Carpal Tunnel Syndrome
What is Carpal Tunnel Syndrome?
 
Carpal Tunnel Syndrome is a group of symptoms including  numbness, tingling, itching, weakness, cramping or pain involving the hand and fingers, that caused by compression of the median nerve in the palm and wrist.  Classically the palmar aspect of the thumb, index finger, middle finger and half of the ring finger is involved, and spares the 5th  "pinky" finger, but any of these fingers can be involved individually or together, or it can involve the entire hand.  People often feel that the hand or fingers feel swollen.  The symptoms often wake the patient from sleep, and tend to be worse when wakening in the morning.  
 
 
Flexing the wrist and keeping it in the same position during sleep is thought
to be the reason for the worsening during sleep.  Symptoms often get worse
with holding a steering wheel when driving, or when working on hair due to
added compression on the carpal tunnel region. 

The carpal tunnel is a passageway in the wrist and proximal palm.  Looking
at your palm, the carpal tunnel runs between the wrist bones (called the
carpal bones collectively) below, and and transverse carpal ligament under
the palmar skin.  The median nerve, as well as several tendons run through
this tunnel.  Thickening of these tendons, excess fluid in this area, swelling
of tissues in the wrist can all contribute to compression of the median nerve.
 
 
Risk Factors:
Women especially around menopausal age and later (Women are 3 times more likely than men to develop Carpal tunnel syndrorme)
Obesity
Diabetes
Smoking
Lifelong Alcohol Intake
Osteoarthritis of CarpoMetacarpal Joint of Thumb
Alterations of Fluid retention - Pregnancy, Menopause, Obesity
Anatomic injuries-- fractures of the wrist., Arteriovenous fistula or shunts for dialysis
Inflammatory Diseases-- Rheumatoid Arthritis
Other Conditions that damage nerves in general - Diabetes, Alcoholism.

There is NO strong scientific evidence that computer keyboard work significantly increases the risk of Carpal Tunnel Syndrome.  Although frequent keyboard work can cause hand and wrist pain and tingling, most of these patient don't have carpal tunnel syndrome on nerve conduction studies, although some do.

Working with vibrating or power tools or on an assembly line that requires repetitive flexing of the wrist may cause pressure on the median nerve, and may aggrevate carpal tunnel syndrome but scientific proof of these activities initiating carpal tunnel syndrome is lacking.     Work that involves cold temperature together with increase load on the palm and wrist together with repetition such as butchery particularly might cause or worsen carpal tunnel syndrome.

 
Diagnosis of Carpal Tunnel Syndrome
HISTORY: 
Numbness, tingling, "sleepy feeling", swelling feeling, pain, cramping in the fingers and hand.
Symptoms worse with sleeping, driving, brushing hair. 
Weakness in the hand if severe

PHYSICAL EXAM:
Sensory changes in a median nerve distribution
Wasting in the thenar region of the hand
Weakness in the "LOAF" muscles - lumbricals, opponens pollicus, abductor pollicus brevis, flexor pollicus brevis.
Tinel sign over the wrist - Pressure over the carpal tunnel region increasing the symptoms.
Phalen sign - Prolonged flexion at the wrist increasing the symptoms.

NERVE CONDUCTION STUDIES and EMG STUDIES (NCV/EMG)
Looking for median nerve sensory or motor conduction slowing across the region of the carpal tunnel.
Looking for denervative changes on EMG in median innervated muscles of the hand.
Looking at other nerves and muscles to rule out other causes of symptoms  -- assess for other locations of compression of the median nerve, or cervical radiculopathies, or alternative diagnoses. 

Optional:  
Ultrasount imaging- looking at cross sectional area of carpal tunnel, and looking for impaired movement of the median nerve.
Magnetic resonance imagine (MRI) of the carpal tunnel area or other potential areas of impingement of median nerve if suggested on NCV/EMG study.
 
 
Treatment for Carpal Tunnel Syndrome
LIFESTYLE CHANGES THAT CAN BE MANAGED TO HELP CARPAL TUNNEL SYNDROME
Stop smoking
Stop alcohol treatment.
Treatment of obesity and obtaining a normal BMI (under 25 in those under 65, under 30 in individuals over 65)
In addition to these lifestyle changes being beneficial to Carpal Tunnel Syndrome, it will decrease heart disease, stroke, and premature death risks as well
Yoga has been shown to reduce pain and improve grip strength in some patients.  
Resting the wrist  and avoiding aggrevating activities.

MANAGE TREATABLE ILLNESSES THAT MAY CONTRIBUTE TO CARPAL TUNNEL SYNDROME
Treat rheumatoid arthritis
Treat  Diabetes
Weight reduction management in obese and overweight individuals

REST THE HAND AND WRIST:
Immobilization of the hand and wrist with a neutral position wrist splint (carpal tunnel splint).    This should be worn whenever sleeping, or doing repetitive activity, and some physicians recommend a period of 24/7 use.

STEROID INJECTION AT THE WRIST:
Corticosteroids reduce inflammation and swelling so may reduce the compression on the median nerve.  It often provides temporary relief of symptoms. 
May be particularly useful in pregnant patients if findings not severe,  whose symptoms tend to improve 3-12 months after delivery.
Risks: Discoloration of overlying skin, Worsening of symptoms, Infection, bleeding.

SURGERY:  CARPAL TUNNEL RELEASE:  (Done under local anesthetic)
Cutting the transverse carpal ligament to enlarge the size of the carpal tunnel region to decrease compression on the Median Nerve.
2 options:
OPEN RELEASE SURGERY-- making an incision in the wrist/palm then cutting the transverse carpal ligament to increase the size of the carpal tunnel. 
ENDOSCOPIC SURGERY -- making 1 or 2 small incisions,  the surgeon inserts a small camera, and cuts the transverse carpal ligament to enlarge the carpal tunnel.  May result in reduced pain and quicker recovery, but  may make it more difficult to visualize to make sure the entire transverse ligament is cut.  
Patients may have immediate relief of symptoms, or the improvement may be seen gradually over time.
RISKS: As with any surgery, risk if bleeding, bruising, infection, scar tissue, pain at the scar, and risk of nerve damage.  
Physical therapy often recommended after surgery to help wrist mobility and strength, and help decrease risk of scarring down of the median nerve within the carpal tunnel region.


UNPROVEN:
Stretching Exercise with physical therapist or chiropractor- May be useful in patient whose symptoms have improved, or postoperatively to decrease risk of scar tissue formation, but unproven.
Acupuncture remains unproven