the mere fact of inclusion of a drug in this table does not imply any endorsement or that the drug is officially approved in the United States for the purpose of treatment of LBP-associated neurological conditions. Nonsteroidal antiinflammatory drugs (NSAIDs) Celecoxib (Celebrex) 200 mg d PO qd
EMG, electromyogram NSAID, nonsteroidal antiinflammatory drug PT, physical therapy. Source Data from Rose et al. (40), Harris and Glass (41), Zuckerman et al. (42), and Guidotti (43). EMG, electromyogram NSAID, nonsteroidal antiinflammatory drug PT, physical therapy. Source Data from Rose et al. (40), Harris and Glass (41), Zuckerman et al. (42), and Guidotti (43). 5. Antiinflammatory medications Nonsteroidal antiinflammatory drugs (NSAIDs) Cox-2 inhibitors (far more expensive than NSAIDs)
Gastrointestinal prophylaxis against ulcers is mandatory. Patients with spinal cord injury have a high incidence of stress ulcers, which can also be exacerbated by the concomitant use of steroids in the acute phase. The use of antiinflammatory drugs should be very cautious since even highly promoted cyclooxygenase-2 (COX-2) inhibitors possess the intrinsic risk of promotion of GI ulceration (24).
Patients with ulnar nerve damage should be treated aggressively and with a certain degree of creativity and personalization of care. Depending on the general medical health status, medications that address vascular and metabolic components of the neuropathic process are warranted. Pain may respond to nonsteroidal antiinflammatory drugs, opioids, tricyclic antide-pressants, stimulants (e.g., methylphenidate), and many anticonvulsants (e.g., gabapentin). Many patients may need surgical care thus all patients should be referred for an appropriate consultation. Electrodiagnostic studies should be repeated as needed, especially in cases of severe pathology (with motor amplitude of 10 of normal or a greatly reduced recruitment of motor units, which, in our opinion, is a sign of poor prognosis for recovery) (43).
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