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CARPAL TUNNEL SYNDROME

What is carpal tunnel syndrome?

Carpal tunnel syndrome describes a condition that results from compression of the median nerve as it passes through the narrowest part of the rigid tunnel of the wrist. It is made up of bones and filled with tendons, the roof is covered with a tight ligament called the transverse ligament. This narrow tunnel is called the carpal tunnel, in which the median nerve is accompanied by the nine tendons that flex the fingers and thumb. The most common cause of carpal tunnel syndrome is swelling of the membranes (tendon sheaths or bursae) that normally surround and lubricate the tendons as they glide in the tunnel. Aging and disease causes changes and thickening of these membranes. The signs and symptoms may be mild, moderate, or severe and usually worsen without treatment.

Who is likely to suffer from it?

The syndrome occurs more often in women, typically after age 30. A non-specific inflammatory swelling of tendon bursae (tenosynovitis) is the common cause. Tasks that require rapid, repetitive bending of the fingers, the use of vibratory tools, or a prolonged power grip, are known to hasten the onset of symptoms. Many diseases, some drugs, direct injury, and even pregnancy may increase the fluid (swelling) in the bursae enough to compress the median nerve in the rigid tunnel. The median nerve functions to provide sensation to a significant portion of the palm and fingers. In addition, it also is responsible for providing the motor control of some of the muscles of the palm and thumb.

What are the signs and symptoms ?

The most frequent complaint is numbness and tingling of the palmar surface of any of the five fingers, except for the little finger. A complaint about "dropping things", for example, dropping rice bowls, is frequent because of this numbness. Occasionally, an accompanying pain radiates into the forearm. Symptoms often first appear, or worsen, at night because of normal fluid shifting to the extremities which becomes congested. In addition, during sleep, the wrist in often in a flexed position and that makes the symptom worse. Prolonged or constant symptoms signal progression of severe nerve compression, and weakness of thumb muscle can follow. 'Locking' of the fingers is an associated complaint in 25% of cases of carpal tunnel syndrome because both can be caused by tenosynovitis.

How is the diagnosis made?

An accurate medical history and the clinical examination will establish the diagnosis in most cases. Often, the symptoms can be reproduced or worsened by bending the wrist firmly palmward for 60 seconds (Phalen's test), and/or by tapping the front of the wrist over the nerve (Tinel's sign). The more uncomfortable (and expensive) electrodiagnostic test which measures nerve function is reserved for the evaluation if there is doubt.

What is the available treatment?

Patients with recent, mild, or intermittent symptoms may be treated successfully with anti-inflammatory drugs and night splints which prevent wrist flexion. However, most cases will recur if the cause of the nerve compression persists. Unless significant improvement is noted early in the treatment phase, non-operative treatment may not be successful.

Surgery is usually the treatment of choice for classic carpal tunnel syndrome. Typically, 80-90% of patients will have permanent relief of their symptoms following division of the wrist ligament (transverse carpal ligament) which covers the carpal tunnel. Release of scar around the median nerve and partial removal of the tendon bursae (sheath) is added in selected cases

By performing these procedures, it is possible to decrease the occlusive pressure on the nerve and to relieve the symptoms. Day surgery and an incision limited to the proximal palm comprise the normal surgical approach today. Following surgery, while the complete relief of the nerve compression symptoms may be immediate, it often may take up to three months. Unfortunately, it is possible for the nerve to suffer permanent damage if treatment is delayed. If this happens, then the likelihood of persistent symptoms, even after surgery, is greater. The annoying ache associated with an underlying tendon bursae disease, like the pains of arthritis, may linger on, without the threat of nerve dysfunction.

Carpal tunnel surgery may be performed either with the traditional open surgery or by using a telescope to visualize the nerve and transverse ligament. The surgery which is performed in this manner is called endoscopic surgery. The advantages of endoscopic surgery include: smaller incisions, faster recovery period, faster rehabiliation period and a decreased complication rate.

What is Endoscopic Carpal Tunnel Release Surgery (ECTR)?

ECTR has become a very popular procedure because it may afford many patients a faster recovery and less pain after surgery.

Endoscopic carpal tunnel release itself is an operation where a small (about 1.5 cm) incision is made in the wrist and an endoscope is used to visualize the carpal ligament which is cut with small blades under direct visualization. The difference between ECTR and open carpal tunnel release is that with ECTR there are only one small incision required. However, with open carpal tunnel procedures, a relatively lengthy incision which is usually between 4 and 8 cms (2" to 5'') is utilized to release the carpal tunnel. By using an endoscopic technique for surgery it is believed that the skin and soft tissue of the palm can be preserved and therefore less post operative pain and more rapid recovery may be possible.

The complication rate of ECTR does not appear to be an greater than open carpal tunnel surgery. The complication rate of open carpal tunnel surgery that is often cited is between 12 - 25 % of patients that have some problem following carpal tunnel surgery. Early studies of ECTR show that there is no greater complication rate with this new procedure, and it may actually have less complications.

The surgery itself (ECTR) is performed under local anesthesia. The operation is performed on a day surgery basis. The operative takes about 30-45 minutes to complete. Some patients wear a "post-operative" splint for 4-5 days until sutures are removed.

Perhaps the most impressive part about endoscopic carpal tunnel release is how quickly patients appear to recover from this operation. Although many patients do complain of pain in the palm and some discomfort with the fingers after surgery, most appear to be able to resume most of their day to day activities within a few days after surgery and often return to work 3-6 weeks after surgery. Open surgery with longer incision takes a substantially longer time for recovery. Even with ECTR, many patients are required to avoid heavy lifting and repetitive motion for 6-8 weeks after surgery. The need for physiotherapy is lower due to less swelling and immediate use of hand following surgery.

THIS MATERIAL DOES NOT CONSTITUTE MEDICAL ADVICE. IT IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. PLEASE CONSULT A PHYSICIAN FOR SPECIFIC TREATMENT RECOMMENDATIONS.