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Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by compression of the median nerve as it travels through the carpal tunnel. Symptoms often wax and wane with periods of remission and exacerbation. As the condition worsens, symptoms may progress from intermittent to constant in either one or both hands. In more severe cases, motor function may be affected leading to weakness when using your hands (dropping objects, difficulty opening lids, or turning knobs).

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What are the Symptoms of Carpal Tunnel Syndrome?

Paresthesia (Numbness)
Pain (Tingling)
Dull aching or discomfort
Weakness or dropping objects from hand
Worse at night, often awakens you from sleep
Worse with flexing or extending the wrist
Worse with activities raising your arms (driving, reading, typing, holding a phone)
Attempt to shake it out or run under cold water for improvement
In more severe cases, atrophy over the thenar eminence (palm below the thumb)
In Median Nerve Distribution :

What are the Risk Factors of Carpal Tunnel Syndrome?

Obesity
Female gender
Diabetes
Pregnancy
Rheumatoid arthritis
Hypothyroidism
Connective tissue diseases
Preexisting median mononeuropathy
Genetics

Evaluation for Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is a clinical diagnosis, meaning when patients have the characteristic symptoms listed above, the diagnosis is suspected.

The more symptoms and provoking factors present, the more likely the diagnosis is.

On examination, sensory and motor deficits in the median nerve distribution may make the diagnosis more likely but the absence is also very common and does not rule out Carpal Tunnel Syndrome. In advanced stages, weakness can occur specifically involving thumb movements and when gripping objects. Atrophy of the thenar eminence may be present in severe cases.

Provoking Maneuvers can be helpful when interpreted in the clinical context alongside symptoms consistent with Carpal Tunnel Syndrome. However, the sensitivity and specificity of these tests are not perfect, therefore they do not 100% confirm or exclude a diagnosis.

Phalen Test: The backs of the hands are placed against each other to provide hyperflexion of the wrist while the elbows remain flexed. Positive test = numbness and/or tingling in the median nerve distribution after one minute.
Tinel Test: Firm percussion over the median nerve just proximal to or on top of the carpal tunnel. Positive test = numbness and/or tingling in the median nerve distribution.
Manual Carpal Compression: Applied pressure over the transverse carpal ligament. Positive test = numbness and/or tingling in the median nerve distribution within 30 seconds.
Hand Elevation Test: Involves raising the hands above the head for one minute. Positive test = numbness and/or tingling in the median nerve distribution.

If the diagnosis is uncertain, electrodiagnostic testing such as nerve conduction studies (NCS) or electromyography (EMG) can be helpful to confirm or exclude Carpal Tunnel Syndrome. The electrodiagnosis of Carpal Tunnel Syndrome is demonstrated by decreased median nerve conduction across the carpal tunnel when compared to normal conduction of a different nerve. EMG is often used when the diagnosis is not certain to exclude other conditions such as polyneuropathy, plexopathy, and radiculopathy.

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What are the Treatment Options for Carpal Tunnel Syndrome?

Treatment for carpal tunnel syndrome is dependent upon the severity of your symptoms. After being evaluated by a specialist, you will discuss whether you will benefit from proceeding with surgical decompression of the median nerve, or if conservative measures should be approached first. While conservative therapy may be sufficient, many patients eventually require surgery for long term relief.

Indications for surgery include persistent numbness and tingling/pain, decreased grip or pinch grasping strength, or evidence of thenar eminence atrophy. Electrodiagnostic studies are often suggested before operating to confirm the impairment of median nerve conduction through the carpal tunnel.

What to Expect During Recovery?

Although there is a recovery period after surgery before noticing significant improvement, post-surgery patients often report more complete and longer-lasting relief of symptoms than with splinting alone.

Evidence shows at the one month mark splinting patients had more relief than surgical patients, however at the three-month mark and beyond, significantly more patients experienced clinical improvement with surgery than with splinting

Surgery can be divided into two main techniques:

Open carpal tunnel release: performed through a standard incision in the palm
Endoscopic carpal tunnel release: performed through a single or double portal

What are the Risks for Carpal Tunnel Surgery?

Studies show, the long-term outcomes of these techniques are equivalent.

The most frequent complication of carpal tunnel surgery is an incomplete release of the transverse carpal ligament, which often requires reoperation.

What are the Non-surgical Treatment Options for Carpal Tunnel Syndrome?

Nonsurgical options include:

Wrist splinting, specifically at night
Hand therapy
NSAIDs (anti-inflammatory drugs)
Glucocorticoid injections or oral
Ultrasound therapy

What to Expect After Surgery?

After surgery, a soft dressing is placed for three days.

We recommend elevation of the hand until swelling resolves and active motion of all the digits and the wrist. Postoperative immobilization is not recommended and may cause more harm.

Without intervention, studies have shown that patients with minimal or mild compression tended to have worsening of their symptoms over time, while those with initially moderate or severe involvement tended to improve.

With intervention and proper treatment of Carpal Tunnel Syndrome, 70-90% of patients often benefit from complete or marked improvement at the one year mark.