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Mathias Masem, M.D.
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Shoulder | Elbow | Wrist | Hand

Carpal Tunnel Syndrome

What is carpal tunnel syndrome

Carpal tunnel syndrome is the effect of pressure on the Median Nerve, one of the main nerves of the hand.

It can result in a variety of problems, including pain, tingling, numbness, swelling, weakness or clumsiness of the thumb, index, middle and ring fingers.

What causes carpal tunnel syndrome?

Carpal tunnel syndrome develops in people who have a tendency toward swelling or inflammation in their hands. Like a telephone cable, the median nerve is a connection between the fingers and the spinal cord. It passes a through a protective conduit (tunnel) deep in the wrist (carpus), along with the nine tendons which bend the fingers. The nerve and each of the tendons are each nearly as wide as a pencil. The tunnel is only a little over an inch wide - just big enough to hold the nerve and tendons. When the tendons are irritated, the lining around the tendons (synovium) swells up and puts pressure on the nerve. This pressure cuts off the blood supply to the nerve.

Early symptoms occur during sleeping hours. This is because the swelling is relieved by normal use of the hand which pumps extra fluid out of the carpal tunnel. The fluid pressure builds up only when the hand is at rest - especially during sleep. Bending the wrist may also increase pressure on the nerve.

In more advanced cases, symptoms occur during waking hours. At this stage, scar tissue may form around the nerve from repeated episodes of pressure. Nerve damage is suspected when any symptoms occur regularly during the day.

What can you do to help?
  • "Over the counter" non-steroidal anti-inflammatory medication (NSAID), such as aspirin, ibuprofen, or naprosyn. Check with your pharmacist regarding possible side effects and drug interactions.
  • A splint or brace which supports the wrist, to use while sleeping.
  • Wait and watch.
What can a therapist do to help?
  • Provide neutral position wrist splint to support the wrist.
  • Help identify aggravating activities and suggest alternative postures.
  • As many as two out of three people with mild carpal tunnel syndrome will have some improvement with stretching exercise designed to relieve pressure within the carpal tunnel along with education regarding aggravating activities.
What can a hand surgeon do to help?
  • Confirm that this actually is the problem. This may require special nerve tests (NCS) done by a neurologist.
  • Prescribe stronger NSAID medication or cortisone-type medication.
  • Prescribe hand therapy and/or a custom prescription splint.
  • The most effective treatment without surgery is a cortisone injection into the carpal tunnel. Depending on several factors, these measures can provide long-term relief in 5 to 60 per cent of patients. Conservative treatment is usually not recommended for patients who have evidence of nerve damage.

Carpal release surgery decreases pressure on the nerve to relieve pain and numbness.

When is surgery considered?
  • Surgery for carpal tunnel syndrome is intended to provide more space for the nerve and tendons, so that swelling will not put significant amounts of pressure on the nerve. It is usually done through an incision on the palm or the front of the wrist.
  • An incision is made to open the carpal tunnel. The tunnel opens up. It heals with more space inside for the nerve and tendons.
  • There are many different techniques used for the surgery - whether it involves a cut in the palm, the wrist, smaller or longer cuts or different instruments, the one thing in common is that the thick layer of ligament in front of the nerve is cut.
  • After surgery, the healing edges of the ligament beneath the skin are usually tender for at least four to six weeks after the procedure. Temporary tenderness on each side of the palm where the ligament is attached to the bones on each side of the palm these bones is common after surgery and is called "pillar pain". This generally resolves gradually. Hand therapy is often helpful during recovery.
How successful is treatment?
  • Swelling, stiffness, aches and pains in the hand may well be due to other problems, and may persist to some extent following any form of treatment.
  • Nerve damage existing before treatment may lead to incomplete recovery.
  • With this in mind, the great majority of patients are improved with appropriate treatment. Most reports indicate that if carpal tunnel syndrome is the only problem, over 95% of patients have a satisfactory outcome from surgery.
What happens if you have no treatment?
  • It depends most importantly on whether or not the problem actually is carpal tunnel syndrome and whether or not there are other medical conditions contributing to the overall picture.
  • Mild carpal tunnel syndrome can improve without treatment in as many as one in three people.
  • The chances of getting better without surgery are less when:
    1. both hands are involved.
    2. the problem has been going on for a longer time.
    3. the person is older.
    4. the more severe the symptoms of numbness and tingling have been.
  • The longer the nerve is irritated, the longer numbness or tingling are constant, the harder it is to have a full recovery - even with surgery. If the problem is severe, however, surgery is a reasonable step to prevent further nerve damage even if full recovery can not be guaranteed.