Carpal Tunnel Syndrome

What is carpal tunnel syndrome?

Carpal tunnel syndrome is a painful condition caused by compression of a key nerve in the wrist.   It occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. While carpal tunnel syndrome can occur at any age, it most often affects people between the ages of 40 and 60. In more than half of cases, both hands are affected; however, the severity may vary between hands. When only one hand is affected, it is most often the hand used for writing (the dominant hand).

Symptoms usually start gradually, with  pain, weakness, or numbness in the hand and wrist, radiating up the arm. These signs and symptoms often develop during sleep and are noticeable upon waking. Affected individuals typically shake their hand to get rid of the pain and numbness, a characteristic move known as the flick sign. As the condition advances, the signs and symptoms begin to occur during the day as well. As symptoms worsen, people might feel tingling during the day, and decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. Affected individuals may have difficulty performing manual tasks such as turning doorknobs, fastening buttons, or opening jars.

The symptoms of carpal tunnel syndrome may be triggered by certain activities that flex or extend the wrist, such as driving, typing, or holding a telephone. In some cases no direct cause of the syndrome can be identified. Most likely the disorder is due to a congenital predisposition – the carpal tunnel is simply smaller in some people than in others.  The risk of developing carpal tunnel syndrome is especially common in those who preform repetitive work tasks, such as assembly line work. Carpal tunnel syndrome is also associated with pregnancy and diseases such as diabetes, thyroid disease, or rheumatoid arthritis.

What are the risk factors of CTS?

Mechanical:

  • Localized repetitive trauma
  • Occupational
  • Forced wrist flexion

Metabolic:

  • Thyroid Dysfunction
  • Hypothyroid
  • Pregnancy
  • Acromegaly
  • Gout

Inflammation and/or infection:

  • Infiltrative disorders such as amyloidosis
  • Sarcoidosis
  • Inflamatory tenosynovitis
  • Soft tissue infection

What other medical conditions could present with symptoms of CTS?

  • Cervical spine disease
    • OA
    • Stenosis (C6, C7)
    • Disc herniation
    • Brachial plexus neuropathy
  • Median nerve compression in the arm or forearm
  • Mononeuritis multiplex
  • Cervical cord abnormalities
  • Angina pectoris
  • Thoracic outlet
  • Pancoast tumor
  • TIA
  • Tendonitis

What are the presenting symptoms of CTS?

  • Pain distal to lesion
  • Burning paresthesia/dyesthesia
  • Awakens at night with numbness
  • Pain may radiate to shoulder
  • Pain is relieved by shaking, dangling, rubbing
  • Sensory loss (median nerve distribution – 1st 3.5 fingers)
  • Muscle weakness
  • Muscle wasting
  • Hemiparesis, dysarthria, visual changes, HA, neck pain (R/O DDx)

What your doctor needs to know about your health?

Your doctor would ask you questions about the following conditions:

  • Onset and progression of your symptoms
  • Motor, sensory or autonomic dysfunction
  • Mononeuropathy vs. polyneuropathy
  • Associated disease
    • Rheumatoid arthritis
    • Diabetes
    • Hypothyroid
    • Acromegaly
    • Vasculitis
    • Amyloidosis
    • Pregnancy
    • Post-injury
    • Alcohol abuse

Occupational History:

  • Type and nature of occupation
  • Length of time in that job
  • Total number of hours worked each in that job

What examinations your doctor would need to do to be able to diagnose carpal tunnel syndrome?

  • Examine
    • c-spine & shoulder
    • joint above and below
    • forearm
    • wrist
    • exam
  • Compare both sides
  • Inspect:
    • Muscle wasting thenar muscles (late)
    • Asymmetry
    • Fasciculations
    • Swelling
    • Erythema
  • Palpate for:
    • Tenderness
    • Anatomical snuffbox
    • Crepitus
  • Sensory exam:
    • Decreased light touch in thumb, index finger or middle finger
    • Decreased 2 point discrimination (> 6 mm)
    • Vibration sense
    • Position sense
    • Temperature sense
  • Motor exam:
    • Range of motion of wrist joint and fingers
    • Weakness of thumb in flexion (flexor pollicis longus)
    • Weakness in extension
    • Finger movements
  • Special tests that could be done:
    • Tinel’s sign (Tap of nerve on wrist ® Tingling from wrist to hand)
    • Phalen’s sign (wrist flexion 90 degrees x 1 min ® numbness, dysethesias in median distribution)
    • Carpal compression test (pressure on carpal tunnel for 30 sec elicits symptoms)

Laboratory work up

Any or all of the following lab work ups might be requested before other causes of your symptoms are excluded or the underlying cause of carpal tunnel is identified:

  • CBC
  • ESR
  • Fasting Blood Suger
  • Rheumatic Factor
  • TSH
  • Uric acid
  • HbA1c
  • Pregnancy test

 

How is carpal tunnel managed?

Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, other nonprescription pain relievers, and oral steroids (prednisone) may ease pain. Steroid injections can also be used to alleviate the swelling and pressure on the median nerve. For more severe cases of carpal tunnel syndrome, open carpal tunnel release surgery or endoscopic carpal tunnel release may be recommended.

The followings can be considered in treatment  of CTS:

  • Minimize wrist movement
  • Improved occupational and workplace ergonomics
  • Splinting:
    • Neutral wrist splint at bedtime
  • NSAIDS
  • Lasix
  • Corticosteroid injections (50-80% effective)
  • Surgery Indications:
    • refractory pain
    • +++ sensory loss
    • muscle atrophy
  • Release flexor retinaculum (>90% effective)

how can I prevent developing carpal tunnel?

  • Avoidance of repetitive movements  of wrist
  • Regular physical activity
  • Control blood sugar

References

  • Atroshi, I.; Gummesson, C; Johnsson, R; Ornstein, E; Ranstam, J; Rosén, I (1999). “Prevalence of Carpal Tunnel Syndrome in a General Population”. JAMA282 (2): 153–158.
  • Amadio, Peter C. (2007). “History of carpal tunnel syndrome”. In Luchetti, Riccardo; Amadio, Peter C. Carpal Tunnel Syndrome. Berlin: Springer. pp. 3–9.
  • Gonzalezdelpino, J; Delgadomartinez, A; Gonzalezgonzalez, I; Lovic, A (1997). “Value of the carpal compression test in the diagnosis of carpal tunnel syndrome”. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand22: 38–41.
  • Wilder-Smith, Einar P; Seet, Raymond C S; Lim, Erle C H (2006). “Diagnosing carpal tunnel syndrome—clinical criteria and ancillary tests”. Nature Clinical Practice Neurology2 (7): 366–74.
  • Nabhan A, Ishak B, Al-Khayat J, Steudel W-I (April 25, 2008). “Endoscopic Carpal Tunnel Release using a modified application technique of local anesthesia: safety and effectiveness”. Journal of Brachial Plexus and Peripheral Nerve Injury3 (11): e35–e38.
  • Ibrahim I.; Khan W. S.; Goddard N.; Smitham P. (2012). “Carpal Tunnel Syndrome: A Review of the Recent Literature”. The Open Orthopaedics Journal6: 69–76.
  • Lozano-Calderón, Santiago; Shawn Anthony; David Ring (April 2008). “The Quality and Strength of Evidence for Etiology: Example of Carpal Tunnel Syndrome”. The Journal of Hand Surgery33 (4): 525–538.
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