Carpal tunnel syndromeClassification and external resources

Transverse section at the wrist. The median nerve is colored yellow. The carpal

tunnel consists of the bones and flexor retinaculum.

ICD-10 G56.0

(http://apps.who.int/classifications/icd10/browse/2010/en#/G56.0)

ICD-9 354.0 (http://www.icd9data.com/getICD9Code.ashx?icd9=354.0)

OMIM 115430 (http://omim.org/entry/115430)

DiseasesDB 2156 (http://www.diseasesdatabase.com/ddb2156.htm)

MedlinePlus 000433

(http://www.nlm.nih.gov/medlineplus/ency/article/000433.htm)

eMedicine orthoped/455 (http://www.emedicine.com/orthoped/topic455.htm)

pmr/21 (http://www.emedicine.com/pmr/topic21.htm#) emerg/83

(http://www.emedicine.com/emerg/topic83.htm#) radio/135

(http://www.emedicine.com/radio/topic135.htm#)

MeSH D002349 (http://www.nlm.nih.gov/cgi/mesh/2012/MB_cgi?

field=uid&term=D002349)

Carpal tunnel syndromeFrom Wikipedia, the free encyclopedia

Carpal tunnelsyndrome (CTS) is anentrapment medianneuropathy, causingparesthesia, pain,numbness, and othersymptoms in thedistribution of themedian nerve due to itscompression at thewrist in the carpaltunnel. Thepathophysiology is notcompletely understoodbut can be consideredcompression of themedian nerve travelingthrough the carpaltunnel.[1] The NationalCenter forBiotechnologyInformation and highlycited literature[2] saythe most commoncause of CTS istyping.[3] Research byLozano-Calderón hascited genetics as afactor,[4] and hasencouraged caution inascribing causality.[5]

The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of thering finger.[6] The numbness often occurs at night, with the hypothesis that the wrists are held flexedduring sleep. Recent literature suggests that sleep positioning, such as sleeping on one's side, mightbe an associated factor.[7] It can be relieved by wearing a wrist splint that prevents flexion.[8] Long-standing CTS leads to permanent nerve damage with constant numbness, atrophy of some of themuscles of the thenar eminence, and weakness of palmar abduction.[9]

Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one from sleep.Pain in electrophysiologically verified CTS is associated with misinterpretation of nociception anddepression.[10]

Untreated carpal tunnel syndrome

Palliative treatments for CTS include use of night splints and corticosteroid injection. The onlyscientifically established disease modifying treatment is surgery to cut the transverse carpalligament.[11]

Contents

1 Signs and symptoms2 Causes

2.1 Work related2.2 Associated with other diseases

3 Diagnosis3.1 Differential diagnosis

4 Pathophysiology5 Prevention6 Treatment

6.1 Immobilizing braces6.2 Localized corticosteroid injections6.3 Other medication6.4 Carpal tunnel release surgery6.5 Ultrasound physiotherapy treatment6.6 Physiotherapy/Occupational Therapy

7 Prognosis8 Epidemiology9 History10 Notable cases11 See also12 References13 External links

Signs and symptoms

Patients with CTS experience numbness, tingling, or burningsensations in the thumb and fingers, in particular the index,middle fingers, and radial half of the ring fingers, which areinnervated by the median nerve. Less-specific symptoms mayinclude pain in the wrists or hands and loss of grip strength[12]

(both of which are more characteristic of painful conditions suchas arthritis).

Some posit that median nerve symptoms can arise fromcompression at the level of the thoracic outlet or the area wherethe median nerve passes between the two heads of the

pronator teres in the forearm.,[13] but this is highly debatable. This line of thinking is an attempt toexplain pain and other symptoms not characteristic of carpal tunnel syndrome.[14] Carpal tunnel

syndrome is a common diagnosis with an objective, reliable, verifiable pathophysiology, whereasthoracic outlet syndrome and pronator syndrome are defined by a lack of verifiable pathophysiologyand are usually applied in the context of nonspecific upper extremity pain.

Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic symptoms(NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar muscles may occurif the condition remains untreated.[15]

Causes

Most cases of CTS are of unknown causes, or idiopathic.[16] Carpal Tunnel Syndrome can beassociated with any condition that causes pressure on the median nerve at the wrist. Some commonconditions that can lead to CTS include obesity, oral contraceptives, hypothyroidism, arthritis,diabetes, and trauma.[17] Carpal tunnel is also a feature of a form of Charcot-Marie-Tooth syndrometype 1 called hereditary neuropathy with liability to pressure palsies.

Other causes of this condition include intrinsic factors that exert pressure within the tunnel, andextrinsic factors (pressure exerted from outside the tunnel), which include benign tumors such aslipomas, ganglion, and vascular malformation.[18] Carpal tunnel syndrome often is a symptom oftransthyretin amyloidosis-associated polyneuropathy and prior carpal tunnel syndrome surgery is verycommon in individuals who later present with transthyretin amyloid-associated cardiomyopathy,suggesting that transthyretin amyloid deposition may cause carpal tunnelsyndrome.[19][20][21][22][23][24][25]

Work related

The international debate regarding the relationship between CTS and repetitive motion in work isongoing. The Occupational Safety and Health Administration (OSHA) has adopted rules andregulations regarding cumulative trauma disorders. Occupational risk factors of repetitive tasks,force, posture, and vibration have been cited. However, the American Society for Surgery of theHand (ASSH) has issued a statement claiming that the current literature does not support a causalrelationship between specific work activities and the development of diseases such as CTS.[26]

The relationship between work and CTS is controversial; in many locations, workers diagnosed withcarpal tunnel syndrome are entitled to time off and compensation.[27] In the USA, carpal tunnelsyndrome results in an average of $30,000 in lifetime costs (medical bills and lost time fromwork).[28]

Some speculate that carpal tunnel syndrome is provoked by repetitive movement and manipulatingactivities and that the exposure can be cumulative. It has also been stated that symptoms arecommonly exacerbated by forceful and repetitive use of the hand and wrists in industrialoccupations,[29] but it is unclear as to whether this refers to pain (which may not be due to carpaltunnel syndrome) or the more typical numbness symptoms.[30]

A review of available scientific data by the National Institute for Occupational Safety and Health(NIOSH) indicated that job tasks that involve highly repetitive manual acts or specific wrist postureswere associated with incidents of CTS, but causation was not established, and the distinction from

work-related arm pains that are not carpal tunnel syndrome was not clear. It has been proposed thatrepetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. Ithas also been proposed that postural and spinal assessment along with ergonomic assessmentsshould be included in the overall determination of the condition. Addressing these factors has beenfound to improve comfort in some studies.[31]

Speculation that CTS is work-related is based on claims such as CTS being found mostly in theworking adult population, though evidence is lacking for this. For instance, in one recentrepresentative series of a consecutive experience, most patients were older and not working.[32]

Based on the claimed increased incidence in the workplace, arm use is implicated, but the weight ofevidence suggests that this is an inherent, genetic, slowly but inevitably progressive idiopathicperipheral mononeuropathy.[33]

Associated with other diseases

A variety of patient factors can lead to CTS, including heredity, size of the carpal tunnel, associatedlocal and systematic diseases, and certain habits.[1] Non-traumatic causes generally happen over aperiod of time, and are not triggered by one certain event. Many of these factors are manifestationsof physiologic aging.[34]

Examples include:

Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons.With hypothyroidism, generalized myxedema causes deposition of mucopolysaccharideswithin both the perineurium of the median nerve, as well as the tendons passing through thecarpal tunnel.During pregnancy women experience CTS due to hormonal changes (high progesteronelevels) and water retention (which swells the synovium), which are common during pregnancy.Previous injuries including fractures of the wrist.Medical disorders that lead to fluid retention or are associated with inflammation such as:inflammatory arthritis, Colles' fracture, amyloidosis, hypothyroidism, diabetes mellitus,acromegaly, and use of corticosteroids and estrogens.Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, inparticular with a combination of forceful and repetitive activities[17]

Acromegaly causes excessive growth hormones. This causes the soft tissues and bonesaround the carpel tunnel to grow and compress the median nerve.[35]

Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel,reducing the amount of space. This is exceedingly rare (less than 1%).Obesity also increases the risk of CTS: individuals classified as obese (BMI > 29) are 2.5times more likely than slender individuals (BMI < 20) to be diagnosed with CTS.[36]

Double-crush syndrome is a debated hypothesis that compression or irritation of nervebranches contributing to the median nerve in the neck, or anywhere above the wrist, increasessensitivity of the nerve to compression in the wrist. There is little evidence, however, that thissyndrome really exists.[37]

Heterozygous mutations in the gene SH3TC2, associated with Charcot-Marie-Tooth, confersusceptibility to neuropathy, including the carpal tunnel syndrome.[38]

Parvovirus b19 has been associated with carpel tunnel syndrome [39]

Diagnosis

There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. Acombination of described symptoms, clinical findings, and electrophysiological testing is used by amajority of hand surgeons. Numbness in the distribution of the median nerve, nocturnal symptoms,thenar muscle weakness/atrophy, positive Tinel's sign at the carpal tunnel, and abnormal sensorytesting such as two-point discrimination have been standardized as clinical diagnostic criteria byconsensus panels of experts.[40][41] A predominance of pain rather than numbness is unlikely to becaused by carpal tunnel syndrome no matter what the result of electrophysiological testing.

Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively verify themedian nerve dysfunction. If these tests are normal, carpal tunnel syndrome is either absent or very,very mild.

Clinical assessment by history taking and physical examination can support a diagnosis of CTS.

Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding thisposition and awaiting symptoms.[42] A positive test is one that results in numbness in themedian nerve distribution when holding the wrist in acute flexion position within 60 seconds.The quicker the numbness starts, the more advanced the condition. Phalen's sign is defined aspain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion. Onlythis test has been shown to correlate with CTS severity when studied prospectively.[1]

Tinel's sign, a classic — though less sensitive - test is a way to detect irritated nerves. Tinel's isperformed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tinglingor "pins and needles" in the nerve distribution. Tinel's sign (pain and/or paresthesias of themedian-innervated fingers with percussion over the median nerve) is less sensitive, but slightlymore specific than Phalen’s sign.[1]

Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve forup to 30 seconds to elicit symptoms has also been proposed.[43][44]

As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within thecarpal tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles in the palmof hand and at the base of the thumb). This is because the palmar branch of the median nerve, whichinnervates that area of the palm, branches off of the median nerve and passes over the carpaltunnel.[45] This feature of the median nerve can help separate carpal tunnel syndrome from thoracicoutlet syndrome, or pronator teres syndrome.

Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physicalexamination suggest CTS, patients will sometimes be tested electrodiagnostically with nerveconduction studies and electromyography. The goal of electrodiagnostic testing is to compare thespeed of conduction in the median nerve with conduction in other nerves supplying the hand. Whenthe median nerve is compressed, as in CTS, it will conduct more slowly than normal and more slowlythan other nerves. There are many electrodiagnostic tests used to make a diagnosis of CTS, but themost sensitive, specific, and reliable test is the Combined Sensory Index (also known as Robinsonindex).[46] Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the

carpal tunnel in context of normal conduction elsewhere. Compression results in damage to themyelin sheath and manifests as delayed latencies and slowed conduction velocities [1] However,normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, as athreshold of nerve injury must be reached before study results become abnormal and cut-off valuesfor abnormality are variable.[41] Carpal tunnel syndrome with normal electrodiagnostic tests is very,very mild at worst.

The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear.[47][48][49]

Differential diagnosis

There are some who believe that carpal tunnel syndrome is simply a universal label applied toanyone suffering from pain, numbness, swelling, and/or burning in the radial side of the hands and/orwrists. When pain is the primary symptom, carpal tunnel syndrome is unlikely to be the source of thesymptoms.[30] As a whole, the medical community is not currently embracing or accepting triggerpoint theories due to lack of scientific evidence supporting their effectiveness.[50]

Pathophysiology

Main article: Carpal tunnel

The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor tendonsand the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpalbones that form an arch. The median nerve provides feeling or sensation to the thumb, index finger,long finger, and half of the ring finger. At the level of the wrist, the median nerve supplies the musclesat the base of the thumb that allow it to abduct, or move away from the fingers, out of the plane of thepalm. The carpal tunnel is located at the middle third of the base of the palm, bounded by the bonyprominence of the scaphoid tubercle and trapezium at the base of the thumb, and the hamate hookthat can be palpated along the axis of the ring finger. The proximal boundary is the distal wrist skincrease, and the distal boundary is approximated by a line known as Kaplan's cardinal line.[51] Thisline uses surface landmarks, and is drawn between the apex of the skin fold between the thumb andindex finger to the palpated hamate hook.[52] The median nerve can be compressed by a decreasein the size of the canal, an increase in the size of the contents (such as the swelling of lubricationtissue around the flexor tendons), or both.[53] Simply flexing the wrist to 90 degrees will decrease thesize of the canal.

Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causesatrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductorpollicis brevis, as well as sensory loss in the digits supplied by the median nerve. The superficialsensory branch of the median nerve, which provides sensation to the base of the palm, branchesproximal to the TCL and travels superficial to it. Thus, this branch spared in carpal tunnel syndrome,and there is no loss of palmar sensation.[54]

Prevention

A systematic review in 2007 of the published English-language literature assessed the quality and

strength of articles addressing causes for carpal tunnel syndrome. The authors applied the BradfordHill criteria to papers on various biological and occupational factors that have been proposed to havea causative effect. Biological factors such as genetic predisposition and anthropometrics hadsignificantly stronger causal association with carpal tunnel syndrome than occupational/environmentalfactors such as repetitive hand use and stressful manual work.[55] This suggests that carpal tunnelsyndrome might not be preventable simply by avoiding certain activities or types of work/activities.Suggested healthy habits such as avoiding repetitive stress, work modification through use ofergonomic equipment (wrist rest, mouse pad), taking proper breaks, using keyboard alternatives(digital pen, voice recognition, and dictation), and employing early treatments such as taking turmeric(anti-inflammatory), omega-3 fatty acids, and B vitamins have been proposed as methods to helpprevent carpal tunnel syndrome. The potential role of B-vitamins in preventing or treating carpal tunnelsyndrome has not been proven.[56][57] There is little or no data to support the concept that activityadjustment prevents carpal tunnel syndrome.[55]

Treatment

There have been numerous scientific papers evaluating treatment efficacy in CTS. It is important todistinguish treatments that are supported in the scientific literature from those that are advocated byany particular device manufacturer or any other party with a vested financial interest. Generallyaccepted treatments, as described below, may include splinting or bracing, steroid injection, activitymodification, physiotherapy, regular massage therapy treatments,medications, and surgical releaseof the transverse carpal ligament.

According to the 2007 guidelines by the American Academy of Orthopaedic Surgeons,[58] earlysurgery with carpal tunnel release is indicated where there is clinical evidence of median nervedenervation or the patient elects to proceed directly to surgical treatment. Otherwise, the mainrecommended treatments are local corticosteroid injection, splinting (immobilizing braces), oralcorticosteroids and ultrasound treatment. The treatment should be switched when the currenttreatment fails to resolve the symptoms within 2 to 7 weeks. However, these recommendations havesufficient evidence for carpal tunnel syndrome when found in association with the followingconditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy,pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.[58]

In a working population, Lyall demonstrated an earlier return to work and a greater percentage ofthose able to return to work in patients treated with early carpal tunnel release compared to thosewho spent time involved in nonoperative treatment, such as injections, splinting, ergonomic jobanalysis, hand therapy. The increased costs from nonoperative treatment were due to longer careand longer time off work; these also increased the overall cost of treatment. < Lyall JM, Gliner J,Hubbell MK: Treatment of worker's compensation cases of carpal tunnel syndrome: an outcomestudy. J Hand Ther 15:251-9, 2002.> A longer duration of symptoms, i.e. a delay to definitive surgicaltreatment, has also been associated with a longer time to return to work, implying that earlierdefinitive surgical treatment reduces the amount of time off of work. < Nancollas MP, Peimer CA,Wheeler DR, Sherwin FS: Long-term results of carpal tunnel release. J Hand Surg [Br] 20:470-4,1995.> Shin also found carpal tunnel release to be superior to nonoperative management, withdecreased disability, and a decreased necessity for job modifications and restrictions compared tothose who did not undergo surgical release. < Shin AY, Perlman M, Shin PA, Garay AA: Disabilityoutcomes in a worker's compensation population: surgical versus nonsurgical treatment of carpal

A rigid splint can keep the wrist straight.

tunnel syndrome. Am J Orthop 29:179-84, 2000.>

Immobilizing braces

The importance of wrist braces and splints in thecarpal tunnel syndrome therapy is known, but manypeople are unwilling to use braces. In 1993, TheAmerican Academy of Neurology recommend anon-invasive treatment for the CTS at the beginning(except for sensitive or motor deficit or grave reportat EMG/ENG): a therapy using splints was indicatedfor light and moderate pathology.[59] Currentrecommendations generally don't suggestimmobilizing braces, but instead activitymodification and non-steroidal anti-inflammatorydrugs as initial therapy, followed by moreaggressive options or specialist referral if symptomsdo not improve.[60][61]

Many health professionals suggest that, for best results, one should wear braces at night and, ifpossible, during the activity primarily causing stress on the wrists.[62][63]

Localized corticosteroid injections

Corticosteroid injections can be quite effective for temporary relief from symptoms of CTS for a shorttime-frame while a patient develops a longterm strategy that fits with his/her lifestyle.[64] In certainpatients, an injection may also be of diagnostic value. This treatment is not appropriate for extendedperiods, however. In general, medical professionals prescribe local steroid injections only until othertreatment options can be identified. For most patients, surgery is the only option that will providepermanent relief.[65]

Other medication

A more aggressive pharmaceutical option is an injection of cortisone, to reduce swelling and nervepressure within the carpal tunnel. The role of Methylcobalamin (vitamin B12) in CTS is debatable anduncertain. [66]

Carpal tunnel release surgery

Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It isrecommended when there is static (constant, not just intermittent) numbness, muscle weakness, oratrophy, and when night-splinting no longer controls intermittent symptoms.[67] In general, mildercases can be controlled for months to years, but severe cases are unrelenting symptomatically andare likely to result in surgical treatment.[68]

Procedure

Scars from carpal tunnel release surgery. Twodifferent techniques were used. The left scar is6 weeks old, the right scar is 2 weeks old. Alsonote the muscular atrophy of the thenareminence in the left hand, a common sign ofadvanced CTS

Carpal Tunnel Syndrome Operation

In carpal tunnel release surgery, the goal is to divide the transverse carpal ligament in two. This is awide ligament that runs across the hand, from the scaphoid bone to the hamate bone and pisiform. Itforms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the ringfinger) it no longer presses down on the nerve inside, relieving the pressure.[69]

There are several carpal tunnel release surgery variations: Each surgeon has differences ofpreference based on his or her personal beliefs and experience. All techniques have several things incommon, involving brief outpatient procedures, palm or wrist incision(s), and cutting of the transverse

carpalligament.[citation needed]

The twomajortypes ofsurgery areopencarpaltunnelreleaseand

endoscopic carpal tunnel release. Most surgeonshistorically have performed the open procedure,widely considered to be the gold standard.However, since the 1990s, a growing number ofsurgeons now offer endoscopic carpal tunnelrelease.[citation needed]

Open surgery involves an incision on the palm about an inch or two in length. Through this incision,the skin and subcutaneous tissue is divided, followed by the palmar fascia, and ultimately thetransverse carpal ligament.[citation needed]

Endoscopic carpal tunnel release

Endoscopic techniques or endoscopic carpal tunnel release involve one or two smaller incisions(less than half inch each) through which instrumentation is introduced including a synovial elevator,probes, knives, and an endoscope used to visualize the underside of the transverse carpalligament.[70] The endoscopic methods do not divide the subcutaneous tissues or the palmar fascia tothe same degree as the open method does.[71] Many studies have been done to determine whetherperceived benefits of a limited endoscopic or arthroscopic release are significant. Brown et al.conducted a prospective, randomized, multi-center study and found no significant differencesbetween the two groups with regard to secondary quantitative outcome measurements.[72] However,the open technique resulted in more tenderness of the scar than the endoscopic method. Aprospective randomized study done in 2002 by Trumble revealed that good clinical outcomes andpatient satisfaction are achieved more quickly with the endoscopic method. Single-portal endoscopicsurgery is a safe and effective method of treating carpal tunnel syndrome. There was no significantdifference in the rate of complications or the cost of surgery between the two groups. However, theopen technique caused greater scar tenderness during the first three months after surgery, and a

longer time before the patients could return to work.[73] In addition, in patients without workerscompensation issues, the single-incision endoscopic carpal tunnel release led to less palmartenderness and a quicker return to work compared to the two-incision endoscopic carpal tunnelrelease (Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK, Olson JD: Endoscopic carpal tunnelrelease: a comparison of two techniques with open release. Arthroscopy 9:498-508, 1993.)

Many surgeons have embraced limited incision methods. It is considered to be the procedure ofchoice for many of these surgeons with respect to idiopathic carpal tunnel syndrome. Supporting thisare the results of some of the previously mentioned series that cite no difference in the rate ofcomplications for either method of surgery. Thus, there has been broad support for either surgicalprocedure using a variety of devices or incisions. The primary goal of any carpal tunnel releasesurgery is to divide the transverse carpal ligament and the distal aspect of the volar ante brachialfascia, thereby decompressing the median nerve.[74] Despite these views, some surgeons havesuggested that in their own hands endoscopic carpal tunnel release has been associated with ahigher incidence of median nerve injury, and for this reason it has been abandoned at several centersin the United States. At the 2007 meeting of the American Society for Surgery of the Hand, a formeradvocate of endoscopic carpal tunnel release, Thomas J. Fischer, MD, retracted his advocacy of thetechnique, based on his own personal assessment that the benefit of the procedure (slightly fasterrecovery) did not outweigh the risk of injury to the median nerve. Contrary to this one or any oneopinion of any individual surgeon it has been shown that while there is a learning curve for a handsurgeon who begins to use an endoscopic technique to release the transverse carpal ligament nosignificant safety issues or morbididty associated with the endoscopic method exist.[75] The use ofendoscopic carpal tunnel release has continued to spread around the world and clinical and nerveelectrophysiological states are significantly improved at the long-term follow-up after endoscopiccarpal tunnel release.[76] A meta-analysis supports the conclusion that endoscopic carpal tunnelrelease is favored over the open carpal tunnel release in terms of a reduction in scar tenderness andincrease in grip and pinch strength at a 12-week follow-up [77]

Experimental procedures

Balloon carpal tunnelplasty is an experimental technique that uses a minimally invasive ballooncatheter director to access the carpal tunnel. As with a traditional tissue elevator/expander, ballooncarpal tunnelplasty elevates the carpal ligament, increasing the space in the carpal tunnel. As anexperiment it has been described but there are no peer reviewed series available in the current handsurgical literature that review or comment upon the procedure. The technique is performed through aone-centimeter incision at the distal wrist crease. It is monitored and expansion is confirmed bydirect or endoscopic visualization. The technique's secondary goals are to avoid to incision in thepalm of the hand, to avoid cutting of the transverse carpal ligament, and to maintain thebiomechanics of the hand.[78]

Efficacy

Surgery to correct carpal tunnel syndrome has a high success rate. Up to 90% of patients were ableto return to their same jobs after surgery.[79][80][81] In general, endoscopic techniques are as effectiveas traditional open carpal surgeries,[82][83] though the faster recovery time typically noted inendoscopic procedures is felt by some to possibly be offset by higher complication rates.[84][85]

Success is greatest in patients with the most typical symptoms. The most common cause of failure isincorrect diagnosis, and it should be noted that this surgery will only mitigate carpal tunnel syndrome,and will not relieve symptoms with alternative causes. Recurrence is rare, and apparent recurrenceusually results from a misdiagnosis of another problem.[citation needed] Complications can occur, butserious ones are infrequent to rare.[citation needed]

Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic surgeon, or plasticsurgeon. Some neurosurgeons and general surgeons also perform the procedure.[citation needed]

Ultrasound physiotherapy treatment

Some claim that ultrasound to the wrist gives significant improvement of symptoms in people withCTS.[86] A treatment process may consist of 20 sessions of 15 minutes of ultrasound applied to thearea over the carpal tunnel at a frequency of 1 MHz, and a power of 1.0 W/cm2.[86]

However, many studies have shown no effect.[87][88] Given these inconsistencies, the role ofultrasound in the treatment of CTS is debatable and it should be considered an experimentaltreatment.

Physiotherapy/Occupational Therapy

One review of the evidence for possible symptom reduction found good evidence (level Brecommendations) for splinting, ultrasound, Laser, Tens, nerve gliding exercises/Neural mobilization,carpal bone mobilization, magnetic therapy, and yoga for people with carpal tunnel syndrome.[89]

However, a recent evidence based guideline produced by the American Academy of OrthopedicSurgeons assigned lower grades to most of these treatments.[90]

Again, some claim that pro-active ways to reduce stress on the wrists, which alleviates wrist pain andstrain, involve adopting a more ergonomic work and life environment. For example, some haveclaimed that switching from a QWERTY computer keyboard layout to a more optimised ergonomiclayout such as Dvorak was commonly cited as beneficial in early CTS studies, however some meta-analyses of these studies claim that the evidence that they present is limited.[91][92]

Prognosis

Most people relieved of their carpal tunnel symptoms with conservative or surgical management findminimal residual or "nerve damage".[93] Long-term chronic carpal tunnel syndrome (typically seen inthe elderly) can result in permanent "nerve damage", i.e. irreversible numbness, muscle wasting, andweakness.

While outcomes are generally good, certain factors can contribute to poorer results that have little todo with nerves, anatomy, or surgery type. One study showed that mental status parameters or alcoholuse yields much poorer overall results of treatment.[94]

Recurrence of carpal tunnel syndrome after successful surgery is rare.[95] If a person has hand painafter surgery, it is most likely not caused by carpal tunnel syndrome. It may be the case that the illness

of a person with hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpaltunnel release has had no positive effect upon the patient's symptoms.[citation needed]

Epidemiology

Carpal tunnel syndrome can affect anyone. In the U.S., roughly 1 out of 20 people will suffer from theeffects of carpal tunnel syndrome. Caucasians have the highest risk of CTS compared with otherraces such as non-white South Africans.[96] Women suffer more from CTS than men with a ratio of3:1 between the ages of 45–60 years. Only 10% of reported cases of CTS are younger than 30years.[96] Increasing age is a risk factor. CTS is also common in pregnancy.

History

The condition known as carpal tunnel syndrome had major appearances throughout the years but itwas most commonly heard of in the years following World War II.[97] Individuals who had sufferedfrom this condition have been depicted in surgical literature for the mid-19th century.[97] In 1854, SirJames Paget was the first to report median nerve compression at the wrist in a distal radiusfracture.[98] Following the early 20th century there were various cases of median nerve compressionunderneath the transverse carpal ligament.[98] Carpal Tunnel Syndrome was most commonly noted inmedical literature in the early 20th century but the first use of the term was noted 1939. Physician Dr.George S. Phalen of the Cleveland Clinic identified the pathology after working with a group ofpatients in the 1950s and 1960s.

Notable cases

HRH Prince Philip, husband of Queen Elizabeth II[99]

Mike Dirnt, bassist with the band Green Day[100]

Michael Einziger, guitarist with the band IncubusKelly Shaefer, guitarist and singer with the band Atheist

See also

Repetitive strain injuryTendinitisTendinosis

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External links

Carpal Tunnel Syndrome Fact Sheet (National Institute of Neurological Disorders and Stroke)(http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm)NHS website carpal-tunnel.net provides a free to use, validated, online self diagnosisquestionnaire for CTS (http://www.carpal-tunnel.net)

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