Carpal tunnel

Overview

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy (condition in which a nerve gets pinched) and results from compression of the median nerve in the wrist region. The median nerve provides sensation to the palm side of the thumb, index, middle, and part of the ring finger, and it supplies power to most of the thumb muscles. The median nerve runs down the center of the forearm (thus the name “median” nerve) and passes through the carpal tunnel into the palm. The carpal tunnel is located approximately where the hand meets the forearm and consists of an arch of bones covered by a strong ligament – the transverse carpal ligament (also referred to as the flexor retinaculum). The carpal tunnel is a relatively small space and contains the median nerve and nine tendons that also pass from the forearm into the fingers.  

Most commonly, CTS results when the tendons or their lining (the synovium) thicken or the ligament tightens. The space available for the median nerve is reduced, and the median nerve becomes compressed or pinched. This commonly results in numbness, tingling, and pain in the palm side of the wrist and fingers and sometimes thumb weakness. Symptoms may occur only or predominantly at night, but often occur during the day with activities such as gripping a steering wheel, tennis racket, or dumbbell, typing, or holding the wrist in bent positions for long periods of time. The goal of treatment is to reduce the swelling of the tissues within the carpal tunnel or loosen or cut the transverse carpal ligament to make more space for the median nerve. Many cases can be managed nonoperatively with activity modification, splinting, and cortisone injections, but in severe or unresponsive cases release of the transverse carpal ligament (i.e., carpal tunnel release) is necessary to relieve symptoms and prevent further damage to the median nerve.

  • Numbness, tingling, burning, or itching in the palm side of the hand and fingers, particularly the thumb, index, and middle fingers
  • Symptoms may initially occur at night when many people sleep with their wrists in bent positions, which increases carpal tunnel pressures. People with carpal tunnel syndrome often wake up at night with numb or tingling fingers and need to shake their hands to resolve the symptoms
  • Some people may report incoordination or difficulty holding and manipulating small objects like pens and tools
  • Symptoms may occur only with specific activities or wrist positions at first but may later become more constant
  • In long-standing or severe cases, the thumb muscles may shrink and become significantly weak

If you are experiencing numbness and tingling in your fingers on a consistent basis, you should have this checked out with your care provider. Your care provider will inquire about your history, perform a physical examination, and potentially order additional testing to determine whether your symptoms are likely due to CTS. Additional testing may include electrodiagnostic testing (also called a “nerve test”) to check the function of the median nerve and other nerves or ultrasound imaging to directly visualize nerve swelling. Some studies indicate that earlier recognition and treatment of CTS may be more likely to result in improvement and avoidance of surgery.

CTS usually results from a combination of factors that result in reduced space in the carpal tunnel region and, therefore, median nerve compression. Often, a single identifiable cause is not identified.  Factors that have been associated with CTS include work-related mechanical stress to the wrist and finger tendons, repetitive use of vibrating tools, diabetes and other metabolic disorders, hormonal imbalance such as thyroid disease, inflammatory disorders such as rheumatoid arthritis, fluid retention as can occur in pregnancy, wrist trauma that results in swelling or deformity of? the bones and tendons of the carpal tunnel, or the development of cysts or tumors in the carpal tunnel.

In addition to the factors noted above, women are approximately three times more likely to develop CTS compared to men. The precise reason for this is unknown but may be related to the relative size of the wrist or hormonal factors. CTS is also more likely to occur in the dominant hand, likely related to relative overuse. In patients who have symptoms in both hands, the dominant hand is usually more severely affected. Although individuals in all occupations may develop CTS, those who work on assembly lines or in manufacturing have a higher risk of developing CTS than those working in primarily desk positions. Finally, obesity has also been identified as  a risk factor for both the development of CTS and the need for carpal tunnel release.

The goal of treatment is to reduce the pressure on the median nerve by reducing the swelling in the carpal tunnel or cutting the transverse carpal ligament to make more space. In most, initial treatment is nonoperative and consists of activity modification, splinting, and, in some cases, formal therapy.  Over-the-counter medications such as anti-inflammatory medications or acetaminophen may reduce symptoms but don’t directly treat the problem.

Cortisone injections have been documented to be effective in relieving symptoms and may result in a cure. In some cases, ultrasound guidance may be used to precisely place the cortisone around the nerve. This procedure may provide superior results in some patients compared to non-ultrasound guided injections. In severe or unresponsive cases, surgery may be necessary to cut the transverse carpal ligament and relieve pressure on the nerve. This is traditionally performed by means of an open surgery or endoscopic surgery, resulting in good or excellent outcomes in the majority of patients. More recently, advanced ultrasound guided procedures have been developed to loosen or even cut the ligament through small incisions, also resulting in excellent results.

The primary complication of CTS is permanent damage to the median nerve. In some cases, severe or prolonged compression can permanently damage the nerve and, despite adequate treatment, people may experience permanent numbness, tingling, incoordination, and weakness. In such cases, the primary role of surgery is to prevent further nerve damage. Incomplete recovery following adequate treatment may be more likely in patients with more long-standing symptoms, muscle weakness, shrinkage of the thumb muscles, co-existing conditions that affect nerves such as diabetes, and who are older. Early recognition and treatment of CTS may avoid or minimize permanent nerve damage.

There is no proven preventative program for CTS. Most clinicians and researchers would agree that utilizing proper technique during work and sports, avoiding prolonged bent wrist postures, and otherwise maintaining good general health may help prevent the development of carpal tunnel syndrome.

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