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The wrist is a small space with a lot of moving parts. Slender tendons pass through it, transferring power from the muscles in our forearms to our fingers and thumb. These tendons are bundled with the median nerve, which branches out in the hand.
Like electrical wires threaded through a conduit pipe, the tendons and nerve must navigate a narrow passageway that lies between the wrist bones and the flat, wide transverse carpal ligament. That passageway is referred to as the carpal tunnel.
The carpal tunnel is an enclosed space and in many individuals the carpal ligament can start to compress the nerve, causing numbness, night pain, tingling, hand clumsiness and eventual muscle loss in the hands. That’s carpal tunnel syndrome (CTS).
And fortunately, for most people, this nerve compression can be relieved through a number of interventions, including non-operative treatment such as bracing or through a simple and reliable surgery—a carpal tunnel release.
Carpal tunnel syndrome starts with numbness and tingling in the long finger, index finger, thumb and part of the ring finger. Untreated, it may lead to muscle loss and permanent weakness. Dr. Kevin O’Malley has the details. @MedStarWHC via https://bit.ly/3r4dI6F.
We refer to CTS as a syndrome because it is a constellation of symptoms related to compression of the tunnel and pressure on the median nerve. The development of CTS involves multiple risk factors—both patient-specific, such as diabetes, and environmental. In many cases, no single specific cause of carpal tunnel is determined. While we don’t always fully understand why it begins, we know that over time this pressure impedes the nerve’s blood supply, restricts nutrition to the nerve cells, causes inflammation and impairs function.
CTS is common, affecting up to five percent of the adult population. Women are at least three times more likely to experience it than men. Certain underlying conditions—including diabetes, hypothyroidism, rheumatoid arthritis, gout, obesity and other specific diseases such as amyloidosis—can increase the risk. In other cases, CTS may acutely follow a wrist fracture.
Carpal tunnel syndrome is commonly seen in pregnancy as well. This is typically a temporary situation that resolves, but some individuals will continue to have symptoms post-pregnancy. In pregnancy-related carpal tunnel cases, I rarely recommend surgery; if the CTS becomes an obstacle, we use bracing and, occasionally, injections to relieve symptoms.
Both CTS and osteoarthritis often appear in patients over 50, and the two conditions are sometimes confused. But they are distinct problems, and one does not cause or increase the risk of the other.
In the 1990s, the theory was that CTS could occur from the repetitive use of computers and desk phones. This spurred a greater focus on workplace ergonomics benefitting many workers. The data connecting typing and carpal tunnel syndrome remains inconclusive. However, repetitive workplace wrist activities such as those seen in assembly line workers does appear to put individuals at risk for carpal tunnel syndrome. We’re also confident in citing vibration as a cause of CTS and recommending preventative measures—for example, limiting use of a jackhammer for construction workers or wearing anti-vibration gloves when operating a motorcycle.
Unlike disorders that have a hidden or asymptomatic phase, CTS causes noticeable indicators. In the beginning, the patient may experience sensory symptoms that follow the median nerve distribution: numbness, tingling or “falling asleep” feelings in the long finger, index finger and thumb, as well as the inside half of the ring finger. Over time, patients may develop hand weakness and, as nerve function decreases, atrophy of the thumb muscles.
Most people first notice symptoms at night. Patients often tell me the numbness and tingling wakes them up, and they feel a need to shake out their hands. This may be due to a number of causes—for example, some people sleep with their wrists bent, putting additional pressure on the nerve.
CTS is generally progressive and can result in permanent disability if not addressed. When it has progressed to the point that the thumb muscles are involved, the success of treatment is less predictable. So I recommend seeing a hand specialist early, when symptoms first appear.
Carpal tunnel symptoms may also signal nerve compression in the cervical spine. It’s not uncommon for those with CTS to have simultaneous issues with their neck, referred to as double crush syndrome. This is another reason to seek professional guidance: If compression exists in more than one location, each site must be addressed individually. Simply fixing one won’t improve the other.
When I examine a patient, I capture their medical history and symptoms and perform a complete physical exam on the arms, hands and neck. Occasionally, tapping the medial nerve can provoke symptoms. I check the thumbs for any signs of atrophy, and probe for cervical symptoms in the neck.
We can generally confirm CTS upon examination. If results are not conclusive, an ultrasound or nerve conduction test can assess nerve function. If the neck and spine are causing symptoms, but CTS is not present, I refer the patient to a spine specialist.
When symptoms occur only during sleep, our first strategy is asking the patient to wear wrist braces in bed. Good quality braces can be found at most drug stores and can be particularly effective for people who sleep with their wrists tucked in and bent.
As nerve compression advances, the patient may notice that symptoms begin to appear during the day. At that point, we move beyond wrist braces to other treatments.
Steroid injections may temporarily alleviate symptoms, and are appropriate for pregnant women, those who cannot tolerate surgery or those who need to delay surgery. Injections offer relief for a few months to a year, but the symptoms return when the medication wears off.
I do not routinely send patients to physical or occupational therapy for carpal tunnel syndrome since no form of exercise or strengthening can physically enlarge the carpal tunnel. I do occasionally perform corticosteroid injections for patients unable to undergo surgery. These injections do not resolve the underlying compression and the carpal tunnel symptoms will return. However, they do help patients understand the relief they may obtain with surgery.
I do not prescribe steroids in pill form, as the potential side effects outweigh the benefits. And although ibuprofen, naproxen and other non-steroidal anti-inflammatory agents may alleviate pain, they typically do not fully address the numbness and tingling present in CTS.
Surgery, known as carpal tunnel release, is the sole treatment to address the root cause of CTS, and typically has an excellent result. We separate the wide, flat ligament at the palm side of the tunnel, releasing pressure on the nerve and bringing improvement very quickly. The procedure is straightforward and normally finished in under 20 minutes. We find that people who responded well to injection also tend to do well with the surgery.
We perform open procedures in the office under local anesthesia, and recovery takes just a few weeks. Endoscopic surgeries require sedation and are limited to the hospital setting, but with these, the incision is small and recovery and return to activities are quick!
The procedures are not particularly painful, and most patients recover well using ibuprofen or acetaminophen, as needed. Driving is OK after both types of procedure, but we restrict any heavy lifting.
Although ligament tissue does not regenerate the way bones do, the body does reconnect the ligament after surgery. As it heals, it accommodates the medial nerve, giving it the space it needs. CTS may recur in some patients if the remodeled ligament becomes large enough to compress on the nerve again.
Recovery varies depending on the patient and the level of compression they’d been experiencing prior to surgery. Some patients will experience relief from improved nerve function almost immediately, with continued gradual improvement over weeks and months.
At MedStar Washington Hospital Center
Here in the Washington, D.C., area, Dr. Derek Masden and I are among a handful of specialists who perform minimally invasive, endoscopic carpal tunnel release. The clinical results are the same as the open procedure, but the incision is much smaller, with patients returning to work and normal activities much faster.
Although the progress of CTS can be slow, we recommend that you do not wait too long to schedule an appointment when you notice symptoms, to avoid any potential motor damage that your CTS may cause.