Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

A syndrome is a group of symptoms that collectively indicate or characterize a disease. Carpal tunnel syndrome (CTS) is a common and progressively incapacitating condition affecting one or both hands. The underlying problem is actually compression of the median nerve at the wrist. It is the most common nerve compression in the body. The symptoms of CTS occur when the median nerve in the wrist is compressed in its passage to the hand.

Its symptoms first appear as episodes of tingling or numbness with strenuous or repetitive movement of the wrist, such as driving a car, knitting, or typing. The numbness and tingling may come and go several times throughout the day, requiring the patient to stop what they’re doing.

If left untreated, the syndrome can progress until it is experienced as a constant numbness and generalized weakening of the hand which makes even simple tasks such as buttoning a shirt, removing a lid from a jar, and hand writing increasingly difficult. Carpal tunnel syndrome often awakens a sufferer during the night with a burning sensation in one or both hands. This is often accompanied by shaking the hand at the side or running warm water over it to get the feeling back.

Who gets Carpal Tunnel Syndrome? (CTS)

Anyone can get CTS, but it is often associated with jobs and hobbies requiring repeated wrist and hand activity. This commonly includes carpenters, mechanics, painters, knitters, artists, golfers, and car drivers, among others. It may not be related to any one particular activity.

Anatomy

The wrist is formed by bones that make the shape of a "U". The top of the "U" is covered by a tough ligament called the transverse carpal ligament. This entire complex essentially makes a tunnel through which several tendons and the median nerve pass. The tendons are tough but the nerve is not. Pressure on the nerve can build as the tunnel is narrowed by arthritis, tendonitis, or thickening of the ligament.

Conditions associated with carpal tunnel syndrome can also contribute to its development. These include: pregnancy, rheumatoid arthritis, diabetes, vascular malformation, tendonitis, obesity, nerve tumors or cysts, and aging

How is Carpal Tunnel Syndrome diagnosed?

Generally, CTS is diagnosed by the history given by the patient. An electromyography and nerve conduction (EMG/NCV) study is recommended when the syndrome is suspected. This test will show the degree of nerve damage and eliminate the possibility of other causes for symptoms experienced by patients.

What causes Carpal Tunnel Syndrome?

The syndrome is associated with repetitious, though often minor, injury to the contents of the carpal tunnel. The injury leads to swelling of the contents of the tunnel and compression of the very delicate median nerve that is also trapped in this tunnel with other less affected structures, such as tendons. It is often caused by an underlying arthritis (chronic inflammation of bones and joints) or tendonitis (chronic inflammation of tendons), that causes a chronic swelling within the carpal tunnel. Although few people may have a genetic predisposition to CTS, most get it as the result of natural aging, or overuse. Nerve entrapment by this pressure causes the tingling and numbness which can lead to the eventual death of the nerve itself. When ignored over a period of months, the nerve injury can become permanent and irreversible. Nerve death, in turn, creates atrophy of those muscles the nerve controls, and hence, the loss of some hand function.

Sensory Distribution of Median Nerve - This is where most of the pain and numbness is located.

How is Carpal Tunnel Syndrome treated?

Non-operative treatment consists of anti-inflammatory agents, wrist splinting and occasionally steroid injections into the wrist. Behavioral adjustments in lifestyle that may be augmenting symptoms are helpful in the early stages.

Adjustments in the work station, modification of those activities that cause inordinate strain on the wrist and hands are very helpful in early CTS.

When non-operative measures fail, the mainstay of treatment is a carpal tunnel release. This involves cutting the transverse carpal ligament to relieve the nerve of its compression. Surgeons worldwide cut the ligament, how I do it is a little different from many others, but the ligament is cut, none the less.

I choose a minimal access technique, that requires a one-half inch incision in a wrist crease. I then use a specially designed instrument that allows me to reach under the ligament and cut it from beneath, preserving all other structures. I have performed this procedure on more than 3000 patients and my statistics are at least as good as those that use a larger, and more invasive incision. Only three stitches are required to close the incision and twenty-four hours later, a band-aid is the only evidence of surgery.

What are the results of Carpal Tunnel Release Surgery?

In the days following, there is usually a varying degree of discomfort, alleviated by ice, Tylenol or propping the wrist on pillows at night. You may use plenty of ice--more helpful than pain pills-- on the days following the procedure. The hand, or hands, may be used to the extent that this does not cause inordinate discomfort. In fact, I want you to use the hand(s) as much as is comfortable.

One week after surgery your sutures will be removed. Two to four weeks after surgery most patients will be able to resume all activities of daily living, including return to work

If you’ve had symptoms for a long period of time, or have nerve damage, some symptoms will not improve immediately after surgery. The intermittent symptoms, such as your hand falling to sleep or awakening you from sleep, usually go away immediately after surgery. If your fingers are constantly numb (not intermittent), recovery will be mush slower and is a function of the ability of your nerves to recover. The pain from CTS usually goes away quickly, but if you have pain from underlying arthritis or tendonitis, some pain may still be there after surgery. Also if you have weakness or atrophy of the muscles supplied by the median nerve, recovery can be very slow.

My Personal Statistics

I have performed over 3000 Carpal Tunnel Release operations. In more than 1,200 patients, surgery was performed on both hands at one trip to the operating room. I have produced three professional publications on my results of carpal tunnel release. The results of my patients’ questionnaires indicate that the overwhelming majority claim "excellent" or "good" results regarding relief from pre-operative pain and paresthesias. Most patients had full use of their hands in one week or less. Postoperative physical therapy was infrequently needed, and no wrist splints were required. No injury to the median nerve was noted. Most patients were back to work in three weeks or less.

Satisfactory results were seen in more than 93% of my carpal tunnel release patients. In those patients that were insulin dependent diabetics, the success rate was 85%.

Risks and Possible Complications

When getting a nerve out of a tight spot, it is always possible to injure the nerve. In this case that would result in an increased numbness and/or weakness in the hand. Any of the blood vessels or tendons in the area could also be injured. Most patients have chronic tendonitis &/or arthritis as an underlying problem. These problems will NOT get better after a carpal tunnel release, and the symptoms coming from these problems will remain. And occasionally surgery will make the symptoms of arthritis worse.

Wound infection, or a blood clot in the surgery site are possibilities. Nerves of diabetics are particularly sensitive to manipulation and compression. They are therefore more likely to be injured during any surgical procedure. All of these complications are rare, but do occur. More than 90% of carpal tunnel release patients experience a good result, but a good outcome can never be guaranteed. My personal statistics show an infection and recurrence rate of <1%. To the best of my knowledge I have never cut or injured the median nerve at surgery.

Prior to surgery you should review your expected outcome with me, and please be sure your questions have been answered to your satisfaction.

Click here for printable copy of instructions for "Going Home After Carpal Tunnel Release".