Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common condition which causes pain, numbness, and tingling within the hand and arm. The condition develops when one of the main nerves to your hand — the median nerve — is squeezed or compressed as it travels throughout the wrist.

In the majority of patients, carpal tunnel syndrome worsens over time, so early diagnosis and treatment are necessary. Early on, symptoms can often be alleviated with simple measures like wearing a wrist splint or keeping away from certain activities.

If stress on the median nerve persists, however, it can cause nerve damage and deteriorating symptoms. To prevent permanent damage, surgery to take pressure from the median nerve might be recommended for some patients. Because of the regressive nature of carpal tunnel syndrome, it is particularly important that you arm yourself with facts from Audrain Orthopaedics in Mexico, MO so that you'll be able to avoid an issue later on.

Anatomy

The carpal tunnel is a narrow passageway in the wrist, roughly an inch wide. The floor and sides of the tunnel are formed by small wrist bones referred to as carpal bones. The roof of the tunnel is a strong band of connective tissue known as transverse carpal ligament. Because these boundaries are very rigid, the carpal tunnel has very little capacity to "stretch" or increase in size.

The median nerve is among the main nerves in the hand. It originates as a group of nerve roots in the neck. These roots come together to produce a single nerve in the arm. The median nerve goes down the arm and forearm, moves through the carpal tunnel at the wrist, and goes into the hand. The nerve gives feeling in the thumb and index, middle, and ring fingers. The nerve also controls the muscles around the root of the thumb.

The nine tendons which bend the fingers and thumb also move through the carpal tunnel. These tendons are known as flexor tendons.

Description

Carpal tunnel syndrome occurs when the tunnel becomes narrowed or when tissues around the flexor tendons swell, putting pressure on the median nerve. Such tissues are the synovium. Ordinarily, the synovium lubricates the tendons, making it easier to move your fingers.

When the synovium swells, it occupies space within the carpal tunnel and, with time, crowds the nerve. This unusual stress on the nerve can result in pain, numbness, tingling, and weakness within the hand.

Cause

Most cases of carpal tunnel syndrome originate from a variety of factors. Studies indicate that women and the elderly are more likely to develop the condition.

Other risk factors for carpal tunnel syndrome include:

• Heredity. This is probably an important factor. The carpal tunnel might be smaller in some people or there might be anatomic variations which change the amount of space for the nerve—and these qualities can run in families.
• Repetitive hand usage. Repeating the same hand and wrist motions or activities over a prolonged time period may aggravate the tendons in the wrist, triggering swelling which places strain on the nerve.
• Hand and wrist position. Doing activities that involve intense flexion or extension of the hand and wrist for a protracted period of time can increase strain on the nerve.
• Pregnancy. Hormonal changes during pregnancy may cause swelling.
• Health conditions. Diabetes, rheumatoid arthritis, and thyroid gland imbalance are conditions that can be had with carpal tunnel syndrome.

Symptoms

Symptoms of carpal tunnel syndrome might include:

• Numbness, tingling, burning, and pain—primarily in the thumb and index, middle, and ring fingers
• Occasional shock-like sensations that radiate to the thumb and index, middle, and ring fingers
• Pain or tingling that could travel up the forearm toward the shoulder
• Weakness and awkwardness in the hand—this could make it tough to do fine movements such as buttoning your clothing
• Dropping things—due to weakness, numbness, or a lack of proprioception (awareness of where your hand is in space)

In most situations, the symptoms of carpal tunnel syndrome begin gradually—without a specific injury. Many patients find that their symptoms come and go to begin with. However, as the condition worsens, symptoms could happen more frequently or might persist for longer periods of time.

Night-time symptoms are very common. Because a lot of people sleep with their wrists bent, symptoms could awaken you from sleep. During the day, symptoms often occur when holding something for a protracted time period with the wrist bent forward or backward, such as when using a phone, driving, or reading a book.

Many patients find that moving or shaking their hands helps alleviate their symptoms.

Doctor Examination

Physical Examination

Through your evaluation, your doctor will talk to you about your overall health and medical history and will inquire about your symptoms.

He or she will carefully examine your hand and wrist and conduct a number of physical tests. During these tests, your doctor will:

•   Press down or tap on the median nerve at the inside of your wrist to find out if it causes any numbness or tingling inside your fingers (Tinel sign)

•   Bend and hold your wrists in a flexed position to test for numbness or tingling in your hands

•   Test sensitivity in your fingertips and hands by lightly touching them with a special instrument whenever your eyes are closed.

•   Look for weakness in the muscles around the base of your thumb

•   Check for atrophy within the muscles around the base of your thumb. In extreme cases, these muscles can become visibly smaller.

Tests

Electrophysiological tests. These tests will help your physician measure how well your median nerve is working and help determine whether there's too much pressure on the nerve. The tests will also help your physician figure out whether you have another nerve condition, such as neuropathy, or other sites of nerve compression that might be contributing to your symptoms.

Electrophysiological tests may include:

• Nerve conduction studies. These tests measure the signals travelling in the nerves of your hand and arm and can detect whenever a nerve isn't conducting its signal properly. Nerve conduction studies can help the doctor figure out how severe your problem is and help to guide treatment. Dr. Weaver at Audrain Orthopaedics carefully assesses all of her patients to produce an individualized treatment plan because every patient in Moberly, Columbia, and Mexico, MO is different.
• Electromyogram (EMG). An EMG measures the electrical activity in muscles. EMG results can display whether you've got any nerve or muscle damage.
• Ultrasound. An ultrasound uses high-frequency sound waves to help create pictures of bone and tissue. Your physician may recommend an ultrasound of your wrist to assess the median nerve for signs of compression.
• X-rays. X-rays provide images of dense structures, like bone. If you have limited wrist motion or wrist pain, the doctor might order x-rays to exclude other causes for your symptoms, such as arthritis, ligament injury, or a fracture.
• Magnetic resonance imaging (MRI) scans. These studies offer better images of the body's soft tissues. Your physician may order an MRI to help determine other causes for your symptoms or to look for unusual tissues that could be affecting the median nerve. An MRI will also help your physician see whether there are issues with the nerve itself—such as scarring from an injury or tumor.

Treatment

Though it is a gradual process, for most of us carpal tunnel syndrome will exacerbate with time without some sort of treatment. As a result, it is important to be examined and diagnosed by your physician early on. In the early stages, it might be possible to slow or stop the growth of the disease.

Nonsurgical Treatment

If diagnosed and treated early on, the symptoms of carpal tunnel syndrome can often be relieved without surgery. If your diagnosis is uncertain or if your symptoms are minor, your physician will encourage nonsurgical treatment first.

Nonsurgical treatments might include:

Bracing or splinting. Wearing a brace or splint overnight will stop you from bending your wrist as you sleep. Keeping your wrist in a straight or neutral position reduces stress on the nerve in the carpal tunnel. It can also help to put on a splint during the day when doing activities that exacerbate your symptoms.

Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications including ibuprofen and naproxen can help ease pain and inflammation.

Activity changes. Symptoms frequently take place whenever your hand and wrist are in the same position for too long—particularly whenever your wrist is flexed or extended.

If your work or recreational activities exacerbate your symptoms, changing or adjusting these activities can help slow down or stop advancement of the disease. In many cases, this could entail making changes to your work site or work station.

Nerve gliding exercises. Certain patients will benefit from exercises that help the median nerve move more freely within the confines of the carpal tunnel. Specific exercises might be suggested by your doctor or therapist.

Steroid injections. Corticosteroid, or cortisone, is a powerful anti-inflammatory agent which can be injected into the carpal tunnel. Although these injections usually relieve painful symptoms or help to calm a flare-up of symptoms, their effect is sometimes only temporary. A cortisone injection may also be used by the doctor to help diagnose your carpal tunnel syndrome.

Surgical Treatment

If nonsurgical treatment doesn't alleviate your symptoms after a period of time, your doctor might recommend surgery.

The choice whether to have surgery is based on the seriousness of your symptoms—how much pain and numbness you're having in your hand. In long-standing cases with continuous numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage.

Surgical Procedure

The surgical procedure performed for carpal tunnel syndrome is known as a "carpal tunnel release." There are two different surgical techniques for doing this, but the goal of both is to ease pressure on your median nerve by cutting the ligament that forms the roof of the tunnel. This improves the size of the tunnel and lessens pressure on the median nerve.

In most cases, carpal tunnel surgery is done on an outpatient basis. The surgery can be done with general anesthesia, which puts you to sleep, or under localized anesthesia, which numbs just your hand and arm. In some cases, you will also be given a light sedative through an intravenous (IV) line inserted into a vein in your arm.

Open carpal tunnel release. In open surgery, your physician makes a small incision within the palm of your hand and views the inside of your hand and wrist through this incision. Throughout the procedure, your doctor will divide the transverse carpal ligament (the top of the carpal tunnel). This adds to the size of the tunnel and decreases pressure on the median nerve.

After surgery, the ligament may gradually grow back together—but there may be more space within the carpal tunnel and pressure on the median nerve will be relieved.

Endoscopic carpal tunnel release. In endoscopic surgery, your doctor makes one or two smaller skin incisions—called portals—and utilizes a miniature camera—an endoscope—to see within your hand and wrist. A special knife is used to split the transverse carpal ligament, similar to the open carpal tunnel release treatment.

The results of open surgery and endoscopic surgery are comparable. There are benefits and potential risks connected with both techniques. Your physician will talk to you about which surgical technique is the best for you.

Recovery

Immediately following surgery, you'll be encouraged to elevate your hand above your heart and move your fingers to decrease swelling and avoid stiffness.

You really need to expect some pain, swelling, and stiffness after your procedure. Minor soreness within your palm might last for a couple of weeks a number of months.

Grip and pinch strength generally return by around two to three months after surgery. If the condition of your median nerve was poor before surgery, however, grip and pinch strength might not improve for about 6 to 12 months.

You may have to wear a splint or wrist brace for a couple of weeks. You are going to, however, be permitted to utilize your hand for light activities, being careful to avoid significant discomfort. Driving, self-care activities, and light lifting and gripping may be permitted shortly after surgery.

Your physician will talk to you about when you'll be able to return to work and whether you'll have any restrictions on your work activities.

Complications

Although complications are possible with any surgery, your physician will take steps to minimize the risks. The most prevalent complications of carpal tunnel release surgery include:

• Bleeding
• Infection
• Nerve aggravation or injury

Outcomes

For most patients, surgery will improve the symptoms of carpal tunnel syndrome. Recovery, however, may be gradual and full recovery may take up to a year.

If you've got significant pain and weakness for over two months, your physician might refer you to a hand therapist who is able to help you optimize your recovery.

If you've got another condition which causes pain or stiffness in your hand or wrist, including arthritis or tendonitis, it may slow your overall recovery. In long-standing cases of carpal tunnel syndrome with severe loss of feeling and/or muscle wasting around the base of the thumb, recovery can also be slower. For those patients, a total recovery may not be possible.

Sometimes, carpal tunnel syndrome can recur, although this is rare. If this happens, you may need further treatment or surgery. Audrain Orthopaedics is the best resource for people with carpal tunnel syndrome in Moberly, Columbia, and Mexico, Missouri.