Carpal Tunnel Syndrome

The carpal tunnel is a narrow passageway on the palm side of the wrist containing carpal bones or wrist bones, and ligaments and tendons, with the median nerve passing through its centre.

Carpal Tunnel Syndrome is a common, painful, progressive condition that is caused by compression of the median nerve at the wrist area.

Signs and symptoms

Signs and symptoms of Carpal Tunnel Syndrome usually occur gradually, progressing to the point where the patient seeks medical attention.  Left untreated, Carpal Tunnel Syndrome can lead to permanent nerve damage in the hand.  Commonly reported symptoms associated with Carpal Tunnel Syndrome include the following:

• Numbness and tingling in the thumb, index, and middle fingers excluding the pinky finger. The median nerve does not supply sensation to the little finger.
• Pain and burning in hand and wrist that may radiate up the arm to the elbow
• Weakness in hand with diminished grip strength
• Diminished sensation in the hand causing the person to drop objects or have difficulty handling small objects.

• Symptoms usually are worse at night

Causes

Carpal Tunnel Syndrome is caused by pressure on the median nerve from narrowing of the carpal canal.  Exact causes of the condition are not always known but may include the following which are known to increase a person’s risk of developing the condition:

• Repetitive Motion:  Individuals who perform heavy, repetitive hand and wrist movements with prolonged gripping at work or play are believed to be at high risk for developing carpal tunnel syndrome.  Activities that require this type of repetitive movement include heavy assembly line work, construction work with vibrating equipment, and playing tennis.  Despite popular belief, there is no strong scientific evidence linking computer use to carpal tunnel syndrome.
• Congenital:  Some people are born with narrower carpal tunnel canals putting them at a higher risk of developing this condition.
• Trauma:  Injury to the wrist such as in fractures or sprains can cause swelling which can compress the median nerve.
• Hormonal Changes:  Pregnant women, menopausal women, and women on birth control pills or hormone pills are at higher risk of developing carpal tunnel syndrome due to hormonal changes in the body.

Medical Conditions:  Conditions associated with developing carpal tunnel syndrome include hypothyroidism, rheumatoid arthritis, diabetes, obesity, gout, overactive pituitary gland, or the presence of a cyst or tumour in the canal. 

Diagnosis

Hand and wrist conditions should be evaluated by an Orthopaedic hand surgeon for proper diagnosis and treatment.  Early diagnosis of Carpal Tunnel Syndrome is critical in avoiding permanent nerve damage.    

Your surgeon will perform the following:

• Medical History
• Physical Examination

Diagnostic Studies may include: 

• X-rays: a form of electromagnetic radiation that is used to take pictures of bones.
• Blood Tests: blood tests may be ordered to rule out medical conditions such as diabetes, arthritis, and thyroid problems.

Electrodiagnostic tests:  Tests done to assess the speed and degree of electrical activity in the muscles and nerves.  Examples include electromyography and nerve conduction studies.

Conservative Treatment Options

Your surgeon will recommend conservative treatment options initially to treat the Carpal Tunnel Syndrome symptoms.  These may include:

• Treating any underlying medical conditions that may be causing the problem, such as diabetes or arthritis.
• Immobilization of the hand and wrist with a splint or wrist brace for 4-6 weeks. This place the wrist in a neutral position with the goal of reducing nerve irritation.
• Rest the hand for 2 weeks or more
• Ice packs for swelling
• Avoid activities that tend to bring on the symptoms
• Drugs such as NSAID’s, diuretics, and steroid injections to treat pain and swelling may be ordered.
• Strengthening and stretching exercises once symptoms diminish.

Surgical Treatment

If conservative treatment options fail to resolve the condition and symptoms persist for 6 months or more, your surgeon may recommend you undergo a surgical procedure to treat Carpal Tunnel Syndrome called Carpal Tunnel Release Surgery.

Your surgeon will decide whether to perform your surgery in the traditional manner or endoscopically.  Traditional surgery involves up to a 2” incision in the palm and wrist area, whereas endoscopic surgery involves one or two ½” incisions and the use of an endoscope with a camera for viewing internal structures.   

The television camera attached to the endoscope displays the image of the joint on a television screen, allowing the surgeon to look throughout the wrist joint at cartilage, ligaments, nerves and bone.

The benefits of endoscopic surgery compared to the alternative, open hand surgery, include:

• Smaller incisions
• Minimal soft tissue trauma
• Less pain
• Faster healing time
• Lower infection rate
• Less scarring
• Earlier mobilization
• Usually performed as outpatient day surgery

Your surgeon will decide which options are best for you depending on your specific circumstances.

Procedure

The goal of Carpal Tunnel Release surgery is to reduce the swelling and pressure on the median nerve in the carpal tunnel and alleviate the patient’s symptoms. 

This surgery is usually performed in an operating room under local anaesthesia on an outpatient basis as day surgery.

Your surgeon makes one or two small incisions, about ½ inch each, to the palm and wrist area. Each incision is called a portal. These incisions result in very small scars, which in many cases are unnoticeable.

A blunt tube, called a Trocar, is inserted into each portal prior to the insertion of the endoscope and surgical instruments.

With the images from the endoscope as a guide, the surgeon can look for any pathology or anomaly. The large image on the television screen allows the surgeon to see the joint directly and to determine the extent of the nerve compression.

The second portal is used for the insertion of surgical instruments.  This portal will be used to cut the transverse carpal ligament thereby releasing the pressure on the median nerve by enlarging the carpal tunnel. 

After this ligament is cut, the portals (incisions) are closed by suturing or by tape.

Endoscopic surgery is much less traumatic to the muscles, ligaments, and tissues than the traditional method of surgically opening the hand and wrist area with long incisions.

After surgery, your surgeon will give you guidelines to follow depending on the type of repair performed and the surgeon’s preference.

Common Post-operative guidelines include:

• Elevate the hand above heart level to reduce swelling.
• A splint may be worn
• Ice packs to the surgical area to reduce swelling.
• Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering.
• Physical Therapy may be ordered to restore wrist strength.
• Eating a healthy diet and not smoking will promote healing

Risks and complications

• As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
• It is important that you are informed of these risks before the surgery takes place.

Complications can be medical (general) or specific to hand surgery.

Medical complications include those of the anaesthetic and your general well-being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reactions to medications
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attacks, strokes, kidney failure, pneumonia, bladder infections
• Complications from nerve blocks such as infection or nerve damage
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

The majority of patients suffer no complications following Carpal Tunnel Release surgery; however, complications can occur following hand surgery and include:

• Infection
• Nerve damage causing weakness, paralysis, or loss of feeling in the hand and wrist area
• Stiffness to wrist and hand
• Wrist weakness and loss of strength due to injured tendon
• Pain at site of scar
• Symptoms are worse or not improved by the surgery

Risk factors that can negatively affect adequate healing after hand surgery include:

• Poor nutrition
• Smoking
• Obesity
• Age (over 60)
• Alcoholism
• Chronic Illness
• Steroid Use