Carpal Tunnel Syndrome

Location of the Carpal Tunnel in the Hand

The carpal tunnel is a narrow canal or tube in the wrist. Similarly, to a tunnel you could travel through by car, this tunnel allows the median nerve and tendons to connect the hand and forearm.

Median Nerve and Its Compression

• The median nerve is one of the major nerves of the forearm and hand. It originates from the brachial plexus in the armpit and travels through the arm, and forearm to supply the hand.
• The median nerve can also be compressed at the wrist (most commonly) and near the elbow or in the forearm. Median nerve compression is a mononeuropathy that causes motor and sensory loss majorly in the hand.

What is Carpal Tunnel Syndrome (CTS)?

• Compression of the median nerve at the wrist is called carpal tunnel syndrome (CTS).
• CTS causes numbness, tingling, and weakness in the fingers of the hand.

What causes Carpal tunnel Syndrome (CTS)?

• It happens when there is increased pressure within the carpal tunnel at the wrist on a nerve called the median nerve.
• This nerve provides sensation to the thumb, index, and middle fingers, and to half of the ring finger. The small finger (the “pinky”) is typically not affected.

Risk Factors for Carpal Tunnel Syndrome

Carpal tunnel syndrome is also more common in women than in men in their middle age.

• People who do activities that involve repetitive finger or hand use. Motions that can place people at risk of developing carpal tunnel syndrome include hammering, extreme wrist motions, and vibration.
• After or during Pregnancy.
• In dialysis patients.
• Wrist fractures and dislocation.
• Arthritic diseases such as rheumatoid arthritis and gout .
• Hypothyroidism
• Diabetes
• Alcoholism
• A mass (tumor) in the carpal tunnel.

Symptoms in Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused when the space (the carpal tunnel) in the wrist narrows. This presses down on the median nerve and tendons (located inside the carpal tunnel), which cuts off sensation in the fingers and hand.

Symptoms usually begin slowly and can occur at any time.

Early symptoms include:

• Numbness at night.
• Tingling and/or pain in the fingers (especially the thumb, index, and middle fingers).

In fact, because some people sleep with their wrists curled, nighttime symptoms are common and can wake people from sleep. Shaking the hands helps relieve symptoms in the early stage of the condition.

Common daytime symptoms can include:

• Tingling in the fingers.
• Decreased feeling in the fingertips.
• Difficulty using the hand for small tasks, like: Handling small objects/ utensils. Writing.

As carpal tunnel syndrome worsens, symptoms become more constant. These symptoms of progression include:

• Weakness in the hand.
• Inability to perform tasks that require delicate motions (such as buttoning a shirt).
• Dropping objects.

In the most severe condition, the muscles at the base of the thumb visibly shrink in size (atrophy) or the patient develops tiny ulcers due to burns on the fingertips.

Diagnosis of Carpal Tunnel Syndrome

Diagnosis of carpal tunnel syndrome is mostly clinical where a proper history, clinical examination, and detail of pre-existing diseases help in arriving at a proper diagnosis. Two clinical tests commonly done are-

• Phalen’s test- Individuals with carpal tunnel syndrome will experience numbness and tingling in the fingers within 60 seconds in reverse namaste position. The more quickly symptoms appear the more severe the carpal tunnel syndrome.
• Tinel’s sign – Tapping on the wrist in the region of the median nerve elicits tingling and pain sensation in the thumb, index finger, and middle finger

Few investigations are done to confirm the diagnosis-

a) Nerve Conduction Velocities (NCV) and Electro-Myographic Studies (EMG) of the affected hand is quite diagnostic for carpal tunnel syndrome

b) MRI of the wrist is done in a few cases

c) HR Ultrasonography of the wrist can also be done to see the thickness of the nerve before it enters the canal.

How is Carpal Tunnel Syndrome treated at Kayakriti?

Carpal tunnel syndrome can be treated non-surgically or with surgery. Non-surgical treatments are used for less severe cases and allow you to continue with daily activities without interruption. Surgical treatments can help in more severe cases and have very positive outcomes.

What are the non-surgical treatments for CTS?

Non-surgical treatments are usually tried first. Treatment begins by:

• Wearing a wrist splint at night.
• Taking nonsteroidal anti-inflammatory drugs , such as ibuprofen.
• Steroid injections .

Other treatments focus on ways to change your lifestyle to decrease symptoms. This is often seen in the workplace, where you can make modifications to help with carpal tunnel. These changes might include:

• Raising or lowering your chair.
• Moving your computer keyboard.
• Changing your hand/wrist position while doing activities.
• Using recommended splints, exercises, and heat treatments from a hand therapist.

When is surgery recommended in CTS?

Surgery is recommended when carpal tunnel syndrome does not respond to non-surgical treatments or has already become severe.

Goal of Surgery in CTS?

The goal of surgery is to increase the size of the tunnel in order to decrease the pressure on the nerves and tendons that pass through the space.

CTS Surgery

After all the pre-operative investigations and management of diabetes and hypothyroidism, surgery is planned.

Surgery is done usually in brachial plexus block or General Anesthesia.

A small incision is given about the wrist and carpal tunnel is released. The ligament that covers the carpal tunnel at the base of the palm called the transverse carpal ligament is released/ cut.

Recovery After Surgery for CTS

Finger movements are started once the effect of the brachial plexus block is gone or when the patient is out from in anesthesia.

• You might be in brief discomfort for about 24 to 72 hours after surgery.
• People usually experience complete night-time symptom relief quickly—even the night after surgery
• Wrist immobilization is done till sutures are removed.
• Sutures are removed after a period of 10-12 days.
• Physiotherapy post-operative is most important for hand, wrist, and fingers
• The prognosis is good if muscle atrophy has not started.
• You might be unable to do heavier activities with the affected hand for about four to six weeks.
• There may be some pain in the palm around the incisions that can last up to a few months.

What Is The Success Rate Of Surgery For CTS?

Recovery times can vary depending on your age, general health, severity of carpal tunnel syndrome, and how long you had symptoms. You will continue to gain strength and sensation in the following year after surgery.

Surgery for carpal tunnel syndrome has a very high success rate of over 95%. Many symptoms are relieved quickly after treatment, including a tingling sensation in the hands and waking up at night.

• Numbness may take longer to be relieved, even up to three months.
• Surgery won’t help if carpal tunnel syndrome is the wrong diagnosis.
• When the carpal tunnel syndrome has become severe, relief may not be complete.

Before

After

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When Relief Is Elusive After CTS Surgery?

Only a small percentage of patients do not gain substantial relief from symptoms. These are the patients who either had-

• Severe carpal tunnel syndrome had a nerve that was not completely released during surgery or did not really have carpal tunnel syndrome.
• If the patient has presented very late, prolonged nerve compression can lead to median nerve palsy. In such cases, the muscles of the hand (base of the thumb) have atrophied, then he or she would not be able to bring out the thumb in a perpendicular direction to the palm when the hand is placed flat on the table.
• There would be a loss of coarse movements of the hand with complete loss of sensation over the thumb, index, middle, and half of the ring finger.
• Such a condition is also usually seen in injuries of the median nerve or in patients with leprosy.

Managing Late-Stage CTS with Weak Thumb

Release of the CTS and tendon transfers should be done to strengthen the weak portions of the hand.

A strong tendon of the hand is re-routed to substitute a weaker or lost movement of the hand.

How is the tendon transfer done for median nerve palsy?

During tendon transfers for median nerve palsy, one tendon from the front of the hand is taken, re-routed, and sutured to the tendon of the outer aspect of the thumb so that the patient can abduct (bring out thumb) and also make a meaningful pinch with the other fingers so as to hold objects with the thumb and fingers (OPPONENSPLASTY)

• The surgery is usually done under brachial block or general anesthesia and a splint or slab is given for immobilization in the post-operative period.
• The patient is usually discharged on the second day after the surgery.
• Sutures are removed 14 days after surgery.
• The splint is removed 3 to 4 weeks after the surgery and gradual training of the transferred tendon is started so that it may regain its newly assigned function.