Carpal Tunnel Syndrome

Symptoms

The first symptom is intermittent tingling, often at night. The tingling becomes more frequent as the problem worsens. Numbness or loss of feeling in the fingers usually begins later. Patients often describe this as “loss of circulation” and hang their hands down at night to get the feeling back. Symptoms during the day are tingling and numbness, which are provoked by activities which require the wrist to be extended, such as driving or talking on the phone.

Later symptoms include permanent loss of feeling in the fingers and diffuse pain, which can extend all the way up the arm to the shoulder. The weakness of thumb motion occurs with severe carpal tunnel syndrome, due to wasting of the thumb muscles.

Examination

The doctor’s physical examination and sometimes tests, help differentiate carpal tunnel syndrome from other conditions which can cause almost identical symptoms. The most common of these is nerve root compression in the neck, by arthritis or by a disc prolapse.

Tests

Supportive tests are either physiological or anatomical. Physiological tests include nerve conduction studies, which look at how fast the nerve can conduct impulses at various levels. Delay at the carpal tunnel level implies a problem here, but does not specify that the problem is compression. Nerve conduction studies will remain abnormal for a number of months even after successful decompression and resolution of symptoms.

Anatomical tests look at the shape of the nerve at the carpal tunnel, and include ultrasound and MRI. If the nerve is flattened under the ligament and thicker on either side of the ligament, it implies a compressive problem.

Grading of severity

It is important for the patient and doctor to understand the severity of the nerve damage prior to commencing treatment. In more severe carpal tunnel syndrome, the nerve itself has been damaged, and even after successful decompression, it may be many months before the nerve returns to normal. It is rare that the nerve is so badly damaged that it cannot completely recover, though this does occur.

Treatment

• Splints Splints sometimes help in controlling symptoms in CTS. The carpal tunnel narrows further with any movement away from the neutral position, so the splints must keep the wrist straight. Patients may find splint helpful at nighttime, to minimise symptoms. Splints are especially useful if there is a transient cause of the carpal tunnel syndrome.
• Steroid injections Anti-inflammatory cortico-steroid preparations may decrease the swelling around the median nerve, and relieve the symptoms, though usually only temporarily. A good response to a steroid injection is the best predictor of successful relief of symptoms following surgical decompression, and the injection may sometimes be recommended if the diagnosis is uncertain.
• Open carpal tunnel release Open surgery has been commonly used and continues to be the preference of some surgeons. The carpal tunnel is accessed via an incision through the palm; the fat and palmar fascia are cut to expose the transverse carpal ligament, which is the structure to be released. The wound and then the scar is situated in the palm, which must be kept dry for 14 days. Many patients find the scar is tender, and frequently irritating, for many months.
• Endoscopic carpal tunnel release ECTR is my preference for the majority of patients. Modern ECTR is safe, elegant surgery, which allows double the speed of functional recovery. The recovery of the nerve is identical to open surgery.