Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) one of the most common things I treat in my hand surgery practice - so what exactly is it?

1) What is Carpal Tunnel Syndrome?

The carpal tunnel is a space in the palm side of the wrist that contains the median nerve (a major nerve that provides sensation to the thumb, index, middle, and half of the ring finger, as well as the rest of the tendons that allow you to flex your fingers into a fist.

It's a tight space - so if the walls around the space get thicker, or the space inside gets smaller because the tendons or nerve get swollen, it end up squishing or compressing the nerve. This not only prevents the nerve from sending signals to your brain easily, it also changes the way the nerve gets blood flow. This leads to numbness in the hand and sometimes this can be painful or annoying.

If the nerve gets compressed too frequently or for too long, it can start to develop permanent changes in structure which can make it harder for the nerve to completely recover.

2) How do I know if I have it?

There are some classic symptoms of carpal tunnel syndrome I always ask my patients. Is it worse at night or doing the day? Any specific activities make it worse? This combined with an examination of the hand looking for weakness in one of the thumb muscles, numbness in the area that the nerve provides sensation, and certain maneuvers such as a Tinel sign and Phalen test all can help make the diagnosis more likely than not.

3) Will I need an EMG (electromyography)

Maybe. While EMG's can be a very helpful tool, they are far from perfect - and they are painful! In my practice, an EMG can help determine severity of nerve issues and help detect nerve issues when the symptoms aren't very straight forward. In all types of medical testing, there are what we call false negatives. This means that even if the EMG shows nothing abnormal about the nerve, you might still have carpal tunnel syndrome which would respond to treatment if the symptoms are highly suggestive of carpal tunnel syndrome. For these reasons, I don't order EMG's on every person that might have carpal tunnel syndrome, but rather in situations where the diagnosis isn't entirely clear, or if we are wanting more information on the health of the nerve that will impact what we decide to do together.

4) What are my options?

Splinting

Except for certain case which make me very concerned about the health of the nerve, I will recommend night splinting. Keeping the wrist in a straighter, more neutral position, can help the nerve remain in a non-compressed state at night time. This allows better blood flow at night to the nerve, less compression which makes the nerve less swollen which makes it feel less tight in the carpal tunnel. This may be all that you need, but if we try splinting for 2-3 months, and you are still having symptoms, I will recommend something else.

Steroid Injection (Cortisone Shot)

The purpose of the steroid injection is to decrease inflammation and swelling of the nerve and/or the tissues around it. This can provide very quick symptom relief. Patients should be aware that their hand may feel worse for the first couple of days after the shot, but usually will get relief in symptoms afterward. I regard steroid injections to be a temporary treatment. In some situation, like pregnancy, symptoms usually go away once the baby is born, so a steroid is a great way to give patient relief knowing the symptoms will get better on their own. Sometimes, now is not a good time for surgery, so a steroid can be a good way to get relief for my patients until they are in a better place at work or home to take the time needed to recover. Other times I use steroids as a diagnostic tool. There are studies that indicate that patients who have an injection and respond well to it are more likely to do well with surgery. An injection in the office and good response can help my patient and me feel more confident that surgery is going to be helpful.

Surgery

Surgically providing the nerve with more room by opening the roof of the carpal tunnel is the gold standard for providing symptoms relief. For patients who have had conservative treatment and failed, or have an issue where we know conservative treatment will not succeed, I will recommend surgery.

5) Endoscopic or Open carpal tunnel surgery?

Several studies show that treatment of carpal tunnel endoscopically (a small incision and camera placed in the wrist) compared to open surgery (incision on the palm) are equivalent in success rates. The reason I typically offer endoscopic carpal tunnel release is the smaller incision and the easier time using the hand soon after surgery. It's what I would do for myself, so I offer my patients the same. There are, however, some instances where open surgery is the only reasonable and safe option. The recovery in the short term is slightly different compared to an endoscopic carpal tunnel - but in the long term we can expect the same results.

6) Will this solve all of my hand pain?

Carpal tunnel syndrome has become a popular label for virtually every pain the hand. It is not uncommon for someone who have several things going on all at once. It's important to discuss your symptoms with your surgeon and understand that, while carpal tunnel syndrome is uncomfortable, and can be painful, it may not be the cause of all the pain you may be experiencing in your hand.

I hope this article was helpful to you in understanding your own hands - wishing you all this best!

• Aparajit Naram, MD FACS