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Carpal Tunnel Syndrome
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Myths About Carpal Tunnel Syndrome:
- It is frequently caused by one's work/job overuse.
- It frequently recurs after surgery.
- It will go away if one changes their occupation.
- It responds to "carpal tunnel exercises, vitamins, magnets, massage, and splinting."
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You are at this site to gain a better understanding of just what
carpal tunnel syndrome (CTS) is. You are also inquisitive, seeking the true
facts about
solving carpal tunnel syndrome, as well as possible prevention. This site was developed in response to the overwhelming need to enlighten people due to the amount of
nonfactual nonsense confusing the issue, but so readily available; "cumulative trauma disorder/repetitive strain injury (RSI)," quack treatment with vitamins and exercise, magnets, copper bands, crystals, food supplements, bogus medications (carpal tunnel Qwell and Carpal Tunnel Cream), etc. This website is heavily referenced with an annotated bibliography to substantiate the
facts herein presented.
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Myths About Endoscopic Carpal Tunnel Release:
- Less effective than open filet-of-wrist carpal tunnel release
- Higher recurrence rate than open carpal tunnel release
- Cannot be used for recurrent carpal tunnel syndrome
- Many patients' carpal tunnel syndrome is "too bad" for this technique to be utilized.
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Most Likely Patient
The most likely person to develop carpal tunnel syndrome is a woman over the age of 30 with a family history of hand pain or numbness. Diabetes, obesity and arthritis involving the neck (cervical spine) and/or the base of the neck are additional risk factors.
History of Carpal Tunnel Syndrome
CTS as a diagnosis became possible in 1946 after the landmark publication by Brain & Associates (Bibliography, History/ Reference 1) in England.
They reported six patients with numbness and/or pain in each of their hands due to pressure on the median nerve at the carpal tunnel level of the wrist and the immediate response to surgery. This debunked the widely held and unproven diagnosis of "thoracic outlet syndrome" (TOS) as a cause of these symptoms. (Bibliography, History/Reference 4)
Up to that time, patients with varying presentation such as pain or thumb muscle (thenar) wasting, hand pain, and numbness in various parts of the hand were identified in the literature with no known definite cause or reliable treatment (Bibliography, History/Reference 4)
Carpal Tunnel Symptoms
Nighttime pain or numbness in your hands results in loss of sleep, with the dominant hand being slightly more involved than the nondominant hand, occurring in about 7 out of 10 patients with carpal tunnel syndrome. Ultimately, both hands are typically affected - not necessarily simultaneously. This problem can be seen most often in people over the age of 30 (9 out of 10), but has been reported in children as young as two years of age. In my personal experience, my youngest patient presented at four years of age. Numbness and tingling in the thumb, index, and long fingers plus the thumb side of the ring finger; i.e. split down the middle - see diagram - (this tends to be noticed only in the most alert and sensitive people), with or without clumsiness.
In many patients, a feeling of swelling of their hand particularly in the mornings is noted. Some loss of dexterity with declining penmanship (writing intolerance and poor writing quality) as well as difficulty with handling small objects such as a needle or buttons are quite common. Women specifically will tend to complain of the difficulty with personal grooming and may burn themselves with loss of control of their curling iron, and they may complain of difficulty pulling up their nylons or fastening their bras or clasping their earrings. They often complain of a fear of dropping their infant and in older women, fear of dropping their grandchildren. Men are more likely to complain of having tools fly out of their hands.
Weakness is perceived by many, but measured weakness with use of a dynamometer or pinch strength weakness measured with a pinch meter actually only occur rarely due to carpal tunnel syndrome. This is because the median nerve at the level of the carpal tunnel at the wrist does not innervate much muscle.
It is mostly just the sensory nerve. Measurable weakness of grip and pinch is usually a sign of ulnar nerve dysfunction or some other very significant nerve disorder. It is these distinctions that make nerve conduction studies (NCS) very important and necessary in evaluation and treatment of patients so presenting.
Cubital Tunnel Syndrome
Symptoms resulting from ulnar nerve entrapment at the elbow are termed cubital tunnel syndrome.
This involves easy fatigability of the hand and forearm, numbness in 2/5 of the hand (on the top and palmar side of the hand plus the small finger and the small finger side of the ring finger), clumsiness, weakness, and inner elbow pain. Less common, pain or numbness will radiate as high as the shoulder or neck, and sometimes even up into the jaw, leading some of the patients to present for an emergency evaluation to rule out a heart attack (myocardial infarct). Cubital tunnel syndrome rarely occurs in isolation; i.e. over 90% have been treated for or have ongoing carpal tunnel syndrome concomitantly. One out of five patients who present with carpal tunnel syndrome have at the same time or developed cubital tunnel syndrome, thus for good results and treatment of either, it is important to do a thorough physical examination and equally important to be able to properly apply and interpret nerve conduction studies (see NCS).
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Memo: Doc - please provide photos of person wearing an elbow splint versus sleeping with their arms in the improper posture |
Cause: Prolonged elbow flexion, most due to poor posturing of your hands, placing them by your face while asleep. Sleeping prone essentially mandates this posture. In four or more studies on the cause and treatment of cubital tunnel syndrome, elbow flexed posturing has been implicated and its intervention has been proven to be the sole nonoperative means of treatment for this problem. Up to 7 out of 10 patients will get relief treated nonoperatively if they cooperate with the use of an elbow splint to hold the elbow straight at night.
The effects of the use of the splint; i.e. monitoring for improvement in nerve function or actually worsening of it can be monitored with use of a pressure-specified sensory device (PSSD).
In my experience, patients with cubital tunnel syndrome are generally demonstrating more pervasive peripheral nerve disorder resulting in more sensitive peripheral nerves. These patients are more likely to have problems with numbness, tingling, or burning in their feet from entrapment of the tibial nerves at the ankles (tarsal tunnel syndrome). The presence of ulnar nerve entrapment at the cubital tunnel is the predominant cause of supposed failed or recurrent carpal tunnel syndrome. In fact, properly performed carpal tunnel release whether performed open (filet-of-wrist, see photo) or the more modern endoscopic technique (minimally invasive) has about a 1 in 200 chance of recurring (Bibliography, Failed CTR/Recurrent CTS/References 1 through 11)
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Memo: Doc - please provide Silver
reference |
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Memo: Doc - please provide actual references here that have to do with recurrence |
Notably, a patient complaining of her
entire hand going numb frequently but not always has median nerve entrapment at the wrist, as well as ulnar nerve entrapment at the cubital tunnel. However, frequently the median nerve is entrapped at the wrist and simultaneously the ulnar nerve may be entrapped at the ulnar tunnel of the wrist (ulnar tunnel syndrome/Guyon canal syndrome). Fortunately, both nerves are decompressed at the wrist level with a single operation; i.e. carpal tunnel release (Silver reference).
Thus, the remaining symptoms after carpal tunnel release are usually from undiagnosed and/or untreated cubital tunnel syndrome.
New-onset ulnar symptoms after carpal tunnel release: It is not infrequent to have a patient complaining of first noting some numbness or tingling or burning in the small and ring fingers and that side of the hand after carpal surgery. Usually the person can be forewarned to expect this if they are carefully examined including thorough nerve conduction studies preoperatively. People tend to focus on what they are noticing the most; i.e. who is talking the loudest, the squeaky hinge, etc. thus, they tend to be very aware of the symptoms from the carpal tunnel which relate more to the "eyes" of the hand - the thumb, index, and long fingers for dexterity and only after those symptoms are eliminated with carpal tunnel release will they then become aware of the less noticeable decreased sensibility in the ulnar side of the hand. Aside from the sensory symptoms in the fingers in the ulnar side of the hand, clumsiness, aching in the hand or forearm, and sometimes even the aching or numbness radiating up to the shoulder and neck in addition to awakening at night due to your hands may be experienced with either median nerve entrapment or ulnar nerve entrapment.
Results of Endoscopic Carpal Tunnel Release
Comprehensive review of the literature from 1989 through 1997 by Jimenez (Bibliography, Treatment: ECTR/Reference 4) concluded that there was a 97% successful outcome after ECTR with a very low complication rate. My experience with thousands of patients corroborates this. These good outcomes, however, are dependent upon diagnosis and treatment being provided before the nerve has irreversible damage. Procrastination in acquiring treatment and prolonged use of placebos such as use of wrist splints, vitamins, magnets, copper bands, etc., instead of surgery in a person with ongoing symptoms are more likely to lead to a poor outcome. Treatment should always be provided before the development of continuous numbness, continuous burning, or continuous tingling of a nerve. When a person is treated at this point, it takes much longer for them to get relief of symptoms (except for the sleep disturbance which frequently is still eliminated right away) and the response to treatment is less predictable; i.e. a person may not get complete recovery.
History of Endoscopic Carpal Tunnel Release
Endoscopic carpal tunnel release (ECTR) evolved as the ongoing attempts of physicians interested in carpal tunnel syndrome attempted to come up with a definitive solution to a nagging problem that has almost an exclusively surgical endpoint. Traditional open carpal tunnel release (filet-of-wrist) regardless of the size of the incision has tended to keep people off their job or in a diminished capacity to utilize their hand for between 6 and 12 weeks minimum. Open carpal tunnel release has been associated with many cases of sympathetic dystrophy or chronic regional pain syndrome (CRPS), unappealing visible scar, wound separation (dehiscence), pain from damage to the palmar cutaneous nerve, and recurrence (about 1%). The cost both directly to the person who is off work; i.e. temporary disability and to their employer has been substantial and continues to be the main source of cost in the treatment of carpal tunnel syndrome nationally.
On a national basis in the United States, the majority of upper extremity claims for worker's compensation benefits have come from carpal tunnel syndrome frequently misdiagnosed as "tendinitis".
Industrial clinics that can't offer a correct diagnosis or definitive treatment are notorious for this. This is often perpetuated by inappropriate shunting of patients to non-hand specialists for prolonged pseudo therapy in the hope that complaints will go away and possibly in hope that the person will jump ship and find another occupation. This has been a particular problem in the meat packing industry, where there is a tendency to have "in-house" treatment with physical therapists, nurse practitioners, and a medical director who is a family doctor displaced from front line treatment and unable to offer a surgical cure.
It was only in 1981 that pressure was proven to be the underlying cause of carpal tunnel syndrome by Gelberman et al at UC San Diego. This created a bit of controversy. This study in various forms was repeated internationally and reported by researchers confirming the elevated pressure in the carpal tunnels of patients with carpal tunnel syndrome compared with the pressures in normals of almost zero.
It was determined that nerve damage from entrapment resulted from pressure on nerves with a destructive effect on the myelin sheath of the nerve; i.e. demyelinization occurs in response to pressure over time. Greater pressure results in an abnormality faster and lesser pressure takes longer to affect the nerve. At the same time, the question continued as to what could be done to minimize the pressure in the carpal tunnel or the development of the elevated pressure; i.e. what was causing the elevated pressure in the first place.
In 1986, Dr. Ikira Okutsu (Bibliography, Treatment: ECTR/Re