Carpal Tunnel Syndrome

Hand/Finger/Wrist IssuesHand/Finger/Wrist Issues

22

Presentation:A 64-year-old, right-handed, retired womanpresents with:intermittent numbness, tingling, and burning pain Location: The three radial digits of both hands Duration: Had these symptoms for three monthsHistory: These symptoms awaken her several times each night. On examination: She has no atrophy of the thenar muscles.Sensation to light touch is intact. How should she be evaluated and treated?

33

Scope of the problem

2.7 million office visitsDifferential diagnosis:Entrapments of the nerves-Carpal tunnel syndrome, Entrapment of the ulnar nerveCervical radiculopathy

Tendon disorders, Overuse of muscles, Nonspecific pain syndromes

44

CT Anatomy

55

CTS Data F: 3%, M:2%, Average age: 55 yrsF: 3%, M:2%, Average age: 55 yrs Elevated pressure in the carpal tunnel Results in ischemia of the median nerve Causes impaired nerve conduction and attendant

paresthesia and pain Related Conditions:

PregnancyInflammatory arthritis- RAColles’ fracture AmyloidosisHypothyroidismDiabetes mellitus 6%Acromegaly Use of corticosteroids and estrogens

66

CTS: Occupational

Repetitive activities of the hand and wrist particularly with a combination of forceful andrepetitive activities:Food processingManufacturingLogging Construction workData entry

77

History

Pain, tingling, burning, numbness, or some combination of these symptoms on the palmar aspect of the thumb, index finger, middle finger, and radial half of the ring fingerNo such symptoms affect the fifth fingerNocturnal symptoms reported (51-77%)“Flick Sign”: Shake the symptomatic hand or hands when symptoms are at their worst gives relief

88

Assessment

Late signs:Loss of two-point discrimination in the median nerve distribution

Thenar atrophyPhalen’s maneuver: Flexion of the wrist for 60 seconds elicits pain or paresthesia in the median-nerve distribution (40-80%)Tinel’s sign: Present if tapping lightly over the volar surface of the wrist causes radiating paresthesia in the digits innervated by themedian nerve (67-87%)

99

TherapiesTreat associated conditionsTreat associated conditionsWrist splint alleviates symptoms (80%); maintain the wrist in neutral posture rather than in extension

Medications- ?NSAIDs, B6Prednisone helps (10mg/day)Local Corticosteroid Injection (75% relief) symptoms recur within 1 yr (Poor prognosis: constant numbness, impaired sensibility, and weakness or thenar muscular atrophy) Limit injections to 3/yr

1010

?Surgery

Carpal-tunnel–release surgery (on demand)Indications: constant numbness, symptoms for more than one year, loss of sensibility, and thenar muscular atrophy or weaknessDirect or endoscopic carpal ligament releaseEndoscopic –increased risk of median nerve injury/

benefit earlier return to work

“mini”-open release70-90% success in pain reliefElectro-diagnostic studies help to choose patients

1111

Surgical Scars

1212

?Alternative Therapies

““not been evaluated”yoga-based stretching, strengthening, and

relaxationchiropractic therapyminimize forceful hand and wrist activitiesacupuncture, dietary supplements

1313

1414

U/S imaging