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DISCUSSION
Breast cancer and CTS are common diseases in older women and thus they will inevitably occur together. There is no evidence to conclude that lymphoedema predisposes to CTS but there is some evidence to suggest that CTS is more common after this kind of breast surgery 2. It could be explained by the accumulation of fluid in the limb that might increase the pressure in the carpal tunnel. Our results demonstrate the increment in cross-sectional area in medial nerve in patients with clinical signs of CTS in lymphoedema arms.
Our results about cross-sectional area of median nerve are higher than the results of studies in patients without lymphoedema, in the affected limb. On the other limb they are also higher, but to a lesser extent. In all patients, after physiotherapy treatment, there was a marked improvement in clinical findings, clinical signs had disappeared or improved. Thus, in patients with lymphoedema diagnosis test of CTS should not be considered until oedema has improved.
There is a consensus that in patients with lymphoedema needle examination should not be used, but there are recent studies that found no evidence of either infection or worsening of lymphoedema after needle EMG examination2. Nevertheless, there is a possibility of nerve exploration with ultrasound, which is a cheap and safe option, and it could be considered after any needle examination.
Tinnel sign consist on the appearance of dysesthesias with wrist percussion. It has a level of sensitivity of 25-63% and a level of specificity of 67-87%. Meanwhile, Phalen sign consist on the appearance of dysesthesias with a wrist bilateral flexion of 90° during sixty consecutive seconds. It has a level of sensitivity of 70-89% and a level of specificity of 48% 12. These two signs together have high diagnostic capabilities, so with the confirmation of the diagnosis with another diagnostic test, should be sufficient to confirm the diagnosis, it should not be indispensable the EMG.
EMG is the gold standard test to confirm the diagnosis of CTS, but it cannot show pathologic changes inside median nerve or pathology inside carpal tunnel associated3. These pathologies should be detected after a surgery treatment because the operative procedure will not resolve this situation or it will need another operative techniques 4,5,10. Ultrasound could show these defects after surgery, so it can prevent complications during surgery.
In patients with lymphoedema is important to identify real CTS, because a surgical procedure stimulates a localized inflammatory response, thereby increasing the load on an already compromised lymphatic system. Furthermore, the sluggish flow of lymph though lymphoedematous tissues increases susceptibility to percutaneous introduction of bacteria by iatrogenic or other mechanisms, which can result in infection and lymphatic blockage 13. For this reason, ultrasound should be included in CTS diagnose.
CONCLUSIONS
Ultrasound has to be taken into account in the diagnosis of CTS in breast-cancer-related lymphoedema patients, because it can avoid unnecessary surgical procedures in patients with increased risk of postsurgical complications.
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THE EUROPEAN JOURNAL OF LYMPHOLOGY - Vol. XXIX - Nr. 75 - 2017
The evaluation of CTS before physiotherapy treatment is not recommended, because the improvement of the oedema can result a clinical beneficial improvement of CTS.
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