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Carpal tunnel syndrome

Carpal tunnel syndrome or CTS is a painful and debilitating condition of the hand and arm caused due to pinched or pressed nerves in the wrist (median nerve). Carpal is derived from the word, carpus (meaning wrist), and taken from the Greek word, Karpos. In medical jargon, the carpus refers to an assembly of eight small bones that lie side-by-side in the wrist – in two rows – which join the forearm to the hand. The tunnel is a narrow passageway for nine (some anatomists say, ten) tendons and one nerve (the median nerve – so-called, since it lies in the middle of the forearm and the wrist), to pass from the forearm to the hand. This passageway lies on the carpal bones and is roofed by a strong ligament, the flexor retinaculum. In  CTS, a group of symptoms occur together, and it is therefore called a syndrome.

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Stages

The five stages of severity of Carpal Tunnel Syndrome revolve around paraesthesia complaints (an abnormal tingling sensation), sensory deficits, loss of sensations, weakness of the thumb muscles.

Stage1: Nocturnal paraesthesia is experienced in any part of the hand supplied by the median nerve.

Stage 2: Daytime paraesthesia after extended or repetitive movements.

Stage 3: Deficits in sensation in areas innervated by the median nerve.

Stage 4: Degeneration or weakness of the muscles at the base of the thumb.

Stage 5:  Reduction in muscle mass or paralysis of the muscles at the base of the thumb, resulting in reduced movement of the thumb.

Symptoms

Someone suffering from CTS will experience pain, numbness and paraesthesia (a pins-and-needles sensation) in the affected hand and the areas supplied by the median nerve. The median nerve supplies structures on the outer half of the hand — this includes the thumb, index, middle finger and the outer half of the ring finger. Later, as the disease progresses, a patient might notice a weakened grip in the affected hand and fingers along with a loss of muscle mass on the outer side of the hand. Sometimes the pain may extend to the forearm and beyond the wrist.

Causes And Risk Factors

Causes

What causes nerve compression is more often than not impossible to determine. In such cases, CTS is said to be idiopathic in origin. This syndrome is often a consequence of injury to the wrist and conditions that pressure the median nerve at the wrist like rheumatoid arthritis, diabetes, osteoporosis, hypothyroidism, obesity, and even pregnancy. CTS has also been seen in patients who have used medicines like phenytoin (for epilepsy) and oral contraceptive pills for an extended period. And finally, lipomas and ganglions (seen as lumps on the wrist) can also pressure the nerve from the outside leading to CTS.

Strangely, the symptoms of CTS are usually seen in the middle of the night, with symptoms on both the wrists or bilaterally. Nowadays, this condition is usually associated with the use of computers, and is the most familiar form of  computer-related injury (CRI). This injury is caused due to over-use of the wrist. It occurs most commonly in people who work with their hands all day long, such as cradling a phone or typing on a keyboard. This over-use results in tendonitis (strain in the tendons) in the wrist, thumbs or shoulder. Such an injury is called a Repetitive Strain Injury (RSI).

Risk Factors

There are a few risk factors of this condition that you need to know about.

Heredity - Certain factors like change in the carpal tunnel’s structure or size or area for the nerve may run in families.

Age - It is highly prevalent in individuals after the fifth decade of life.

Gender - Women> men

Hormonal - Certain hormonal changes experienced during pregnancy can risk women for CTS.

Weight - Obese individuals are at a higher risk of CTS.

Habits - Smoking and alcohol.

Occupations- People in certain occupations are at more risk for CTS. Such as computer users, transcriptionists, factory workers, butchers, barbers, janitors, musicians, vehicle drivers, and cashiers.

Prevention

In such cases, the patient must adjust their lifestyle to accommodate and treat the symptoms. Since this is essentially due to the overuse of the wrist, the patient should take frequent breaks, rest the painful part the moment you notice some discomfort and consult a doctor if the symptoms persist.

Keeping your wrists in a neutral alignment can help prevent excessive pressure on them. Wearing a splint at night-time can help maintain your wrist in the correct position. Avoid placing undue pressure on your thumb and utilise your entire hand and fingers to grasp an object.

For relieving the symptoms and pain related to CTS, it is crucial to rest your arm when at home and exercise when the pain is less. Exercising to improve your muscle strength can help reduce symptoms and enable you to follow proper positioning when grasping and lifting objects.

Finally, timely treatment is essential for CTS. Ignoring symptoms only leads to irreversible damage.

Diagnosis

The symptoms of CTS are very characteristic, so diagnosis is not very difficult. The doctor will ascertain the patient’s history and examine the patient for signs of median nerve neuropathy by performing the Durkan Test and checking for the Tinel’s sign (a pins-and-needles sensation that is a positive sign of CTS). Phalen’s test is another physical examination done to reproduce the symptoms, which will further confirm CTS. An X-ray may be advised to rule out any trauma or arthritis. A doctor may also advise the patient to get a nerve conduction velocity test (NCV) done to further confirm the diagnosis. An electromyogram (EMG) can show nerve or muscle damage by measuring the electrical activity in the muscles. An ultrasound may also be done to identify any signs of compression to the median nerve. A Magnetic resonance imaging (MRI) scan is not routinely done but is useful in determining unusual issues like scarring, tumours or injury to the median nerve.

The differential diagnoses for wrist and hand pain are as follows:

De Quervain’s tendinosis: Pain experienced while making a fist or performing a handshake.

Trigger finger: experiencing pain and stiffness on bending the thumb and other fingers.

Arthritis: which is pain experienced due to joint swelling or stiff joints.

Treatment

When a patient is diagnosed, the treatment options are many. They may be divided into non-surgical and surgical options. Combined with lifestyle changes, the condition can be treated appropriately. Non-surgical options are done in cases where the patient has a less severe form of CTS. Some of the non- surgical options are:

Splints: Braces and splints are advised, especially at night, to support the wrist.

Physiotherapy and exercises: Once diagnosed, the patient will be taught to do exercises to tone the muscles of the upper limb, along with specific nerve gliding exercises to treat CTS that can reduce the severity of the symptoms, especially in the early stage. Exercises aim to stretch the carpal tunnel, and hopefully create some space for the affected nerve.

Steroid injections: These injections help temporarily by reducing the inflammation, and therefore the symptoms. That being said, they cannot be considered appropriate as a permanent or long-term therapy.

If symptoms are not relieved by non-surgical interventions, then surgery may be advised. Surgical management for CTS is as follows:

Surgical release of the carpal tunnel: This may be done as an open surgery or endoscopy. In this surgery, the retinaculum is divided to create more space for the nerve. This surgery is essentially for those patients for whom other conservative therapy has not worked. So far, it is the only permanent solution to the problem.

The outcome of an operation is usually good, and recurrence of symptoms rare. 2-3 months post-surgery; your grip strength should improve. One serious (and late) complication of the operation is the development of a ‘trigger thumb’(where the tendon associated with the finger catches, snaps or locks due to the malfunction of the tendon itself). But whether the treatment given was conservative or operative, a small amount of residual nerve damage will remain, which is probably because of the tunnel’s structure and physiology and the nerve itself.

Lifestyle/management

Since many activities in our daily life cause CTS, taking measure to avoid future recurrences, especially making changes in the workplace, can be beneficial. Paying special attention to maintaining body posture, positioning of hand and wrists, taking frequent breaks from work, especially jobs which cause excessive strain on the wrist due to repetitive actions, can help in reducing future risk or reoccurrence of CTS. Further adapting positions while sleeping, like maintaining wrists in a neutral position or utilising CTS braces, can be beneficial. Ergonomic evaluation at the workplace to avoid repetitive movements will also prove useful in reducing CTS. Further, an evaluation of the tools used at the workplace or utilising safe methods when using them can help reduce the risk of CTS.

Prognosis And Complications

Prognosis

Post-surgical recovery is not long drawn. After a few days of surgery, the stitches will be removed. Post-surgery, relief of symptoms is experienced around 14 days after the removal of stitches. Most individuals recover well and can return to their usual activities after around 6 weeks. Making necessary workplace modifications like taking frequent rest, performing stretching exercises and utilising a correct posture of wrists can help minimise relapse.

Complications

If left untreated, the patient will have irreversible nerve damage leading to intractable pain, numbness and muscle weakness in the areas supplied by the median nerve.

Alternative Treatments

In some individuals, alternative treatment modalities like yoga have proven beneficial in pain reduction and grip strength improvement.

References


  1. Mondelli M, et al. PLoS One. 2016;11(10):e0164715.

  2. Risk factors for Carpal Tunnel Syndrome. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=19194 Accessed on: March 8, 2021.

  3. Carpal Tunnel Syndrome. OrthoInfo. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome/. Accessed on: March 8, 2021.

  4. Carpal Tunnel Syndrome Prevention Tips. Fairview. Available at: https://www.fairview.org/patient-education/82404. Accessed on: March 8, 2021.

  5. Carpal Tunnel Syndrome. Available at: https://my.clevelandclinic.org/health/diseases/4005-carpal-tunnel-syndrome. Accessed on: March 8, 2021.

  6. Risk factors for Lifestyle Changes to manage Carpal Tunnel Syndrome. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=19189#:~:text=Avoid%20or%20limit%20doing%20repetitive,as%20jackhammers%20and%20floor%20sanders. Accessed on: March 8, 2021.

  7. Carpal Tunnel Syndrome. NIH. Available at https://www.ninds.nih.gov/Disorders/All-Disorders/Carpal-Tunnel-Syndrome-Information-Page#:~:text=In%20general%2C%20carpal%20tunnel%20syndrome,for%20several%20weeks%20following%20surgery. Accessed on: March 8, 2021.

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