Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a medical condition caused by compression of the median nerve as it travels through the carpel tunnel in the wrist. The “roof” of this tunnel is the transverse carpal ligament which attaches to 4 bones in the wrist. As we age, all our tissues become slightly less supple and typically the ligament tissue slowly becomes thickened and stiffer. CTS occurs more commonly in female patients, usually after the age of 45.

The true cause of carpal tunnel syndrome is unknown, but it is thought to occur due to periods of prolonged wrist flexion and therefore patients present with night time symptoms initially due to abnormal sleeping position. Patients who are pregnant or have diabetes, rheumatoid arthritis, hypothyroidism or amyloidosis are more prone to getting carpal tunnel syndrome.

The median nerve passes through this tunnel along with 9 other tendons, and as it is ultimately a limited space, any condition causing a decrease in this space is likely to cause CTS. Patients with tenosynovitis of any of the flexor tendons may experience CTS.

Symptoms of CTS are a combination of numbness, tingling, pain, or weakness and are experienced differently by all patients. That said, there is usually a very typical history, especially in early phases of the condition. Patients are woken in the early morning by symptoms of tingling and numbness (they often mention the fingers feel swollen) in the fingertips of the thumb, index and middle fingers. Occasionally the thumb side of the ring finger is also included, with the index and middle finger most commonly affected. They commonly say they have to shake their hands (or even put them in the fridge or freezer!) to improve symptoms. In established disease the numbness may be constant and some might lose strength in their hands or muscle bulk over the palm of the thumb. Severe established carpal tunnel syndrome can lead to permanent symptoms of numbness, paraesthesia, weakness and even neuropathic pain.

Making a diagnosis of CTS is done on history and clinical exam at the consultation. In atypical cases nerve conduction studies (NCS) or Electromyography (EMG) may be requested to aid the diagnosis.

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  • Management

Patients with associated medical problems should be managed medically first, especially hypothyroidism. Pregnant patients should be managed conservatively where possible as the disease often resolves once the baby has been delivered.

Non-operative management

Night time splinting works especially well in early disease with night time symptoms only. Full time splinting may be necessary in pregnancy. A steroid injection into the carpal tunnel can relieve symptoms, but usually only provides temporary relief. Good response to an injection is a good prognostic indicator that surgery will be successful.

Operative management

Patients who have failed non-operative measures or with constant symptoms, wasting or weakness should undergo carpal tunnel release. Patients with symptoms lasting longer than 6 months should also have a carpal tunnel release, as their response to a steroid injection is poor. Carpal tunnel release is a very common procedure that has a good predictable outcome, and may be performed via either an open or an endoscopic (keyhole) technique.

Open carpal tunnel release
This is the traditional method of releasing the carpal tunnel, with a 3-4cm incision in the base of the palm, closed with nylon sutures and takes about 10-14 days to heal completely. The hand is kept in a bulky bandage for 3-5 days following the procedure.

Endoscopic carpal tunnel release
This method involves a transverse skin crease incision in the wrist, and direct release of the offending ligament under camera vision. The advantage of this over the open release is there is no requirement for a bulky bandage in the palm in the early stages, making washing easier. There is also no scar on the weight bearing surface of the palm.

Nerve function may be expected to return to normal only after 3- 12 months, especially if the carpal tunnel syndrome is long-standing.

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