NeuroSurgeon
conditions
C A R P A L   T U N N E L   S Y N D R O M E

Definition:
Carpal Tunnel Syndrome (CTS) is a common and often painful condition that can interfere with the normal use of your hands. CTS occurs when the Median Nerve becomes compressed within the wrist resulting in pain, numbness, and weakness. The Median nerve normally supplies sensation to the palmar surface of the thumb, index, middle and half of the ring finger. As this nerve enters into the palm, it must do so via a small canal known as the Carpal Tunnel.

Presentation:
The most common presentation occurs in females from 40 to 50 years of age. It then later reappears in the geriatric population as a result of degenerative joint disease also described as Osteoarthritis. The third most common area of presentation is in those individuals who perform repetitive work or activities with their hands. In this latter category, typist are the most frequent. In men, butchers have a very high prevalence. Generally, temporary CTS is frequently seen in pregnancy, and usually resolves several weeks following delivery. Individuals who are low in thyroid can also present with CTS.

Diagnosis:
Carpal Tunnel Syndrome is often easily diagnosed by its more classical history: Intermittent, but generally worsening numbness of the first three ½ fingers (see figure above), nighttime pain which can be relieved by shaking the hand back to "life", and weakness in ones grip, often followed by atrophy (muscle wasting) of the thumb.

Clinical exam usually confirms the classical pattern of numbness. In addition there is frequently a shock-like sensation elicited by tapping the nerve just proximal to the carpal tunnel at the wrist. This sign is known as a Tinel's Sign. Weakness in opposition of the thumb and little finger is usually present in more severe cases. EMG/NCV tests are diagnostic for CTS in over 90% of individuals. In some early cases, even when pain is significant, the EMG/NCV test may be normal. It generally takes 4 to 6 weeks before nerve damage will show up electrically.

Treatment:
Where pain and/or mild numbness are the only presenting symptoms, conservative measures will be tried. These include a hand splint to be worn at night and during painful activity. Anti-inflammatory medications such as Advil, Alieve (and stronger prescriptions) may also be of help. It is often noted in the "health-food" literature that Vitamin B6 can improve CTS. It is worth a try, if nothing else.

Splints are designed to keep your wrist in a neutral position., Bending the wrist makes the symptoms worse because it narrows the carpal tunnel increasing pressure on the nerve.

In milder forms, a steroid-type injection may be prescribed. These are often very effective in stopping the pain, but nerve damage often continues because the compression remains.

Surgery:
Surgery may be advised if symptoms continue after conservative treatment, or if you are experiencing severe pain. Surgery is designed to stop further nerve damage, and in over 90% of cases results in significant improvement in neural function.

The surgery is called Carpal Tunnel Release. It takes about 30 minutes to perform and is usually done as an out-patient service. The surgery is performed through a cosmetic one inch incision along the palm's "life-line". As only the ligament over the nerve is released, hand strength is maintained.

Complications which occur rarely, can include continued pain and numbness in cases of prolonged and severe nerve compression.

Follow up:
For the first two days after surgery, whenever at rest, you should try to keep your hand elevated. The bandage is removed the day after surgery. It is recommended that you clean the incision with alcohol or peroxide, and leave it open to air. Keep your hand dry. You may shower, but do not soak your hand.

Our office will call and schedule an appointment for you to be seen 5 to 7 days post-op.

Starting the night of surgery it is recommended to begin gentle exercises. Move and wiggle each finger, and try to touch your fingertips to the thumb. Follow this by making a gentle fist.

Recovery:
Nerves regenerate at approximately ½ to 1 inch per month. Therefore you can expect to see sensory improvement in as far out from surgery as 6 months, and even up to 2 years. If the muscle in the thumb was atrophied (shrunken) before surgery, most likely it will not re-grow. You may get stronger however, in the muscles of the hand which were still functioning prior to surgery.

About a third of patients will experience a soreness in the muscle of the thumb following surgery. It is often described as feeling like a "stone-bruise". This tenderness can last up to three months.

Generally golf is allowed at 6 weeks after surgery. Tennis may have to wait 3 months, but often can be played safely at 6 weeks with a wrist support. You can never use the palm of your hand for a Hammer! Remember the Median nerve is no longer protected by the tough carpal ligament and will be sensitive to direct blows.