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Carpal Tunnel Syndrome

Carpal tunnel syndrome is the most common compression neuropathy affecting the upper limb, which results from the entrapment of the median nerve in the carpal tunnel. Carpal tunnel syndrome adversely affects daily activities, limits work capacity, and impacts general health and quality of life. In a primary care population, prevalence has been reported to be 3720 to 5700 per 100,000 people in a year, with an annual incidence of 72 to 8200 per 100,000. CTS is more common in women with a female-to-male ratio ranging between 0.78 and 9.66.

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Carpal Tunnel Syndrome Summary

Carpal Tunnel Syndrome is a common condition characterized by median nerve compression at the wrist. Understanding the causes and pathophysiology of CTS is crucial for effective treatment. While non-surgical interventions, such as medications, splinting, and physical therapy, are often the initial approach, corticosteroid injections and surgery may be necessary in more severe cases. It is important to consult with a healthcare professional to determine the most suitable treatment plan based on individual circumstances. With proper management, individuals with carpal tunnel syndrome can experience significant relief and improved hand function.

Procedures offered for Carpal Tunnel Syndrome

Carpal tunnel Syndrome

Causes Of Carpal Tunnel Syndrome

Carpal Tunnel Syndrome can be caused by several factors, including:

  1. Repetitive Movements: Engaging in repetitive motions that involve the wrist and hand, such as typing, using vibrating tools, or performing assembly line work, can increase the risk of developing carpal tunnel syndrome. The repeated stress and strain on the wrist can lead to inflammation and swelling of the tissues within the carpal tunnel, resulting in compression of the median nerve.
  2. Wrist Position and Ergonomics: Prolonged and sustained flexion or extension of the wrist can contribute to the development of carpal tunnel syndrome. Activities that involve keeping the wrist in a bent position, such as using a computer mouse or keyboard, operating machinery, or playing musical instruments, can increase pressure on the median nerve. Poor ergonomic practices, including improper wrist positioning and inadequate support, can exacerbate the risk.
  3. Anatomical Factors: Certain anatomical variations or conditions can predispose individuals to carpal tunnel syndrome. A narrow carpal tunnel, which may be present from birth or developed as a result of conditions like osteoarthritis, can make the space within the tunnel more prone to nerve compression. Additionally, wrist fractures or dislocations that result in misalignment of the carpal bones can cause narrowing of the tunnel and subsequent compression of the median nerve.
  4. Hormonal Changes: Hormonal changes associated with pregnancy, menopause, or certain endocrine disorders can affect the balance of fluid retention and inflammation in the body. Increased fluid retention can lead to swelling and increased pressure within the carpal tunnel, potentially compressing the median nerve.
  5. Medical Conditions: Several medical conditions have been linked to an increased risk of developing carpal tunnel syndrome. These include:
    • Rheumatoid Arthritis: Chronic inflammation associated with rheumatoid arthritis can affect the tissues surrounding the carpal tunnel, leading to compression of the median nerve.
    • Diabetes: Individuals with diabetes are more prone to nerve damage (neuropathy), including the median nerve, which can increase the risk of developing carpal tunnel syndrome.
    • Hypothyroidism: Underactive thyroid function can cause fluid retention and soft tissue swelling, potentially leading to carpal tunnel syndrome.
    • Obesity: Excess body weight can contribute to increased pressure on the median nerve and carpal tunnel, increasing the risk of compression.

Understanding the specific causes and risk factors associated with carpal tunnel syndrome can help individuals make appropriate lifestyle modifications, seek early treatment, and adopt preventive measures to mitigate the condition’s impact on their hand function and overall quality of life.

Pathophysiology Of Carpal Tunnel Syndrome

Certainly! Here’s a paragraph explaining the pathophysiology of carpal tunnel syndrome:

The pathophysiology of carpal tunnel syndrome (CTS) revolves around the compression and irritation of the median nerve as it passes through the carpal tunnel. The carpal tunnel is a narrow passageway in the wrist formed by the carpal bones and a transverse ligament. When the tissues within the carpal tunnel become inflamed or swollen, the available space for the median nerve decreases, leading to compression.

The primary contributors to this compression are the flexor tendons that pass through the tunnel and the synovial sheaths surrounding them. With repetitive hand and wrist movements or sustained wrist positions, these tendons can become irritated and inflamed, causing them to thicken and encroach upon the already limited space within the tunnel. This leads to increased pressure on the median nerve, which results in the characteristic symptoms of CTS, including pain, numbness, tingling, and weakness in the hand and fingers.

Over time, if left untreated, the prolonged compression of the nerve can cause damage and loss of nerve function.

Symptoms Of Carpal Tunnel Syndrome

  • Pain: The most common symptom of carpal tunnel syndrome is pain, which may radiate from the wrist to the hand or forearm.
  • Numbness and Tingling: Individuals with CTS often experience numbness and tingling in the thumb, index, middle, and ring fingers. This sensation of “pins and needles” may start intermittently but can progress to become constant over time.
  • Weakness: Weakness in the hand and a loss of grip strength are frequently observed in carpal tunnel syndrome. Tasks that require fine motor skills may become increasingly challenging.
  • Nighttime Symptoms: The symptoms of CTS often worsen at night, potentially causing discomfort and interrupting sleep.
  • Localization: The symptoms primarily affect the palm side of the hand, sparing the little finger, as this area is innervated by a different nerve.
  • Functional Limitations: If left untreated, carpal tunnel syndrome can lead to persistent symptoms and functional limitations in daily activities that require hand and wrist movements.
  • Bilateral symptoms occur in more than 50% of patients.

Diagnosis Of Carpal Tunnel Syndrome

The diagnosis is based on clinical history, examination findings, and provocation tests.

Two common provocation tests used for the diagnosis of carpal tunnel syndrome are Phalen’s sign, with a sensitivity of 10 to 73% and specificity of 55–86%, and Tinel’s sign with 8–100% page sensitivity and 55–87% specificity.

Nerve conduction tests are commonly used to diagnose and evaluate the severity of carpal tunnel syndrome. During this test, small electrodes are placed on specific points along the hand and wrist. A mild electrical impulse is then applied to the median nerve, and the speed and strength of the nerve signals are measured. This test helps determine if there is a delay or blockage in the conduction of nerve signals through the carpal tunnel. It can provide valuable information about the extent of nerve compression and assist in confirming the diagnosis of carpal tunnel syndrome. Nerve conduction tests are especially useful when the clinical presentation is atypical or when surgical intervention is being considered. They can help guide treatment decisions and provide baseline measurements for comparison during follow-up assessments.

Treatment Options For Carpal Tunnel Syndrome

There exists no consensus on the best primary care management for mild or moderate carpal tunnel syndrome.

  1. Non-Surgical Treatments:
    • Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to reduce pain and inflammation associated with carpal tunnel syndrome.
    • Splinting: Wearing a wrist splint or brace, particularly at night, helps keep the wrist in a neutral position and reduces pressure on the median nerve.
    • Ergonomic Modifications: Making ergonomic changes to the work environment, such as adjusting the height and position of the keyboard or using ergonomic tools, can alleviate symptoms and prevent further aggravation of the condition.
    • Activity Modification: Modifying or avoiding activities that exacerbate symptoms, such as repetitive hand movements or prolonged wrist flexion/extension, can help reduce pressure on the median nerve.
  2. Corticosteroid Injections:
    • Corticosteroid injections are a common treatment option for carpal tunnel syndrome. They involve the injection of a corticosteroid medication into the carpal tunnel to reduce inflammation and alleviate symptoms. This treatment provides temporary relief and can be particularly beneficial for individuals with acute or severe symptoms.
  3. Physical Therapy:
    • Physical therapy can be prescribed to individuals with carpal tunnel syndrome to improve symptoms and restore hand function. Therapeutic exercises focus on stretching and strengthening the muscles of the wrist and hand, as well as improving overall flexibility and range of motion.
  4. Occupational Therapy:
    • Occupational therapy may be recommended to teach individuals proper ergonomics and techniques for reducing stress on the wrist and hand during daily activities. Occupational therapists can also provide advice on adaptive devices and techniques to assist with tasks and minimize symptom aggravation.
  5. Surgical Intervention:
    • When non-surgical treatments fail to provide sufficient relief, or if there is evidence of nerve damage, surgical intervention may be necessary. Carpal tunnel release surgery involves cutting the transverse carpal ligament to enlarge the carpal tunnel, relieving pressure on the median nerve. It can be performed traditionally as an open surgery or endoscopically with smaller incisions. Surgery is typically effective in relieving symptoms and restoring hand function, although a period of rehabilitation and recovery is necessary.

The choice of treatment for carpal tunnel syndrome depends on the severity of symptoms, individual circumstances, and the preferences of the patient.

Steroid Injections For Carpal Tunnel Syndrome

Corticosteroid injection is a well-studied and effective intervention for patients with mild and moderate CTS. It is a straightforward procedure with minimum side effects that can result in remarkable improvement of symptoms and functional status even within the first week after injection. The Ultrasound guidance might improve the accuracy and the effectiveness of steroid injection in CTS.

In The Lancet, Linda S Chesterton and colleagues report the results of a randomised trial done in 25 UK primary care centres, which compared a single steroid injection (20 mg methylprednisolone acetate) with 6 weeks’ night splinting in patients with mild or moderate carpal tunnel syndrome. Among the 212 patients who completed the questionnaire, the overall Boston Carpal Tunnel Questionnaire score (combined symptom severity and functional status scores, 1–5 scale) at 6 weeks was significantly better in the injection group than in the night splint group by an adjusted mean difference of −0·32 (95% CI −0·48 to −0·16), corresponding to an effect size of 0·41. At 6 weeks, the mean symptom severity score improvement was 0·84 in the injection and 0·48 in the splint group. Between-group differences did not persist at 6 months. It is important to highlight the participants’ characteristics: 199 (85%) had a first-time carpal tunnel syndrome diagnosis and all had symptoms for at least 6 weeks.

Many approaches to carpal tunnel injection have been studied by several authors. Formerly, one of the most widely used techniques was the midline longitudinal US-guided injection. This method had some disadvantages; especially, when we aim to perform perineural injection, sometimes called hydro-dissection. Previous research advocated that a short-axis or transverse scan is superior to a long-axis scan considering that the US image in a longitudinal scan might confuse operators between swollen nerve fascicles, muscles, and inflamed tendons in the same plane; hence, raising concerns regarding the incidence of nerve trauma due to injections in the long-axis (longitudinal) scan.

Smith et al developed the in-plane ulnar approach for the administration of US-guided carpal tunnel injection. Several studies showed that US-guided local steroid injection using an in-plane ulnar approach in the CTS might be more effective than out-of-plane injections. Nonetheless, other injection approaches had not been evaluated in the prior studies. The primary purpose of this study was to compare the efficacy and safety of the in-plane radial versus the more common ulnar in-plane approach in US-guided carpal tunnel injection.

Surgical Treatment For Carpal Tunnel Syndrome

Surgical treatment for carpal tunnel syndrome should be considered for individuals who have moderate to severe symptoms that significantly impact their daily activities and have not responded well to conservative treatments such as splinting, medications, injections and physical therapy.

Surgical intervention, known as carpal tunnel release (CTR), may be recommended to relieve the compression of the median nerve in the wrist.

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Dr Murli Krishna

Consultant Pain Medicine