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Carpal tunnel syndrome

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Carpal tunnel syndrome
SpecialtyNeurology, orthopedic surgery Edit this on Wikidata

Carpal tunnel syndrome (CTS) is a medical condition in which the median nerve is compressed at the wrist causing symptoms like tingling, numbness, night time wakening, pain, coldness, and sometimes weakness in parts of the hand. CTS is much more common in women than it is in men, and has a peak incidence around age 50 (though it can occur in any adult). It likely is present to some extent in up to 10% of the adult population.

Anatomy

The median nerve runs through the carpal tunnel, a canal in the wrist that is surrounded by bone on three sides, and a fibrous sheath (the flexor retinaculum) on the other. In addition to the nerve, many of the hand's tendons pass through this canal. The median nerve is usually compressed by swelling of the contents of the canal. Other causes include soft tissue swelling in and around the tunnel or even by direct pressure from part of a broken or dislocated bone. However, bone dislocations are a rare cause of carpal tunnel syndrome that are a result of severe traumatic events.

Symptoms

The first symptoms of CTS usually appear when trying to sleep. Symptoms range from a burning, tingling numbness in the fingers (especially the thumb and the index and middle fingers) to difficulty gripping and making a fist. Inability to firmly grasp and dropping things can become an issue. If left untreated the symptoms can progress, and increasing pain intensity can further restrict hand functionality.

In the early stages of CTS, sufferers often mistakenly blame the tingling numbness on their sleeping position, thinking their hands have had restricted circulation and are simply "falling asleep".

It is important to note that unless numbness is one of the predominant symptoms, it is unlikely the symptoms are primarily caused by carpal tunnel syndrome. In effect, pain of any type, location, or severity with the absence of significant numbness, is not likely to fall under this diagnosis.

Carpal tunnel syndrome is known as a "hidden disability" because people can do some things with their hands and appear to have normal hand function. However, despite these appearances, those aflicted often live with severely restricted hand activity due to the pain.

Causes

By and large the most common "cause" of carpal tunnel syndrome is "no cause at all." It actually occurs quite frequently without provocation of any specific type. Most people with carpal tunnel syndrome have gradual increasing symptoms over time.

A common contributor to developing carpal tunnel symptoms is increased hand use/activity. While a certain activity is often blamed for the development of the problem, it is really often the "last straw." People's basic physiology and family history have as much or more to do with getting carpal tunnel syndrome than most anything else.

Many cases of carpal tunnel syndrome are provoked by repetitive grasping and manipulating activities. The exposure can be cumulative. Activities can certainly be work-related or related to other activities (i.e. home improvement chores.) It is commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations, including jack hammer operators, meat packers, computer users and musicians. The condition has been documented for decades, but in recent 10 to 20 years has become more prevalent, probably due to better public awareness and earlier diagnosis.

There are a number of causes of carpal tunnel syndrome. They can be either traumatic, or non-traumatic.

Work related exposure is a common contributor to of carpal tunnel syndrome. In the U.S., for instance, carpal tunnel syndrome is the biggest single contributing factor to lost time at work. Carpal tunnel syndrome results in billions of dollars of workers compensation claims every year.

However, recent studies and peer review articles have found no relationship between carpal tunnel syndrome and office-type work. Specifically, research studies have found no statistically significant association between CTS and keyboard use. The jury is still out on what, if any, realtionship may exist between CTS and light office work and computer use.

Recently the Harvard Medical School published a report in which it addressed carpal tunnel syndrome. The Harvard report cited to the 2003 Journal of American Medical Association study (JAMA, 2003; 290:1853-1854) and the 2001 study in Neurology (the "Mayo Clinic Study" Neurology 2001; 56:1568-1570) in reporting that computer use did not increase a person's risk of developing carpal tunnel syndrome.

The Mayo Clinic study, found that even heavy computer use, up to seven hours a day, doesn't make a person more likely to develop carpal tunnel syndrome. Several studies have indicated a strong correlation between an employees general physical condition and carpal tunnel complaints. [citation needed]

Hyperthyroidism, osteoarthritis and diabetes were most often associated with CTS-like symptoms, as were variables such as age, obesity and wrist dimension. In a study done by Dr. Steven G Atcheson, only 35 of 297 subjects were aware of the underlying health condition which could account for their CTS like symptoms (Arch Internal Med 158:1506 1998 & Hospital Practice, March 1999). Hence, these causes would be missed by doctors if they were relying on a patient's health history to rule out other causative factors. It is important that a doctor rule out other causes of CTS-like symptoms. If a patient does not have CTS, corrective surgery is destined to fail.

Studies have also related carpal tunnel and other upper extremity complaints with psychological and social factors. A large amount of psychological distress showed doubled risk of the report pain, while job demands, poor support from colleagues, and work dissatisfaction also showed an increase in the report of pain, even after short term exposure. (J. Rheumatology. 2001; 28(6):1378-84)

On the other hand, in 1997, studies done by the National Institute for Occupational Safety and Health (NIOSH), indicated that job tasks involving highly repetitive manual acts or necessitating wrist bending or other stressful wrist postures were connected with incidents of CTS or related problems. However, it appears that the 30+ studies reviewed were concerned with the occupations of assembly line workers, meat packers, food processors, and the like, not general office work.

This panoply of medical and scientific studies are consistent in finding no statistically significant relationship between upper extremity repetitive trauma claims and the workplace. [citation needed]

In summary, carpal tunnel syndrome can easily be aggravated by activity. It occurs frequently in the population. People that develop symptoms will frequently blame this on their work exposure, even though this exposure may indeed have little to do with the root cause of their carpal tunnel syndrome. This is where the mixture of science, economics and social policy combines to determine societal behavior and expectations in individuals.

Trauma-based causes:

  • Fractures of one of the arm bones, particularly a Colles' fracture.
  • Dislocation of one of the carpal bones of the wrist.
  • Strong blunt trauma to the wrist or lower forearm, incurred for example by using arm extremity to cushion a fall or protecting oneself from falling heavy objects.
  • Hematoma forming inside the wrist, because of internal haemorrhaging.
  • Deformities due to abnormal healing of old bone fractures.

Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging and should not be considered preventable. Examples include:

  • Tenosynovitis, which is inflammation of the thin mucinous membrane around the tendons. Part of the process of inflammation is swelling, and this compresses the nerve. Swelling of this membrane is the final common pathway for most cases of carpal tunnel, whether caused idiopathically, through exposure, or medically.
  • With pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium.
  • Acromegaly, a disorder of growth hormones, compresses the nerve by the abnormal growth of bones around the hand and wrist.
  • Tumours (though not necessarily cancer), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the amount of space. This is exceedingly rare (less than 1%).
  • Diabetes, rheumatoid arthritis, and obesity tend to cause swelling and thickening of the tenosynovium, thus decreasing the amount of space left for the median nerve in the carpal tunnel.
  • Double crush syndrome, where there is compression or irritation of nerve branches contributing to the median nerve in the neck or anywhere above the wrist. This then increases the sensitivity of the nerve to compression in the wrist. This, while a possible factor, is also a rare contributor in most cases.
  • Idiopathic causes, which no one can explain, can also cause this disease. This is very common.

Common activities that have been identified as contributing to repetitive stress induced carpal tunnel syndrome include:

  • Computer keyboarding or typing in some situations, especially when keying over 15,000 ksph (Key Strokes Per Hour) is performed. The exact relationship has not been proven, however.
  • Playing video games
  • Playing a musical instrument
  • Driving the Melbourne variant of the Alstom Citadis low floor tram, the C class, the traction/braking controller includes a yellow button which drivers originally had to click every ten seconds, if this didn't happen, a buzzer would sound, followed soon by track brake application, the operating cycle has now been extended to thirty seconds as a result of driver complaints.
  • Any activity where hand use is vigorous and routine could contribute (surgeons, dentists, possibly masturbation), although these activities are often merely associated with but do not actually cause carpal tunnel syndrome

An exhaustive list can be found in the external links below

Often people suffering from carpal tunnel syndrome can have multiple contributing factors which are aggravated by vigorous hand activities and repetitive stress trauma to the hand.

Proper attention to ergonomic considerations can reduce or eliminate these kinds of exposures.

While carpal tunnel syndrome is often called a "repetitive strain injury" (RSI) or "cummulative trauma disorder" CTD, these labels are looked down on by medical doctors, particularly hand specialists. Carpal tunnel is a specific condition with specific typical symptoms that responds fairly reliably. Most of the time carpal tunnel is not casued by an "strain" or "trauma" of any type. RSI and CTD are relatively non-specific terms with non-specific symptoms that respond variably to treatment. Labelling someone with RSI or CTD can be unhealthy psychologically.

Diagnosis

Physical examination can be helpful for diagnosing carpal tunnel syndrome.

Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms. A positive test is one that results in numbness in the median nerve distribution. The quicker the numbness starts, the more advanced the condition.

A classic, though less effective method, Tinel's sign, is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve. Tinel's sign is sometimes referred to as "distal tingling on percussion" or DTP.

Physical examination, however, is of limited utility in definitive diagnosis of carpal tunnel syndrome. The best way to form a solid preliminary diagnosis of carpal tunnel syndrome is to obtain a good history of the progression of symptoms.

If, based on history and physical examination, carpal tunnel is suspected, then patients will likely be tested electrodiagnostically with nerve conduction studies or electromyography. These are objective measurements that look at the health of the nerve and can be correlated to the symptoms.

Treatment and Prevention

There has been much discussion as to the most effective treatment for CTS. However, treatments can be generally divided into five basic categories.

Immobilizing braces

A splint can keep the wrist straight.

Rigid immobilizing braces and wrist splints can help some people, but they are limiting, unsightly and uncomfortable to wear. Over several weeks braces and splints often result in hand and forearm muscle atrophy. For this reason braces should not be worn continuously for more than a few days at a time. Instead many health professionals suggest that, for best results, one wear them at night and, if possible, during the activity primarily causing stress on the wrists.

Localized Steroid Injections

Steroid injections can be quite effective for temporary relief from the symptoms and pain of CTS for a short time frame while a longterm strategy that fits with one's life style is developed. However, it is not a long-term solution. Ethical medical professionals would only resort to localized steroid injections for a short time until another acceptable treatment option could be identified. In certain patients an injection may also be of diagnostic value.

Prioritizing Hand Activities and Ergonomics

Any forceful and repetitive use of the hands and wrists can cause upper extremity pain. While avoiding activities that cause repetitive stress is an option that can help avoid the pain, it causes people to curtail their careers, forfeit earnings and give up whole segments of their lives. Our self esteem as human beings and contributors at home, at work and at recreation is directly tied to the way we use our hands. Giving up activity is a poor option for most people.

More frequent rest can be useful if it can be orchestrated into one's schedule, but rest is not very practical in today's active work and play environments. It has been shown that taking multiple mini breaks during the stressful activity is more effective than taking occasional long breaks. There are computer applications that aid users in taking breaks. All of these applications have recommended defaults, following the most effective average break configuration, which is a 30 sec. pause every 3 to 5 minutes (the more severe the pain, the more often one should take this break). Before investing in these types of programs, it's best to consult with a doctor and research whether computer use is causing or contributing to the symptoms, as well as getting a formal disagnosis.

More pro-active ways to reducing the stress on the wrists which will alleviate wrist pain and strain involve adopting a more ergonomic work and life environment such as using an ergonomic keyboard (and perhaps switching from a QWERTY key layout to a more efficient Dvorak Simplified Keyboard layout). Studies have shown ergonomic keyboards reduce wrist stress by 30% or more and Dvorak reduces stress an additional 30%. It's also important that one's body be aligned properly with the keyboard. This is most easily accomplished by bending one's elbows to a 90 degree angle and making sure the keyboard is at the same height as the elbows. Also it is important not to put physical stress on the wrists by hanging the wrist on the edge of a desk, or exposing the wrists to strong vibrations (e.g. manual lawn mowing). Position the computer monitor directly in front of your seat, so the neck is not twisted to either side when viewing the screen.

Excercises that relax and strengthen the muscles of the upper back can reduce the risk of a double crush of the median nerve. Spinal manipulations performed by an osteopath or chiropractor may be required to relieve compression of the nerve.

Dietary Changes and Medication

Dietary changes can provide the body with the necessary nutrients needed to repair nerves and help reduce inflammation. With this, pressure on the nerve can be reduced, thus allowing it to heal. Certain vitamins and nutrients can also be taken to repair nerve damage, such as amino acids, vitamin B complex and hypercium (an extract of St. John's wort). No specific vitamin or nutrient has been shown to have a noticeable anti-inflammatory effect, but taking a diverse multivitamin may have a noticeable effect on reducing inflammation in the body. One could argue that diet and vitamins have a small effect on carpal tunnel syndrome, similar to placebo. Their effect would certainly be negligible in anything but the most mild of cases.

Using an over-the-counter anti-inflammatory such as aspirin or ibuprofen or Naproxen can be effective as well for controlling symptoms. Pain relievers like Tylenol will only mask the pain, and only an anti-inflamatory will affect inflammation. Non steroidal inflammatory medications theoretically can treat the root swelling and thus the source of the problem. Oral steroids (prednisone) does the same but is generally not used for this purpose due to significant side effects. The most common complications associated with long-term use of anti-inflamatory medications are gastrointenstinal irritation and bleeding. Also, some anti-inflamitory medication have been linked to heart complications. No one should rely on these type of medications for chronic long-term pain without a doctor's supervision.

A more aggressive pharmaceutical option is an injection of cortisone, to reduce swelling and nerve pressure within the carpal tunnel.

Carpal Tunnel Release Surgery

Carpal tunnel syndrome begins with numbness and tingling in the hand, specifically from the thumb to middle finger, and may involve aching in the hand, forearm or shoulder. These symptoms are caused by a pinched nerve in the wrist at the base of the hand (specifically the carpal tunnel). The symptoms may occur intermittently during the day and sometimes occur at night, awakening the person from sleep. It is not uncommon for the sufferer to think that the hands have "poor circulation" and shake the hands in an attempt to "restore circulation". It however is not an issue of circulation, but nerve pressure.

When visiting a hand surgeon, the first step would be examination of the hands and a review of the symptoms. If a condition other than carpal tunnel syndrome is present, the doctor will suggest the appropriate treatment. If CTS is suspected, depending on the severity and the situation, he will first prescribe non-operative treatment with splinting and anti-inflammatory drugs. A test conducted on the nerve will positively determine whether or not it is pinched and if carpal tunnel syndrome is indeed the diagnosis.

If all the symptoms go away with splinting and medication, then surgery will not be necessary. If not, then the "carpal tunnel release" surgery is recommended. [citation needed] In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and likely will come to surgical treatment.

There are several variations of technique to perform carpal tunnel release surgery. Each surgeon has differences of preference based on their personal beliefs and experience. All techniques have several things in common.

  • They all involve brief (10-15 minute) outpatient procedures.
  • They all involve some type of incision(s) on your wrist and/or palm.
  • They all involve dividing (cutting) the transverse carpal ligament.
  • They all involve a relatively rapid recovery (days to weeks depending on the activity and technique).
  • They all leave a cosmetically insignificant scar in most cases.

The two major types of surgery are open and endoscopic. Most surgeons perform open surgery, which is widely considered to be the gold standard. However, many surgeons are now performing endoscopic techniques. Open surgery involves a small incision somewhere on the palm about an inch or two in length. Through this the ligament can be directly viewed and divided with relative safety. Endoscopic techniques involve one or two smaller incisions (less than half inch each) through which instrumentation is introduced including probes, knives and the scope to see what you are doing. The ligament is viewed through a "keyhole" in this way and can be divided with relative safety. There are perhaps a half dozen commercial systems available that surgeons can use to do the endoscopic surgery.

Much debate has existed in the medical community of which technique is best. Open surgery is arguably a bit safer as there is less likelyhood of inadvertent damage to surrounding nerves and blood vessels. Endoscopic surgery very likely will result in a quicker early recovery. In other words, people will feel less sore and be able to be more active in the several (1-5) weeks after surgery with endoscopic techniques. Several studies have suggested that either technique leaves patients with similar results if examined after about six weeks.

If the decision to operate is made, the technique choice is between the patient and surgeon. Surgeons can do either or both techniques. Surgeon can tailor treatments to patients' specific needs.

Surgery to correct carpal tunnel syndrome has given a 90% or better success rate. Success is greatest in patient with the most typical symptoms. The most common cause of failure is incorrect diagnosis, and it should be noted that this surgery will only fix carpal tunnel syndrome, and will not relieve symptoms with alternate causes. Recurrence is rare, and apparent recurrence usually results from a misdiagnosis of another problem. Complications can occur, but serious ones are infrequent to rare.

Carpal tunnel surgery is usually performed by an Orthopaedic or Plastic surgeon. Less frequently, Neurosurgeons and General surgeons have been known to perform the procedure.

Long term recovery

The early signs of carpal tunnel syndrome should not be ignored. Early denial of carpal tunnel symptoms is a sure way to lead to progessive symptoms.

Most people who find relief of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage." Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. symtoms of numbness, muscle wasting and weakness.

Many mild carpal tunnel syndrome sufferers either change their hand use pattern or posture at work or find a conservative, non-surgical treatment that allows them to return to full activity without hand numbness/pain and sleep disruption. Other people end up prioritizing their activities and possibly avoiding certain hand activities so that they can minimize pain and perform the essential tasks.

Changing jobs is also commonly done to avoid continued repetitive stress tasks. Others find success by adjusting their repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods of performing the movements.

In summary, one has the choice of controlling the symptoms with any of the non-surgical options listed, or correcting the condition with surgery.

While recurrence after surgery is a possibility, true recurrences are uncommon to rare. Non-CTS hand pain is commonly mistaken for recurrence. Such hand pain may have existed prior to the surgery, which is one reason it is very important to get a proper diagnosis.

See also

References

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