- Carpal Tunnel Syndrome (CTS)
- Causes of Carpal Tunnel Syndrome
- Symptoms of Carpal Tunnel Syndrome
- Diagnosis of Carpal Tunnel Syndrome
- CTS Prevention
- Treatment for Carpal Tunnel Syndrome
- Open Carpal Tunnel Release (OCTR) surgery
- Endoscopic Carpal Tunnel Release (ECTR) surgery
- The MANOS™ Carpal Tunnel Release System
Carpal Tunnel Syndrome (CTS)
The carpal tunnel is a narrow, tunnel like structure at the base of the hand. The bottom of the tunnel is made up of the wrist bones, and the top of the tunnel is covered by the transverse carpal ligament. Nine flexor tendons and the median nerve make their way through the carpal tunnel as they run from the forearm to the hand. The flexor tendons provide motion to the fingers. The median nerve is an extremely important nerve that controls sensation to the palm side of the hand and also supports movement of the fingers and thumb. Sometimes, due to injury, repetitive motion, or disease, the carpal tunnel can become inflamed and swell. This swelling causes pressure on the median nerve. When the pressure on the median nerve becomes great enough to disturb the normal function of the nerve, numbness, tingling, and pain can be felt in the fingers and hand. These are the symptoms of carpal tunnel syndrome.
Causes of Carpal Tunnel Syndrome
There are several factors, and combinations of factors that can cause CTS. Essentially, anything that causes expansion within the finite space of the carpal tunnel, increases the amount of tissue in the tunnel, increases the sensitivity of the median nerve, decreases the amount of space in the carpal tunnel, or anything that increases the sensitivity of the median nerve can lead to carpal tunnel syndrome. Some common triggers are:
- Rheumatoid arthritis
- Thyroid conditions
- Trauma to the wrist
- Thickening of flexor tendon sheath
- Canal deformity
- Joint dislocations
- Fractures of the carpal bones
- Prolonged wrist flexion
Commonly, CTS is a work-related injury. Work that requires repetitive hand movements, regular hand vibration, or working for long periods in the same positions, can cause carpal tunnel syndrome. This is especially true when combined with other health conditions.
Sometimes the cause of CTS cannot be determined.
Symptoms of Carpal Tunnel Syndrome
Symptoms are often first noticed at night, when patients may wake from CTS symptoms. Relief may come from shaking the hand. Symptoms usually include pain, weakness, numbness, and tingling. Most often symptoms appear in the thumb, index finger, middle finger, and ring finger. Symptoms appearing in these fingers, but not in the little finger may be a sign of carpal tunnel syndrome, as a different nerve controls the little finger.
Sometimes patients will notice a decrease in grip strength. They may be somewhat clumsy with their hands, leading to a tendency to drop things. When left untreated, CTS can cause permanent loss of sensation, and cause shrinking of the thumb muscles.
When mild, symptoms are generally limited to the hand. As the condition progresses, symptoms can affect the arm, and eventually radiate all the way up to the shoulder. Severe symptoms restrict normal daily activities. In this state, everyday activities like brushing your teeth, holding a child, holding a glass of water, or using your fork at dinner can become very difficult. Persistent loss of feeling in the fingers, loss off hand dexterity, no strength in the thumb, and severely disturbed sleep are common in severe cases.
It should be noted that not all pain in the wrist or hand is caused by carpal tunnel syndrome. There are many other conditions with similar symptoms.
Diagnosis of Carpal Tunnel Syndrome
A detailed patient history including medical conditions, work history, and prior hand/wrist injuries is important. X-rays may be used to rule out other causes, such as fractures or arthritis. A physical exam, including the Tinel test, Phalen exam, Webber test, or Van Frey test will likely be performed. Physicians commonly look for positive results from multiple tests to build the case for diagnosis of CTS. Electrodiagnostic studies are often performed to confirm the diagnosis of carpal tunnel syndrome. The most common form is a nerve conduction velocity test. This measures the speed at which a nerve communicates. When impinged, as in CTS, nerves communicate at an impaired rate.
Repetitive wrist and hand movements increase the risk of developing carpal tunnel syndrome. Some examples of common activities that could be associated with this are: typing, note-taking, working with small instruments, construction with hand tools, hand-sewing and knitting, and even driving. Below are a few prevention steps you can take to reduce your risk.
Do your best to stay healthy and active. Taking care of any health conditions or diseases that you may have is one of the best preventions of CTS. This is because many health conditions such as arthritis, diabetes, and obesity make you more likely to get CTS.
Take advantage of ergonomics where possible. Whether you’re in construction or you work in an office, there are tools available to you that can make your workplace more comfortable. Arrange your workspace efficiently to avoid repetition or unnecessary motions. Use ergonomically designed products, and take frequent short breaks from your activities.
Treatment for Carpal Tunnel Syndrome
For the fortunate majority, CTS symptoms are relieved without surgery. Improved healthy living habits, treatment for medical conditions such as diabetes, changing the patterns of hand use, icing the wrist, splinting, and taking mild oral pain relievers or anti-inflammatory medications like ibuprofen are normally effective at relieving mild symptoms. For moderate symptoms, a steroid injection into the carpal tunnel may be needed to reducing inflammation around the nerve.
Generally, surgery is considered only after symptoms have not improved after a long period of nonsurgical treatment has been ineffective. Several weeks to months of conservative nonsurgical treatment is the usual protocol before surgery is considered. In the case that nerve damage is evident, surgery is considered more urgently.
When symptoms are severe or do not improve, surgery is generally recommended to make more room in the carpal tunnel for the median nerve. By cutting the transverse carpal ligament (TCL), which forms the roof (top) of the carpal tunnel, the addition space for the nerve is made. All forms of carpal tunnel surgery work in this way, though the approach may vary. Carpal Tunnel Release (CTR) surgery is one of the most common surgeries performed in the U.S. today, with nearly 600,000 patients undergoing surgery annually. It is widely regarded as very safe and effective, with high patient satisfaction, and low complication rates. However, CTS symptoms may not completely resolve after surgery, depending on how severe and how long the condition existed.
Open Carpal Tunnel Release (OCTR) surgery
For an OCTR, the surgeon will normally use a tourniquet to restrict bleeding during the surgery. General anesthesia is commonly used during OCTR, due to the pain from both the tourniquet, and the incision made to release the TCL. The surgeon will make up to a two inch incision in the wrist and palm to gain access to the transverse carpal ligament. After retracting the surrounding tissue, the surgeon will then cut the ligament to open up more space within the carpal tunnel, thereby relieving pressure on the median nerve. The incision will then be closed with stitches, and the hand will be wrapped and braced. The wound will most likely leave a scar, and pain may be felt at the incision site for a number of months. Postoperative care normally includes office visits for wound care and removal of stitches, pain medication, bracing, and physical therapy. Patient recovery time before returning to work averages 30-40 days.
Endoscopic Carpal Tunnel Release (ECTR) surgery
Endoscopic carpal tunnel release was popularized in the early 1990’s by surgeons who believed in the benefits of eliminating the palmar incision used in open surgery. There goal was to reduce surgical trauma, scarring, post-operative pain, and patient recovery time. One or two half-inch incisions are made in the wrist and palm to allow a camera, an endoscope, to be placed within the carpal tunnel. Normally, a dilator will then be inserted into the incision(s) to create enough space to fit the endoscope and other instruments into the carpal tunnel. Once the surgeon has visualized the transverse carpal ligament on screen, a blade will be inserted to cut the ligament. Stitches are generally used to close the incision(s), but scarring is reduced as compared to an OCTR. Postoperative care is similar to OCTR, but varies based on the endoscopic system used.
Though ECTR is widely accepted by surgeons as a safe and effective alternative to OCTR, and clinical literature supports the patient benefits of eliminating the palmar incision, the technique has not been widely adopted. Several clinical studies noted an increased risk of complication with ECTR. Also, it requires the purchase of expensive capital equipment to accommodate the endoscope, involves more instrumentation, and requires specialized training to learn. Today, only about 15% of carpal tunnel release surgeries are performed endoscopically in the U.S.
The MANOS™ Carpal Tunnel Release System
The latest advancement in carpal tunnel release technology, the MANOS™ Carpal Tunnel Release System gives patients the option to release the transverse carpal ligament through surgical access measuring as little as 2mm. Through this access to the carpal tunnel, the surgeon releases the TCL with the MANOS™ cutting surface. The MANOS™ cutting surface is exposed only after the surgeon first safely positions the device in the carpal tunnel. While positioning the device, MANOS™ is completely blunt and compatible with nerve stimulation guidance and ultrasound guidance. The entire procedure is performed in about ten minutes. After the procedure, two small band-aids are used to cover the surgical access points. Like ECTR, MANOS™ eliminates the palmar incision. It is designed to minimize surgical trauma and reduce patient recovery time. Because surgical access is so small, stitches are not normally required and scarring is minimized or eliminated altogether. MANOS™ patients typically recover quickly, with some patients returning to work as early as the same week of surgery. Postoperative care is limited and generally does not include splinting or physical therapy. Click here to find a MANOS™ surgeon near you.