Carpal Tunnel Syndrome
Carpal Tunnel Syndrome
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| Nerve Entrapment |
Introduction
The carpal tunnel is a narrow passageway on the palmer side of the wrist made up of bones and ligaments. The nerve is much like a truck passing through a tunnel. The truck (nerve ) should be able to pass through the tunnel with ease and without friction. If the tunnel is narrow than the truck (nerve) cannot pass . If you want the nerve to pass, widen the tunnel. The carpal tunnel is defined by Scaphoid tubercle and trapezium radically, Hook of Hamate and Pisiform ulnaly. Proximal Carpal row dorsally. And Transverse carpal ligament palmary (roof).
Carpal tunnel consist of 9 flexor tendons . One nerve Median Nerve. The median nerve runs through this passageway along with the tendons to the fingers and thumb. The palmer cutaneous branch of median nerve arise from the radio palmer part of the nerve 5 cm proximal to the volar wrist crease. The palmer cutaneous branch of median nerve runs between the palmaris longus and the flexor carpi radialis interval. It passes superficial to the transverse carpal ligament to supply sensation to the thinner eminence. After passing through the carpal tunnel, the median nerve gives a branch on the radial side called the recurrent motor branch
In pregnancy, even in those who don't do a lot of repetitive hand motions. That's because the carpal tunnel in the wrist, through which the nerve to the affected fingers runs, becomes swollen during pregnancy ( as do so many other tissues in the body., you might have noticed). With the resultant pressure causing numbness, tingling, burning and pain. The symptoms can affect hand and wrist and they can radiate up the arms.
Though CTS symptoms can strike any time of the day, you might feel yourself wrestling with wrist pain more at night. That's because fluids accumulated in your feet and legs during the day are redistributed to the rest of your body (including your hands) when you lie down at night. Sleeping on your hands can make the problem worse, so try elevating them on a separate pillow.
Typically CTS symptoms resolve sometimes after delivery, once all that pregnancy swelling goes down. In the mean time acupuncture may bring relief.
Classification
Mild
- Only sensory conduction is affected.
- No weakness
- Diagnosis is only by medical history
- Physical finding not ready.
Moderate
- Both sensory and motor are affected
- Patient will have symptoms throughout the day
- Provocation test are positive.
Severe
- Both Sensory and motor and needle finding in EMG.
- Weakness and atrophy.
Cause
- Repetitive Motion & Vibration : causes thickening of the carpal ligament.
- Pregnancy
- Systemic Disease : Diabetes, dialysis. Rheumatoid Arthritis, obesity, Hypothyroidism, Amyloidosis, mucopolysaccharidosis.
- Idiopathic CTC Pathology : Oedema and fibrosis of ten synovium.
- Not inflammatory
- CTC has high coincidence with thumb CMC Osteoarthritis.
- Repetitive tasks (typing, numbers, working a smart phone)
- Piano playing.
- Using the hand or wrist in a repeated fashion – typically with the hand lower than wrist. This includes computer work, work with vibrating tools, and activities that requires a strong grip.
- Medical conditions such as diabetes, hypothyroidism and some types of arthritis can cause carpal tunnel syndrome.
- Pregnancy has also been a reported condition with higher risk rates.
- Obesity.
- Hypothyroidism.
- Genetic predisposition.
- Medical disorders that lead to fluid retention.
- Medical conditions associated with inflammation such as inflammatory arthritis.
- Amyloidosis : Amyloidosis is a rare disease that occurs when a protein called amyloid builds up in organs. This amyloid buildup can make the organs not work properly. Some types of amyloidosis may lead to life-threatening organ failure, particularly in the heart.
- Female
- Smoking
- Advanced Age
- Alcoholism
- Obesity
- Repetitive motion
- Certain athletic activities such as throwing, tennis or cycling, may cause CTS.
- Space occupying lesion: Seen in patient with atypical presentation such as being male , young or unilateral, suspect a space occupying lesion such as ganglion cyst , gout, lipoma, synovial sarcoma, anomaly of the muscles, or dislocation fracture.
- Double crush syndrome: Patient with CTS feels pain in fore arm, elbow, upper arm, shoulder, chest and upper back.
- Compression on at e site decreases threshold at another.
- C6 radiculopathy and CTC co exist.
- Upper extremity exam begins at the neck
- Beware most common radiculopathy is C6 similar to CTS creates confusion.
- Always consider spine pathology in patients with CTS
Signs & Symptoms
- Numbness and tingling in radial 3 1/2 digits. Numbness should be less at the thinner area of the palm.
- Clumsiness & Weakness.
- Thinner atrophy may be present
- Loss of strength
- Sensations of pins and needle in hands
- Forearm tenderness.
- Pain up in arms
- Pain during the night starting gradually. Pai and paresthesia that wakes the patient up at night and is relieved by shaking the hands away.
- Weak grip strength
- After a long time muscles at the base of the thumb deteriorate.
- Burning and pain
- Tingling
- Numbness in the hands and most often strikes those who spends a lot of time. The numbness and pain is confined to a thumb, index finger, middle finger and half of your ring finger, you probably gave carpal tunnel syndrome.
- Weakness in the hand.
Diagnosis
- Durkan's Test : Carpal tunnel compression test. Most sensitive test to diagnose CTC. Performed pressing thumb over the carpal tunnel and holding pressure for 30 seconds.
- Phalen Test : Wrist volar flexion for approximately 60 seconds produces symptoms.
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- Tinel's Test : Test is performed by tapping on the median nerve over the volar carpel tunnel.
- Semmes Weinstein's Testing : Most sensitive sensory testing for detecting early carpal tunnel syndrome
- Innervation Sensitive test : Static and moving two point discrimination
- Nerve regeneration.
Do Electromyogram (EMG) and Nerve studies if surgery is considered.
EMG & Nerve Conduction studies:
Only objective evidence of a comprehensive neuropathy.
Use NCS for sensory and motor study: Use distal latency for sensory and anything >3.5msec is diagnostic.
Use distal latency for motor and anything for >4.5 msec is diagnostic.
Nerve conduction velocity less than 52m/sec is abnormal.
Radiographs are not routinely used for the diagnosis.
Occasionally carpal tunnel views and MRI can be used for diagnosis
numbness and pain is confined to a thumb, index finger, middle finger and half of your ring finger, you probably gave carpal tunnel syndrome.
If you have 4 abnormalities:
- Abnormal hand diagram
- Abnormal sensory testing
- Semmes Weinstein's testing in a wrist at a neutral testing.
- Positive compression test and night pain.
- Night pain is the most sensitive predictor in 96%
- Positive compression test (Durkin's test 89%
- Semmes Weinstein's test 83 %
- Hand diagram most specific test 76 %
- Tinel's sign 71 %
Get an MRI and rule out pressure on a motor branch of the Median nerve.
Prevention
- Being physically active can decrease the risk of developing CTS.
- Physical Therapy.
- Symptom can improve by wearing a wrist splint.
Treatment
- NSAIDS
- Night Splint in neutral especially when EMG and nerve study is negative.
- Activity modification
- These are first line of treatment.
- Steroid injections : Failure to improve after injections is a poor prognostic factor.
- Surgery is less effective in patients who see improvement in steroid injections.
- Eliminating the activity
- Icing the area
- Corticosteroids injections
- Vitamin B6 Supplements
- Pain relievers
- Steroidal anti-inflammatory drugs
- Wrist splint (though you may find wearing one more uncomfortable than the CTS itself)
- Acupuncture
Tunnel Syndrome Wrist in splint - Raise your office chair so your wrist are straight and your hands are lower than your elbows as you type.
- Switch to a wrist friendly ergonomic keyboard (one that has a wrist rest) as well as a mouse that offers wrist support.
- Wear a wrist brace while typing.
- Take a frequent breaks from the computer.
- Go hand free if you're on the phone a lot.
- In the evenings, soak your hands in cool water to reduce any swelling.
During open carpal tunnel release surgery, the transverse carpal ligament is cut, which releases pressure on the median nerve and relieves the symptoms of carpal tunnel syndrome. An incision is made at the base of the palm of the hand. After the ligament is cut, the skin is closed with stitches. Open carpal tunnel release surgeries are usually performed on an out-patient basis and are highly successful.
Endoscopic Carpal Tunnel Surgery
Endoscopic surgery uses an endoscope, which is a thin tube with a camera attached. The endoscope lets the surgeon see structures in the wrist without opening the entire area with a large incision. Endoscopic surgery uses very small surgical tools.
The endoscope is inserted through a small incision in the wrist (single-portal procedure) or at the wrist and palm (two-portal procedure). One small tube contains both the camera and a cutting tool in the single-portal procedure.
The transverse carpal ligament is cut during endoscopic carpal tunnel release surgery, releasing pressure on the median nerve. This relieves carpal tunnel syndrome symptoms.
Because the procedure does not cut the palm open and disturb a large area of the hand, there is a shorter recovery period after an endoscopic surgery than with open surgery.
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