Carpal Tunnel Syndrome

  • Carpal tunnel syndrome (CTS) is compression of the median nerve at the wrist. The median nerve provides feeling to the thumb, index, middle and half of the ring fingers.

  • The floor of the carpal tunnel is the wrist bones and the roof is the Transverse Carpal Ligament. The median nerve along with 9 tendons that flex the fingers occupy the tunnel.

  • CTS presents as pain, numbness, tingling, and occasional loss of dexterity in the hand and fingers. Symptoms are often worse when you are sleeping, driving, or using vibrating tools.

  • The most common cause of carpal tunnel syndrome is chronic inflammation of the synovium (joint lining) or the tendons. This chronic inflammation compresses the nerve. Some repetitive motion can make it worse but typing is usually good rehab for CTS.

  • Tapping on the nerve or pressing the nerve will create symptoms. Keeping your wrist bent will create symptoms. In severe CTS you will notice loss of muscle bulk in the base of the thumb.

  • We will often order nerve conduction studies to confirm the diagnosis, check the severity, and make sure no other nerves are compressed. The test measures the velocity of the nerve signals from your neck to your fingertips. We expect the message to slow down where the nerve is compressed.

The Basics

  • Mild cases can be treated by wearing a wrist splint when sleeping. Most people will sleep in the fetal position with their wrist flexed at some point in the night which causes compression of the median nerve. A night splint will often relieve symptoms.

  • Steroid injection can give temporary relief with about 80% success. We use injections for temporary relief when the patient needs to delay surgery.

  • Surgery:
    Greater than 95% of patients get better by undergoing a carpal tunnel release. This surgical procedure involves release of the transverse carpal ligament. This surgery can be done endoscopically with a relatively small incision over the wrist or an open palm incision which is larger and extends into the palm of the hand. The results are about the same for either type of procedure (endoscopic vs open) however, endoscopic procedures do have slightly faster recovery times. In rare instances, the carpal tunnel is so inflamed the surgeon needs to convert to an open incision to see properly.

    Additional Considerations:

    Anesthesia
    Sedation - Most patients are sedated and given a numbing injection at the wrist. In order to be sedated, some patients will need pre-op clearance from a primary care provider (PCP). Patients will need to not eat or drink after midnight on the night prior to surgery. Additionally, patients will be unable to operate a vehicle after waking from sedation, so transportation arrangements will need to be made.

    Local - some patients just get numbed with a shot. This avoids a pre-op clearance, eating and drinking restrictions, and driving restrictions. The drawback to local anesthesia is that the shot and the tourniquet can be uncomfortable and the nerve can still be sensitive even when numb. Older patients without much palm muscle usually tolerate carpal tunnel release under local anesthesia best.

    Recovery
    1. The hand will remain bandaged with the fingers free for 4 days after the surgery.

    2. The numbing medicine will usually last 6-8 hours after the procedure but can occasionally last until the next day.

    3. You can remove your bandage in 4 days and place a band aid over the incision. Soap and water is OK to clean the incision, but do not submerge or put the hand in any ocean, river, bay, or pool water. No lotions or antibiotic ointments need to be used.

    Activity - There are no specific restrictions and you can do what you want but you will be sore if you overuse the hand. I have worked on surgeons who operated in a few days and golfers who played in a few days. Typing is good rehab. In general, sedentary workers take off 1-14 days and manual laborers take off 2-6 weeks. It depends on how much control you have on how long you work and how much you have to do if your hand is sore.

    Results - numbness and tingling resolve in most people in just a few days. Certain groups, such as the elderly, diabetics, and smokers can take up to 6 months or longer for symptoms to resolve. It is not uncommon for some patients to experience pain in their palm for a few months after surgery.

    Therapy - therapy is rarely necessary, but is occasionally ordered for desensitization of the palm or incisional pain.

    Revision Carpal Tunnel Release - Failure of surgery and recurrence of symptoms is rare. If a patient is not better in 6 months or symptoms return a revision surgery can be considered. This procedure often involves a somewhat longer incision, removal of scar tissue, and cushioning of the nerve with wrist fat. 75% of people get complete relief or some relief after a revision carpal tunnel release. The vast majority of people who return to the office thinking their carpal tunnel syndrome has returned have something else going on such as a different nerve compression, tendinitis, or arthritis.

Treatment

Prevention

There is little that can be done to specifically prevent carpal tunnel syndrome. However, Carpal Tunnel Syndrome is a disease of chronic inflammation and thus improving your overall chronic inflammation can decrease your chances of developing CTS. Improving your nutrition, exercise/fitness, sleep, and stress can help prevent CTS and all diseases of chronic inflammation.