Richard A. Bernstein, MD
Carpal tunnel syndrome is an extremely common disorder affecting the hand, present in approximately 1 in 100 people. It is a condition characterized by numbness and tingling in the fingers. Pain can extend to the elbow, shoulder or neck and can occur any time, either in the day or night. People oftentimes complain of awakening from their sleep and oftentimes shake their hands to try to restore sensibility. Symptoms often occur during the day when one talks on the telephone, holds a book or newspaper. Many people awaken in the morning with their hands numb and tingling and it will take some time before the symptoms diminish.
To understand carpal tunnel syndrome, one needs to learn about the basic structures occurring at the wrist and hand level. The basic supporting structures are the bones of the wrist, which include the forearm bones, the wrist bones, medically known as the carpal bones, and the bones of the hand. The flexor tendons are the structures that extend from the muscles to the fingers like the strings of a marionette. They allow us to perform the multiple activities during the day. There are three main nerves to the hand to control the muscles and tendons known as motor nerves and it gives us the ability to feel, which the sensory nerves are. The nerve involved with carpal tunnel is known as the median nerve which generally gives sensation of the thumb, index, long and ring fingers. There is also a small branch of the nerve that goes the muscles base of the thumb.
The median nerve involved with carpal tunnel syndrome runs with the tendons in the area appropriately called the carpal tunnel. The bones of the wrist cover this tunnel on three sides and on the palm side, there is a thick ligament called the transverse carpal ligament that forms the roof of the tunnel. It is within this tunnel that pressure builds up that can cause the classic symptoms of numbness and tingling.
Idiopathic: Many cases of carpal tunnel have no known cause and are thought to be anatomic abnormalities that make an individual at risk.
Overuse: There is some information to suggest that overuse of the fingers or wrist or certain positions, for extended periods of time, can contribute to pressure on the nerve.
Injuries: An injury to the wrist involving bleeding, such as with a fracture, can cause increased pressure within the tunnel leading to symptoms either early or late in the course after a fracture or dislocation.
Medical Conditions: Pregnancy, diabetes and thyroid problems are all known causes of carpal tunnel syndrome.
In many cases the long-term consequences of numbness and tingling can be prevented through simple modifications. Altering the way one does certain activities, whether be at work, home or at recreation, can significantly improve and sometimes eliminate the symptoms of numbness and tingling.
Oftentimes wearing a proper splint, time or over the counter medications can significantly help.
Prescription medication known as anti-inflammatories can oftentimes help relieve the swelling. An injection of Cortisone can be helpful either temporarily or permanently to improve and eliminate the symptoms associated with this condition. Sometimes, physical therapy can be helpful.
Scientific studies have not today shown any predictable benefit from vitamins, though there have been anecdotal reports that vitamin B6 is helpful, though studies are not conclusive.
An early, thorough approach is very beneficial to diagnose, treat and prevent ongoing symptoms of carpal tunnel syndrome; one is history. It is very important to obtain a thorough history of other medical conditions, injuries and the characteristics of the condition. It is helpful to write down certain information that you can pass on to the doctor at the time of the examination.
A thorough examination of the area is very helpful to either rule in or rule out the diagnosis. Most patients do not have textbook-like symptoms and it is important for you and me to look at the characteristics and the physical examination findings.
Three commonly used maneuvers are a Tinel's test, tap over the nerve,
the second is the Phalen's maneuver, which is performed by flexing the wrist and seeing if this causes characteristic numbness, and the third is termed a forearm compression test where wrist pressure is placed over the nerve to determine the distribution of tingling.
Copyright © 2010, TOG All rights reserved.
Richard A. Bernstein, MD
When conservative measures fail, surgery is also an option for a carpal tunnel syndrome with success rates in the 85% to 95% range. Surgery is done on an outpatient basis under a local anesthetic. I do it with the anesthesiologist present, who can let you be as awake as you want or you could also be somewhat sleepy. In most cases, the surgery takes under 10 minutes and it involves a small incision in the middle of the palm to release the ligament over the nerve. After surgery, you will be in a bulky dressing for two days after surgery. Then, you will see the therapist who will remove the dressing, place a lighter dressing, and begin an exercise program. Approximately one week after the surgery, you will see me for suture removal. At that time, you can let the incision get wet and begin wrist exercises.
Most of the surgery I do is performed on an outpatient basis. I operate at Saint Raphael's Hospital, Temple Surgical Center, Shoreline Surgery Center, Milford Hospital and Yale. My secretary organizes my surgical schedule and will find the location that works best for the surgery. I feel equally comfortable at all facilities. If you have any questions, please talk to me or my staff.
To assure your understanding, I recommend a preoperative appointment to discuss the surgery, risks and benefits and answer any questions. You will also see me the day of surgery. If any questions come up, we will answer them then. Though the surgery is quite safe, there are some inherent risks. Please see the surgery section. These risks include the risk of anesthesia, infection, nerve, vessel, or tendon injury, stiffness, and pain. Usually, surgery goes very well and the success rate is high but unfortunately, the results of surgery cannot be guaranteed.
For five to seven days before surgery, you should stop taking Aspirin or antiinflammatories such as Advil, Aleve, or Motrin unless recommended otherwise by your primary care doctor or cardiologist. These medications can prolong your bleeding and can lead to complications. If it is medically safe, you should avoid these medications, Tylenol (Acetaminophen) is usually okay. Unfortunately, the surgical facilities do not tell me until the day before what time your surgery will be. Though you can request the specific time for surgery, unfortunately, this is usually outside of our control. The facility will call you the day before surgery, tell you where and when to come and will give the details.
Surgery: As with any surgical procedure, you should not have to eat or drink after midnight the night before; this includes coffee, orange juice or even water in the morning. For most surgeries, daily medications prescribed by your regular physician can be taken with a sip of water, but please discuss this with me and my staff if you have any questions.
Most patients will receive an intravenous dosage of an antibiotic at the time of surgery; this does keep the risk of infection under 1%. These procedures are considered "clean" procedures and if you have artificial joints or heart valves, the antibiotic given at surgery will generally suffice, unless the surgeon who implanted your device has told you otherwise, please let us know.
The day of surgery, you will have a very large bulky dressing that looks like a boxing glove. Please wear a loose-fitting garment since the dressing is big, to help control swelling. In most cases, the therapist will remove it in two days, and you will be placed in a smaller dressing to. For a complex surgery, the dressing may stay on up to 10 days, but this will be clearly noted in your postoperative appointment cards. When you leave surgery, you will have a packet that includes a prescription for pain medication, two appointment cards; one to see the therapist for the dressing and the second to see me for your postoperative check. You will also be given a series of instruction sheets that is also included in this website, postoperative instructions.
Two days after surgery, I encourage you to return as quickly as you can to normal activities using your fingers and a week later, the wrist. Most people ask "how long does it take to recuperate after the surgery?" There is no hard and fast answer. As I mentioned, two days after the surgery, you should begin moving your fingers and a week later, your wrist. I encourage you to return to normal activities as quickly as you can, progressively use the hand more and more every day. Driving is fine once you feel you have control of the car and you are off narcotic medications. Keyboarding is fine as soon as you start to get comfortable; heavy lifting usually takes three to four weeks.
The surgery is successful in most cases. There are risks included, but are not limited to the risk of anesthesia, infection, nerve, vessel, or tendon injury, recurrent scar tissue, pain, reflex sympathetic dystrophy, (abnormal pain output); these complications occur less than 5% of the time.
Copyright © 2010, TOG All rights reserved.
By Laura Adair MS, PT, CHT
Does your hand hurt? Have you noticed strange sensations, discomfort, and weakness occurring more often? Do you find yourself rubbing or shaking your hands to get them to feel normal? Most people have experienced pain, numbness or weakness in their hands at one time or another. As we grow older these symptoms can become more persistent and interfere with our daily lives. Since the symptoms often develop gradually many people are not sure when to seek medical advice. Many people are afraid that there is no solution for their pain except surgery and therefore avoid seeing a doctor . Fortunately, surgery is not the only treatment and many patients can relieve their symptoms with non-surgical intervention. This article will explain two of the more common diagnoses of hand pain and possible solutions for each.
Do you have numbness or tingling in your hand? Does it wake you up at night or do you wake in the morning with the hand feeling numb and you have to shake it in order to “wake it up?” Do you have pain or numbness with daily activities such as driving, buttoning or blow drying your hair? Does your hand feel weak or do you occasion- ally get sharp pains into your palm or up your arm? These are all common complaints of patients with Carpal Tunnel Syndrome (CTS).
The carpal tunnel is the area at the base of your hand and is formed by the carpal (wrist) bones at the base and a thick sheath of connective tissue (ligament) over the top. The median nerve and nine different tendons that control your fingers travel through this tunnel. Carpal Tunnel Syndrome occurs when the median nerve and tendons become compressed or squeezed at the tunnel. CTS is usually caused by a combination of factors. Age, heredity, hormonal changes, diabetes, thyroid conditions, trauma, and hand use can all contribute to the development of CTS.
Early diagnosis and treatment of CTS can help prevent permanent damage to the median nerve and can often avert surgical intervention. The doctor will perform a thorough examination of the neck, arm and wrist in order to eliminate other sources of pain. The doctor may per- form special tests to provoke the tingling or numbness in order to help localize the origin of the symptoms to the wrist. Often an x-ray is taken to assure no bony problems are present. Sometimes, it is necessary to have a neurologist evaluate and perform electrodiagnostic tests such as nerve velocity conduction test (NCV) or electromyography (EMG). These tests help clarify the level of severity of nerve compression or damage.
Just as early diagnosis is important, so is early treatment. Non-surgical treatments are often successful in controlling symptoms in the early stages of CTS. Wearing splints at night, a short course of anti-inflammatory medication(aspirin, ibuprofen, etc), activity modification and therapy can often alleviate early symptoms. The doctor may recommend a corticosteroid injection to help de- crease the inflammation in the carpal tunnel. If all these treatments fail to relieve your symptoms or if the doctor feels there is a risk of perm anent damage to the nerve and tendons, surgery may be necessary. Surgery is generally done on an outpatient basis and consists of a small incision at the wrist allowing the surgeon to release the ligament at the top of the tunnel. This relieves the pressure in the tunnel resolving the symptoms in the vast majority of patients within a couple of months.
But what if your wrist and thumb are sore but you don’t have the numbness and tingling? Have you developed aching or sharp pain at the base of your thumb over the years? Do your symptoms increase with activities such as knitting, opening jars, using tools, using a computer mouse, or turning a key in the lock? Does your hand feel weak or achy after use? Do you have increased pain when you rub where the thumb meets the wrist? These are complaints common to arthritis at the thumb carpometacarpal (CMC) joint.
CMC arthritis is basically a “wear and tear” arthritis that affects women more than men and usually starts after the age of 40. It is the most common form of arthritis in the hand. CMC arthritis is usually a result of aging, hormonal changes, injury or the stress of daily use of the hand.
As with CTS, early diagnosis and treatment can prevent/ delay progression of CMC arthritis. The doctor will perform a thorough examination of your hand to rule out other conditions (like CTS). This exam may include palpating the joint and compressing the joint. X-rays are important to assess the amount of joint damage that has occurred. This, along with the patient’s symptoms will help the doctor determine th e level of appropriate treatment.
Initial treatment usually consists of protective splinting either with a premade splint or one that is fabricated by a therapist. It is critical to have the thumb immobilized along with the wrist in order to rest the CMC joint. Anti -inflammatory medication, rest and activity modification are also important initial treatments to help decrease CMC arthritis symptoms. Some doctors may recommend hand therapy to help treat the initial symptoms. If these measures are not effective, or the evaluation indicates further intervention the doctor may recommend an injection. A corticosteroid injection is often quite effective in providing significant relief of pain for an extended period of time. While the injection may provide relief, splinting and activity modification re- main important to help delay further damage to the joint.
In a small percentage of patients symptoms may persist, reoccur and/or interfere with daily function to the point that surgery is the only solution. A referral to a surgical hand specialist is very important. Surgeries usually consist of removing the damaged joint and rebuilding the joint with other tendons from the wrist and hand. The surgery is performed on an outpatient basis and usually requires complete immobilization in a cast for 4 to 6 weeks followed by hand therapy for splinting and progressive exercises for several weeks after the cast is removed. The majority of patients who undergo surgery and rehabilitation have excellent pain relief and in- creased functional use of the hand.
These are just two of the many reasons your hands may hurt. It is important to seek appropriate medical advice to determine what is causing your pain. One of the most critical factors in avoiding surgery is to diagnose and treat the problem in its early stages. Hopefully, this information has reassured you that there are often conservative, non-surgical treatment s that can provide significant relief of pain and increased function. Your hands are too important to ignore!