| Carpal Tunnel Syndrome | |
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Carpal tunnel syndrome refers to numbness, tingling, burning or weakness that occurs from compression of the median nerve. It affects approximately 1 out of 100 people, and represents the most common disorder of the hand. The syndrome affects men and women of all ages but is most prevalent in women thirty to sixty years old. Symptoms: The most common symptoms are the presence numbness, and tingling in the fingers, especially the thumb, index, middle, or part of your ring finger, but may also include aching, pins and needles, burning, or just pain in the wrist and fingers. This pain many also radiate up to the elbow. This is commonly worse during sleep or early in the morning If the disease progresses, weakness in the hand (especially the thumb) and decreased control of fine movements can occur, such as difficulty writing or buttoning your clothes. It may affect either one or both hands irrespective of hand dominance. If you do have Carpal tunnel syndrome, you are also at higher risk for getting the following diseases: Trigger finger and Dequervain’s Disease. Biology: Why does it occur? The median nerve is a delicate structure that provides the sensation to the thumb, index, middle and half of the ring finger, as well as the muscle control to the thumb. This nerve travels in a tight compartment along with nine tendons as it traverses the wrist. Because it is such a delicate structure, anything that creates excess pressure to the median nerve as it passes through the carpal tunnel can lead to carpal tunnel syndrome. This can occur from applying external pressure to the palm side of the wrist, keeping your wrist in a excessively flexed or extended position, or from anything that causes swelling or pressure increases inside the carpal tunnel compartment. Disorders that may lead to carpal tunnel syndrome are injuries to the wrist (i.e. breaks or sprains), rheumatoid arthritis, fluid retention (due to kidney failure, under-active thyroid, or during pregnancy), diabetes, or a condition where excess growth hormone is produced (acromegaly). People who are pregnant, overweight, taking contraceptive pills, or going through menopause, have certain endocrine disorders, or have been diagnosed with Trigger finger or Dequervain’s disease are more inclined to acquire the condition. In some, the condition may occur for no apparent or obvious reason. Many diseases can mimic carpal tunnel syndrome. Also, it should be pointed out that the median nerve starts out from the spinal cord in your neck and traverses down from the neck to the hand. This nerve is can be compressed from any area from the neck to the hand, and is often compressed by more than one area. Just like a garden hose that can be compressed from a rock, a bicycle, and a kid stepping on it, the end cumulative result is less water coming out of the hose as compared to water coming out from a hose that has only the rock compressing it. Similarly, the nerve may be compressed at the neck, shoulder, elbow, forearm, and wrist. The end result: numbness or weakness in your hands. Your physician may inquire about and examine other sources of compression that may mimic your symptoms. Why is it more common when you sleep or first thing in the morning? First, many people either sleep on their hands causing increased external pressure on the nerve. Second, many people sleep with their wrists in either a flexed or extended position. Third, the normal fluid volume of your body, which because of gravity tends to gravitate into your legs during the day, redistributes into your hands at night causing increased swelling/pressure Common Diagnostic techniques: Besides your description of symptoms your physician may; - Tap over the course of your median nerve or apply pressure over the area of the carpal tunnel, to reproduce your symptoms. - Hold your wrist in a flexed position for one minute, also to reproduce your symptoms. - Check the strength of your thumb muscles and compare them to other muscles not innervated by the median nerve, or to the opposite thumb. - Order a EMG/nerve conduction test to determine whether other sources of compression of the median nerve are evident, and also to determine the severity of your disease. It should be known however that an EMG/NCV is not the most sensitive test in the whole world, and when the carpal tunnel syndrome is mild, it may not be picked up by this test. Only when the diseased has progressed beyond the mild stage, it can be picked up by this test. So, if your EMG/NCV test comes back “normal”, it just means that it hasn’t progressed far enough for it to be picked up by this test. - Treatment:
- Nonoperative treatment: o The best proven nonoperative treatment is the application of a wrist splint/brace that allows the wrist to stay in a neutral position, commonly worn at night or can be worn through out the day. o Avoid activities that either cause local pressure to the palm side of your wrist, or place your wrist in any position other than neutral o Decreasing repetitive movements of hands that are causing the condition, also changing the repetitive movement itself, its frequency, and the amount of rest in between bouts of said movement o Oral medication § NSAIDs (non-steroidal anti-inflammatory drugs) may reduce swelling and therefore relieve some pressure off the median nerve. These can include over the counter medications such as Advil, Motrin, Ibuprofen, Aleve, or prescription versions. o Hydrocortisone injections can also reduce swelling in the area and provide temporary relief. This should not cause any systemic effects, although in diabetics it may transiently elevate blood sugars. o Ice packs applied to the wrist may also cause relief (Ice packs should be applied indirectly to the wrist via a cloth or paper towel) - Operative treatment (carpal tunnel release) o The primary goal of the surgery is to stop the progression of the disease. The secondary goal is to actually improve the patient’s symptoms. Whether this secondary goal is achieved depends more on the severity and timing that the surgery is performed. The reason for this is that the surgery merely provides more space for the median nerve by taking the pressure off of the nerve. The nerve must attempt to heal and improve on its own which can happen if performed in a timely fashion. This can be likened to a rock compressing a garden hose. If the rock is on the hose for a few weeks, when the rock is removed, the hose should bounce back open and water will likely come through the hose unimpeded. Conversely, if the rock is on the hose for several years, then after the rock is removed, the hose will be permanently deformed, and it is not likely that water will come through the hose normally. Anything in between is anyone’s guess as to how much the hose will bounce back up. In its most simplistic description, all we are doing in surgery is taking the rock off the hose. o So when is an operation indicated? Either one of two conditions: If the patients symptoms are aggravating them too much despite nonoperative treatment. This is a decision that the patient gets to make b/c only the patient knows how bad they feel. Second, if the disease is progressing too far such that if surgery is not done, that the patient may suffer permanent damage. How do we know when that might be? When there is documented muscle weakness in the thumb, then the condition has progressed too far to watch nonoperatively and the surgeon must tell you that surgery is necessary. If the operation is delayed so long such that there is atrophy (muscle wasting), surgery is still necessary in order to prevent further damage, but then the results of surgery become even more variable. o Endoscopic Procedure § A small incision is made in the wrist. A thin flexible endoscope is then inserted into the slit and transmits a picture to a screen. The surgeon will then cut the transverse carpal ligament to make more room for the median nerve. The procedure is commonly done in an outpatient facility leaves a small scar, and allows for one to relatively quicly return to their normal lives. o Open Procedure § The gold standard approach is an open procedure where the surgeon makes a slightly longer incision in the hand and opens the area and then proceeds to make room for the median nerve. The scar is usually placed in your “lifeline” crease in your palm. When this incision heals, it usually is difficult to distinguish your scar from your “lifeline” crease. There is a slightly lower risk of nerve damage in this procedure. § For a skilled surgeon, the total operative time from skin incision to the last suture is typically between 5-10 minutes only. After Surgery Your splint and sutures are removed approximately 7-10 days after the surgery. You will be asked to start using your fingers shortly after the surgery. Often a short period of hand therapy can expedite your recovery. How successful is the surgery? First, there are never any guarantees in any type of surgery. Again, the primary goal of the surgery is to stop the progression of the problem. This goal of the surgery is achieved at least 98% of the time. But then how often and when will the symptoms be relieved? How quickly your symptoms may be relieved, if at all, is dependent mostly on how severe the pathology was to begin with as well as any underlying ongoing diseases. Often in patients who have had surgery in a timely fashion before the onset of permanent damage, the symptoms may start resolving within the first few days or weeks after the surgery. On the other hand, those patients whose disease has progressed past the time of permanent damage will still likely stop the progression of the disease, but may not get any significant relief of their symptoms. Adverse effects of surgery/complications: - All surgeries no matter how simple or small have possible associated complications or adverse effects. We have tried to list the most common ones. However, it is not practical to predict and or list every conceivable complication that may occur. Most of these are not the result of your surgeon’s doing, but rather possibilities that cannot be controlled. - It is not uncommon to have a prolonged amount of tenderness at the incision site, which usually improves over about 4-6 weeks. In a rare occasion, this hypersensitivity may be prolonged. - Infections at the surgical incision site occurs less than 1% of the time, although more commonly in patients with comorbid disorders such as diabetes, rheumatoid arthritis, etc. Often this can be treated with oral antibiotics and local wound care. - Anesthetic complications are possible. Please refer to the anesthesia section. - It is possible that the nerve can be accidentally either partially or completely cut, although this is extremely unlikely. - A rare form of Dupuytren’s disease may ensue after any form of surgery in the hand. Please refer to the Duputyren’s section for more info. - RSD. Possible after any surgery. - Remember, carpal tunnel syndrome is associated with higher incidence of getting - Carpal tunnel can recur, although probably occurs less than 5% of the time. FAQ’s - Is Carpal tunnel caused by computers? o Computers by themselves do not cause carpal tunnel syndrome. It was first described in the mid 1800's. The first surgery for release of the carpal tunnel was done in the 1930's, well before widespread use of typewriters or computers. - Can this surgery be performed with Laser surgery? o Laser surgery is not used. Not only does it not offer any benefit, it in fact could be harmful. - What is the success rate of the surgery? o Again, this is dependent mostly on the patient’s preoperative status. Some people may have heard that they knew somebody who did not improve after surgery. This may be correct, and occurs mostly in those patients who have waited too long before pursuing surgical intervention. - What is the recurrence rate after surgery for CTS o Recurrences are extremely unusual, typically less than 3%. |
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