Carpal Tunnel Syndrome Carpal tunnel syndrome is a problem that usually involves discomfort in the distribution of the median nerve, which travels through a compartment space between the thumb and little finger, at their bases in the wrist. The nerve is important to feeling to the thumb, index, middle, and a portion of the ring finder. Carpal tunnel syndrome can occur at any age but is particularly prone to be seen in patients with arthritis or with heavy use of their hands and wrists. It is also seen in patients who are pregnant when they retain fluid or in patients with heart or kidney problems who retain fluid. This retained fluid is essentially entrapped in the wrist carpal space. This fluid puts pressure on the median nerve and causes the symptoms of pain as well as numbness of the hand. There is a portion of the median nerve, which innervates the thenar or thumb muscles at the base of the thumb. In longstanding cases of carpal tunnel syndrome, there can be so much pressure on the main trunk of the nerve that the portion of the nerve, which innervates this muscle, is also affected and the muscle will literally shrink up and be non-usable. This, of course, gives a patient a very weak thumb. In the overall, patients often complain of pain at the wrist, which may radiate up to the arm and may particularly be noticeable when doing certain chores or work involving motion of the wrist and movement for long periods. It is also observed in patients who do work with their hands above their heads such as painters or carpenters. It is seen in patients who complain of driving with their hands elevated and their hands and wrists drooped over the steering wheel for a period of time. It is also observed at night. Patients will awake with numbness and discomfort in the involved hand and will literally have to shake away or rub away the discomfort. Patients from time to time will also have similar symptoms involving the little finger. This is due to compression of another nerve called the ulnar nerve in an adjacent compartment running into the hand from the wrist very much like that of the carpal tunnel involving the median nerve. This tunnel essentially compresses the nerve and will give similar symptoms of radiation up the arm, pain at the wrist, and numbness in the little finder or portion of the ring finger. When patients are presented with such symptoms they too will remedy this problem with massage or avoidance of whatever activity exacerbates the situation. There is a hereditary predisposition to carpal tunnel syndrome and it is also seen in bilateral fashion (in both hands). Patients with arthritis, who present with this syndrome, may have other problems including swollen joints, stiffness, and deformity of the fingers or wrists. Multiple physical findings are noted with carpal tunnel. Oftentimes it can be diagnosed by a simple examination by your physician. In other cases nerve conduction studies are recommended, not to exclude or confirm the diagnosis of carpal tunnel, but to rule out the possibility of rare nerve disorders that may be mimicking the syndrome. This nerve conduction test is oftentimes not necessary but when it is ordered, it is a valuable adjunct to the diagnosis of carpal tunnel. One does not need to have a positive nerve conduction study for the diagnosis of carpal tunnel compression on either the median or ulnar nerve. Patients who have had carpal tunnel diagnosed early are initially treated with oral anti-inflammatory agents. These often reduce the swelling within the compartment spaces involved and may relieve the discomfort. Some patients may also require special splinting particularly at night in order to avoid bending the wrist and putting compression on the nerve. In very rare cases it is advised to inject the carpal space with cortisone. Cortisone derivatives can eliminate the symptoms but they are a temporizing method of managing the problem of inflammation in the carpal space. Also cortisone injections carry with them a risk of injuring the nerve as well as the adjacent tendons that run through the spaces involved. Disruption of these tendons is a serious complication and injury to the nerves likewise. For this reason we advocate use of cortisone injections in the carpal space in only rare instances. The preferred method of treating carpal tunnel is a carpal tunnel release. By making an incision in the palm, direct vision of the carpal tunnel space and the flexor retinaculum is achieved. The flexor retinaculum, is a transverse band of fibers at the wrist crease. When this band becomes thickened and compresses the median and possibly the ulnar nerve and when fluid accumulates within the carpal space, the syndrome occurs. By releasing this band one frees the nerve and relieves the pressure on it. The success rate of curing the median nerve compression is quite high with early detection. The longer the nerve remains compressed, the more difficult it is to improve the numbness even thought the pain may be alleviated with the surgical procedure. In severe nerve compression with loss of sensation, the return of sensation is frequently observed over a period of weeks and months. The wasting or shrinkage of the muscles either at the base of the thumb or the base of the little finger may, again, be permanent if the nerve compression has been protracted. Again, though, many of these patients have had return of these muscles with the operation. As with any operation there are possible side effects. Bleeding and infection can occur at the incision sit. There is also the possible reaction to sutures and the need for revision or re-excision of the scar in the palm. Injury can occur to the adjacent nerves, tendons, and blood vessels. Very infrequently carpal tunnel syndrome reoccurs with reformation of a retinaculum again compressing the nerve. This may mandate re-operation. The operative procedure is usually done as an outpatient procedure followed by placement in a forearm dressing with a plaster splint. The patient is immobilized in this fashion for three to five days and maintains elevation and immobilization of the hand, fingers, and forearm. During this time patients will shower with a plastic garbage bag over the arm and maintain some motion of the fingertips. The patient is asked to check for blood supply and capillary fill in the fingertips and is subsequently seen in the office when the dressing is changed. After this the patient is placed into and elastic wrap and sent to hand therapy. The hand therapist works on a program of gradually improving your range of motion and tolerance to exercise. Usually it takes approximately one month to obtain use of the hand the point where the patient is not readily aware of the operative procedure and incision. The sutures are removed between the second and third week after the operation. In the even of infection further antibiotic therapy and topical therapy will be prescribed. Oftentimes other procedures on the hand may be done inclusive of release of trigger finders, excision of ganglions or cysts in the hand or exploring joints in the wrists and fingers. Occasionally tendon surgery is also done adjunctive to the carpal tunnel procedure. Please feel free to ask questions of any of these points raised in this letter of Dr. Kennedy or any members of our staff.
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