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Carpal Tunnel Syndrome (CTS)
By: Andrew J. Bronstein, M.D., James W. Vahey, M.D.* and Robert Gutierrez M.D.

CARPAL TUNNEL UPDATE

Carpal Tunnel Syndrome (CTS) is one of the most common conditions that affect the upper extremity afflicting over 2.5 million Americans every year. Research has shown that the cause can be related to many different medical as well as occupational reasons. Arthritis, Diabetes, Pregnancy, and Hypothyroidism, have all been shown to have a potential role in CTS. Repetitive work activities that involve keyboarding, strenuous use of small hand or vibrating tools have also been shown to have affect on some patients or workers with this condition. Habitual sleeping on the hands is a frequent finding.

Anatomy:
The carpul tunnel is a small region of your palm where the wrist (composed of 8 bones) forms the floor of the tunnel and the roof is formed by the transverse carpal ligament (TCL). Nine finger tendons and the Median nerve travel through the confines of the carpal tunnel.

Pathology:
Swelling of the tendons, secondary to repetitive grasping, squeezing or cutting can lead to nerve entrapment. Sleeping with flexed wrists, bone, soft tissue and metabolic changes can all affect the position of the median nerve as it gets crowded against the TCL and, in turn, the median nerve gets starved of its blood supply.

Symptoms:
Symptoms typically include numbness in the fingers and thumb, tingling, burning, night awakening, increasing clumsiness with menial tasks, and radiation of pain up the forearm towards the shoulder along the course of the median nerve.

Clinical Findings:
Typical findings on clinical exam by your doctor are decreased sensation in the fingers innervated by the median nerve. The doctor will access your ability to sense light touch, your strength, and the quality of the skin on your hands.

Tests:
Frequent tests include tapping on the wrist or testing wrist flexion. A nerve and muscle study called an electromyogram - nerve condition study (EMG/NCV) determines whether or not the nerve is being compressed and its message slowed at the level of the wrist. Usually a neurologist or physiatrist will perform this study.

Treatment:
The first line of treatment is conservative care with removable wrist splints that should be initially worn only at night. The purpose of the splint is to position the wrist in extension and resist the fetal flexion position that we assume at nighttime that leads to compression of the median nerve for 6 to 8 hours at a time.

The second line of conservative care is to minimize or remove the offending activity from the patient's everyday routine. Changing work habits from using larger grip tools, or using shock-absorbing gloves for vibration jobs can be very helpful. Ergonomic evaluation of computer workstations can identify poor typing techniques or keyboard layouts that exacerbate the patient's symptoms. Delivery at the end of pregnancy and controlling diabetes or hypothyroidism also usually helps lessen the symptomatology.

If the symptoms persist or worsen and EMG/NCV studies are with mild to no significant changes, a steroidal injection can be performed directly into the carpal tunnel to try to reverse the inflammation process surrounding the median nerve. The injection typically takes four to six weeks to achieve maximal effect and is successful 80% of the time yet provides only temporary relief.

Surgical treatment is offered for patients with profound changes on their nerve studies. Traditional carpal tunnel surgery called "Open carpal tunnel release" entails making a 3-6" incision at the base of the palm in line with natural palmar creases. Another technique with an endoscope can also be performed with a horizontal incision at the wrist, which has quicker recovery time.

The newest technique, one that I introduced to the community and featured on Channel 8 and 13 news, utilizes less than a 1 inch incision in the mid palm which has a recovery time of three to six weeks, after an aggressive occupational hand therapy program. I have performed almost 600 surgeries with this newer technique in the last four years, and have had significantly improved results that heal even quicker than the endoscopic technique.

All techniques are performed as out-patient requiring no hospital stay and pain relief is near immediate with the numbness slowly resolving thereafter. Depending on the technique and vocation goals, patients typically return to two-handed work in four - eight weeks after range of motion and incisional tenderness has been optimized.

Andrew J. Bronstein, M.D., James W. Vahey, M.D.* and Robert Gutierrez M.D.
Dr. Andrew J. Bronstein, Dr. James W. Vahey and Robert Gutierrez M.D. are orthopaedic, hand and microvascular surgeons.