Síndrome do túnel do carpo: análise dos resultados cirúrgicos.

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AGRADECIMENTOS

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Agfádécemqs

ao nr.

PAULD MATTUSINHU

FILHO

e

ao

Dr;

1RAÊ*RuHLAND,_pe1o_

ines-

timável empenho, dedicáção, oríentaçãó

e

apoio dispensado na elaboração deste trg

balho,

›

` 'V

\

g

RESUMÚ;

'

Os

autores

fazem

um

estudo

de

11

pacientes subme-

tidos

a~cirurgía descompressiva

por Síndrome do Túnel

do

Carpo.

Analisam

comparativamente

dados

clíhícos

e

eletrofísiológicos

pré é

pós-operatóríos,

e

os:confrontam.com

L

-os

achados de-ou-

tros

autores

.

suMÁR1o

Introdução

....

.

... ...

..

...

..

...

.

Material

E-Métodos

...

...

.

..

...

Resultados

...

-

....

.

..

....

... ...

...

~f

Díscussao

-

. . » _{. . . . .} . . . . . . . . . .

.

. ~ . . . . . . . . . .

-

Conclusão

. . . . . . . . . . . . . i . .

..

Abstratt^.»

. . . . . . _{. . . .} . . . . . . . . V . . . . . . . .

..

Bibliografia

. . . . . . . . . . . . . . . . . V . . . . . . .

..

. . . `

INTRODUÇÃO

.

/”

wf°`“`P

r

A

ih

_

_

///¿/›

Algumas neuropatias compressivas

tem

seu

diagnós-

tico

facilmente estabelecido clinicamente, sendo

a

sindrome

do

Túnel do

Carpo

(STC)

e

melhor

e

maís.frequente exemplo.

~

Define-se

a

síndrome

como um

conjunto

de

sinais

e

sintomas causados pela compressão

do

nervo mggigggfino canal

do

carpo.

_

`

Desde

que

encontramos pacientes

com esta

patolo-

gia na prática¬

médica

geral.

e.=~

também em

'diversas

-

especialidades;

algum

conhecimento

desta compressão

do

nervo

é

esencial

à

pra-

ticamente todos

na

profissão

médica.

Além disso deve-se enfati

~

r -' r

~

zar

que

a

condiçao

e

potencialmente curavel

e

que

se

nao

reco-

nhecida

e

tratada,

os

pacientes

tem

que

suportar

um

sofrimento

severo

e

desnecessário, enquanto

a

perda

de

força

muscular

e

prejuizo

da

funçao motora

e

sensorial

da

mao vai

se

desenvol

vendo.(27)

"

` `

`Os

_{autores analisam}

_os

_resultados

do

tratamento

cirúrgico

em

nosso meio

e

fazem uma

breve revisão

bibliográfi-

ca.

v '

-QATERIAL

E

MÉTooos

Realizamos

um

levantamento

dos

_{pacientes Que fo}

ram

a

cirurgia

descomprššsiva

por

STC,

operados

no

Serviço

de

Neurocirurgia

do

Hospióal

de

Caridade

em

Florianópolis

-

_SC,no

período

de

ganeiro

de

1983 até

agosto

de 1987.

'

~

V '

Convocamos

16

pacientes para

uma

reavaliaçao,

por via

postal

(todos)

e

alguns também

por via

telefônica-

Des

,

_

tes,

11

pacientes compançceram, perfazendo

um

total

de

13

maos

operadas

(

2

pacientes com ambas

as

mãos

submetidas

a

tratamen

to

cirúrgico);

A

reavaliação aconteceu

na

última semana

de

ou-

tubro

do

corrente ano,_e incluiu

um

inquérito

que

constava

de:

Identificação, Anamenese pré-cirúrgica, História

Mórbidaíägres

sa

e

Familiar, Tratamento Clinico pré-pperatório

e

também uma

avaliação

atual.

›

vç

'

Levantamos

os

dados

de

eletromiografia

pré-ope

ratória

que não foram

disponíveis

em

apenas

um

paciente,

e

em

mais

uma não

obtivemos-

os

dados

da

condução sensitiva.

Não

conseguimos

obter

os

dados

de

exame

físico

e

laboratório

geral

pré-operatórios

pois não

constavam nos

prontuários.

O

tratamento cirúrgico constitui-se

em

todos

os

casos

em

retinaculotomia

seguida

de

epineurectomia, através

da

incisão clássica de.IaleisniK.

-

Após

a

retináculotomia

procedia-se

a

epineurec¢

tomia

sob

microscopia,

com

o

cuidado

de

não

lesar

a

vasa

ner-

à

. i . .

vorum,

seguindo-se

a

isto

a

hemostasia cuidadosa

com

coagula-

çao

bipolar.

*r

_

Procedíamos

então

a

imobilização

da

articulação

do

punho

por

10

dias.

07

_

Emcientes

encontramos

no

prontuário.

a

des-

crição

do

achado cirúrgico.

'

ç

~

V

Na

avaliaçao atual (pós-operatória) interroga-

mos

sobre

a

melhora clinica, recidiva, tratamento clinico,

bem

como úacerca

da

sintomatologia-atual

e

realizamos exame fisico

e

eletrofisiológico.

*

_

›.

Todos

os

pacientes foram questionados quanto

a

sua

evolução pós-operatória, interrogando-se

a

respeito

do

com

portamento

da

sintomatologia até

a

data

da

consulta; Cura,

Ali

vio

parcial

e

Recidiva.

i

~

No

nosso inquérito demos

ênfase

às

atividades

manuais

de

risco,

que foram consideradas naqueles

pacientes

que

exerciam

atividade.manual

repetitiva

e

prolongada, profis¬

~

sionalmente-ou-nao.

.

~

i

A

avaliaçao

do

exame fisico

foi

realizada

wpor

apenas

um

examinador,

e

constou

de

observação

da

função sensi-

tiva

e

motora

da

mão, efide

manmfias provocativas (SüEflideF%mlen

e

Tinel).

«

'

.. ›

-~

Primeiramente observamos

a

presença

ou

nao

de

atrofia_tenar, comparando

a

massa muscular fdessa região

com

a

do

lado

contralaterald

A

pesquisa

da

função-motora destes mús-

culos (principalmente

o

oppenens pollícís)

foi

procedida com

a

observação

da

força

de

"pinça"

do

IQ

e

29

quirodáctilos.

Consi

deramos

como

comprometido

o

movimento

de

pinça quando

o

pacien

te

se

mostrava incapaz

de

sustentar

uma

folha

de

papel tracio-

nada pelo

mesmo movimento

pelo

examinador.

'

A

avaliação quanto

à

sensibilidade

constou

de

pesquisa

de

tato, dor

e

discriminação

tátil, zem

*território

inervado pelo nervo mediano

e

ulnar.

`

O

tato

discriminatório

foi

conduzido com

um

com

passo

de

Weber quando procuramos reconhecer

a

distância mini-

ma

perceptível

entre

dois

fpontos

estimulados

simultaneamente.

al-08

terações

de

pele no

território inervado

pelo mediano.‹

.

_

No inquerito pré-cirúrgico

_e

atual,

estabelece-

mos

a

presença deëperda

da

habilidade manual

pela_informação

subjetiva

do

paciente

da

sua

dificuldade

em

realizar ativida-

des

manuais delicadas,

efa

diminuição

de

força foi

caracteri-

zada quando referiam incapacidade

em

manter

alguma'

atividade

manual grosseira

(e×.:

carregar

uma

sacola).

Procedemos

à

avaliação eletrofisiológica

a

uma

temperatura ambiental de-27`C,

e

nos

membros

em

exame

foi

as-

segurado

uma

temepratura corporal

em

torno

de

36,5'C.

Utiliza-

mos um

aparelho STANDARD

de

eletromiografia, sendo

realizado

~

~

avaliacao

da

neuroconduçao sensitivo-motora

dos

nervos mediano

RESULTADOS

\I

'

.

Todos

os

pacientes

em

nossa casuística eram do

se

xo

feminino,

com

idade.variando entre

34

e

66

anos com

uma

mé-

dia de 47 anos.

'

'

Em

duas

pacientes

foi

realizada cirurgia

nas

duas

~

maos.

_

«

Em

apenas

uma

paciente

a

descompressão

foi

reali-

zada

na mão não

dominante

e

nas

demais

na

mão

dominante,

pois

procedeu-se

ao

tratamento

cirúrgico

habitualmente

no

lado onde

a

sintomatologia

era mais

importante. Convém lembrar que

em to

dos

os

casos

a

sintomatologia

era

bilateral,

e

mais

intensa

no

lado dominante.

,

O

tempo

de

pós-operatório

no

momento

da

avaliação

variou

de

10

a

57

meses

com uma

média

de 22

meses.

Consideramos

6

das

nossas pacientes

como

perten-

centes

ao

grupo

de

risco, por

exercerem atividade

extenuante

da

mão, tais como:

professora

,

lavadeira, empacotadora

de

ba-

las

e

atividades manuais domésticas

(e×.:

crochê).

Lembramos

que

as

próprias pacientes referiam exacerbação

da

sua

sintoma-

tologia

nos

periodos

de

maior atividade manual

e

alivio com

o

repouso.

V

Não

encontramos

na

história familiar dados rele-

vantes;

já

na

história mórbida pregressa, encontramos

um

caso

de

Esclerodermia

e

_um

de

Hipotireoidismo,

ambas

em

tratamento,

que

são

consideradas

como

condições predisponentes

à

STC.

Em

3

casos relacionou-se

claramente

o

início

da

sintomatologia

conf..

aj

gestaçao

.

V

_

Observamos

que

a

média

de

tempo desde

io

_início

dos

sintomas

até

a

cirurgia

foi

de

7

anos

e 7

meses

(

variando

10

-

Notamos variação sazonal

da

intensidade

da

sinto-

matologia (agravo motinverno),

com

piora progressiva,

aumentan

do

a

intensidade

e

diminuindo

o

período íntercríses.

Hâ.relatofde

um caso

de

inicio súbito

e

intenso,

no

pós-operatório

imediato

de

uma

cirurgia ginecológica, sendo

operada

do

seu

túnel do`o

carpo

3

semanas

após. Por

outro

flado;

háhfion

relato

de

outra paciente

que

iniciou

com

sintomatologia

bilateral

desencadeada

pela

primeira gestação,

com

piora

pro-1

~

~

gressiva

nas

gestaçoes

subsequentes,

e

evoluçao intermitente,

culminando

com

necessidade

de

cirurgia

após

25

anos.

'

.

V

Todos

os

pacientes referiam aumento progressivo

dos

sintomas"

-

Com

relação

ao

quadro clinico pré-operatório

as

queixas mais comuns

foram:

-

_dor

e

parestesia

na mão

(100%)

-

_déficit

_de

_{força tenar (100%)}

_¿

~

-

-

exacerbaçao

noturna dos sintomas(103%)

-

_perda

_da

_{habilidade manual}

_(100%)

-

_hipoestesia

_em

território

do

me-

'

diano (76,9%)

' -

(vídeiGRBEICUII)

, `

Sete

paoiemtes

referiam alivio

dos

sintomas, sen-

~

~

do

5

com

movimentaçao

da

mao

no

periodo noturno,

2

com

repouso

da

mão

e

1

destas melhorava também

com

massagem

da mão

A

sensação

de

congestão

da

mão

foi

relatada porí9

pacientes

(69,2%).

Somente

em

6

prontuários constavam

os

achados

ci-

rúrugicos.

Foi

relatado

em

5

cirurgias

a

presença

de

edema

com

aumento

de

volume

do

nervo

mediano,

em

1

relato

de

engurgita-

mento

e

em

outro apagamento

da

vasa

nervorum.

Também

foi

rela-

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