Carpal Tunnel Syndrome

21th OCTOBER 2021



Carpal Tunnel Syndrome

Carpal Tunnel Syndrome (CTS) is a common condition caused by compression of the Median Nerve in the Carpal Tunnel at the wrist. Compression of the Median nerve in the tunnel gives rise to sensory and motor symptoms which constitute carpal tunnel syndrome. It usually occurs in females between the age of 40-70. Women are 3 times more likely to develop CTS than men. Diagnosis is suggested by signs and symptoms and is confirmed by nerve conduction velocity. Treatment includes avoiding activities that cause symptoms, painkiller, splinting, and sometimes steroids injection in tunnel or surgery.

Carpal Tunnel

Carpal Tunnel is a bony tunnel on the front of the wrist bounded on three sides by wrist bones and a very strong ligament, flexor retinaculum bridging the wrist bones. The tendons of flexor muscles and median nerve which supply the skin over the thumb, index, middle finger, and half of the ring finger, pass through this tunnel. The median nerve also supplies motor power to some small muscles of the hand. 

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Symptoms

The patient complains of intermittent attacks of pain in the hand and wrist in the distribution of the Median nerve on one or both hands (the palmer side of thumb, index, middle and radial half of ring finger) The attacks are frequently in the night. The patient wakes at night with burning or aching pain in the wrist and hand. Pain may be referred to proximally in the forearm and arm. As the compression increases in severity, numbness, tingling (pins and needles sensation) is felt in the palm and fingers. In more severe cases pain is permanent and there may be wasting of thenar muscles supplied by median nerve causing flattening of palm at the base of the thumb. There is a weakness of the thumb and a loss of grip strength. Patients find it difficult to handle small objects.

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Causes

A single cause is not found always. Sometimes many different problems contribute to the development of CTS. Any condition that takes up space in the carpal tunnel can cause pressure in the tunnel. Most cases are idiopathic.

  • Any condition that causes fluid retention including Pregnancy
  • Bony deformities from arthritis or previous fractures at wrist
  • Hypothyroidism ; generalized myxodema cause deposition of mucopolysaccharides within Perineurium of median nerve and in tendons passing through the tunnel.
  • Acromegaly
  • Diabetes
  • Amyloidosis
  • Repetitive activity or certain types of work rarely.

Risk Factors

  • Obesity
  • Family history
  • Pregnancy
  • Arthritis
  • Injuries
  • Repetitive wrist work
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Diagnosis

A detailed history will point to the diagnosis. The Simple provoking tests can be performed to confirm the diagnosis. Although widely used, the presence of positive tests alone is not sufficient for diagnosis. Clinical differentiation from other types of peripheral neuropathy may sometimes be difficult.

Phalen Sign

Phalen’s maneuver is performed by flexing the wrist gently as far as possible and holding this position for 60 seconds. A positive test results in numbness in median nerve distribution area within 60 seconds.

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Tinel Sign

Tinel’s test is a classic test to detect median nerve irritation. By lightly tapping the skin over flexor retinaculum a tingling sensation is felt in the median nerve distribution.

Durkan test

Durkan test or median nerve compression test done by applying firm pressure on the palm over the nerve up to 30 seconds to elicit symptoms.

Hand elevation test

Lifting both hands above head and if symptoms appear within two minutes the test is positive. It has higher sensitivity than above test.

Electrodiagnostic tests

Nerve conduction studies are most sensitive, specific, and reliable. If the diagnosis is uncertain, nerve conduction testing should be done to exclude more proximal pathology. However normal test does not preclude the presence of CTS.

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Treatment

Treatment of any underlying disorders like diabetes, Rheumatoid arthritis, hypothyroidism may provide some relief. Patients with arthritis may respond to anti-inflammatory medicine. CTS associated with pregnancy may settle once the pregnancy is over. Most patients with mild symptoms improve with non-surgical treatment. Severe and resistant cases may require division of the flexor retinaculum.

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Non surgical treatment

Wrist splint

Splinting is beneficial in patients with mild symptoms and a short history. The pain may be relieved by splinting the wrist to keep it straight, for 3-4 weeks especially overnight. Up to 33% of patients improve without any treatment over a few months or a year.

Avoiding activities that may provoke symptoms.

Frequently bending wrist, gripping hard, using vibrating tools for work or playing instruments can cause CTS. Making some ergonomics corrections e.g. while working on a computer may provide some relief.

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Painkillers

Over the counter mild analgesic like paracetamol or non-steroidal anti-inflammatory medicine can be taken to relieve pain.

Steroids injection

Steroids like cortisone relieve inflammation around the nerve temporarily. They are effective in the short term. Pain may come again after a month. Patients with mild symptoms may get benefit in long term. In injecting in the carpal tunnel there is always a small risk of injury to the median nerve. Cortisone might be directly injected into the nerve which can cause irreversible damage to the nerve. Injecting steroids are needed in some patients who can not go under surgery.

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Surgical treatment

In resistant cases, in cases of recurrence or if hand weakness and thenar wasting develop then carpal tunnel can be surgically decompressed. Patients with moderate to severe symptoms and those with underlying bone deformities are unlikely to get benefits from non-operative treatment and are better to have surgical treatment. Whatever the pathology, simple decompression of the tunnel by longitudinal incision of the flexor retinaculum cures the condition. There is a 95 % success rate for surgery. Intermittent symptoms like pain at night or occasionally tingling will go better within days after surgery. Permanent symptoms take longer to resolve. The degree and speed of recovery depend mainly on the degree of damage to the nerve from long-standing entrapment. Some bad cases may only resolve partially if the nerve already has been damaged beyond recovery. It takes 15-20 minutes for open surgery and a month before getting back to work. Endoscopic carpal tunnel release is better option than open surgery. It gives the opportunity for quick recovery and a quick return to work. A small incision is given at the wrist under local anesthesia and the carpal tunnel ligament is divided.

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