Jump to content

Carpal tunnel syndrome: Difference between revisions

From Wikipedia, the free encyclopedia
Browse history interactively
← Previous editNext edit →
Content deleted Content added
VisualWikitext
m Reverted addition of dubious unsourced content (HG)
Line 103: Line 103:


==Frequency==
==Frequency==
Carpal tunnel syndrome affects everyone in the world, not just here in the United States. Within the U.S., an approximation of 50 out of 1000 people within the general public will suffer from the effects of carpal tunnel syndrome. With more and more technological gadgetry being released, it would not be surprising to see a sharp increase in that number within the next few years. On an international level, CTS is reported, but nothing too different in comparison to the U.S. results. Whites are of the highest risk of being diagnosed with CTS than other races such as Non-White South Africans. <ref name="N_Ashworth">{{cite journal|last=Ashworth-Nigel|title=Carpal Tunnel Syndrome|updated=December 4 2008|url=http://emedicine.medscape.com/article/327330-overview}}</ref> Surprisingly, women suffer more from CTS than men with a ratio of 3:1 in between the ages of 45-60 years of age. Considering that more and more children are beginning to use the computer a lot more for learning, only 10% of reported cases of CTS are younger 30 years of age. <ref name="N_Ashworth">{{cite journal|last=Ashworth-Nigel|title=Carpal Tunnel Syndrome|updated=December 4 2008|url=http://emedicine.medscape.com/article/327330-overview}}</ref>
Carpal tunnel syndrome affects everyone in the world, not just here(?) in the United States. Within the U.S., an approximation of 50 out of 1000 people within the general public will suffer from the effects of carpal tunnel syndrome. With more and more technological gadgetry being released, it would not be surprising to see a sharp increase in that number within the next few years. On an international level, CTS is reported, but nothing too different in comparison to the U.S. results. Whites are of the highest risk of being diagnosed with CTS than other races such as Non-White South Africans. <ref name="N_Ashworth">{{cite journal|last=Ashworth-Nigel|title=Carpal Tunnel Syndrome|updated=December 4 2008|url=http://emedicine.medscape.com/article/327330-overview}}</ref> Surprisingly, women suffer more from CTS than men with a ratio of 3:1 in between the ages of 45-60 years of age. Considering that more and more children are beginning to use the computer a lot more for learning, only 10% of reported cases of CTS are younger 30 years of age. <ref name="N_Ashworth">{{cite journal|last=Ashworth-Nigel|title=Carpal Tunnel Syndrome|updated=December 4 2008|url=http://emedicine.medscape.com/article/327330-overview}}</ref>


Being diagnosed with CTS is not a life-threatening condition, but it can hinder a person's life if it is left untreated.The median nerve can become severely damaged and result in total loss of movement within that hand.
Being diagnosed with CTS is not a life-threatening condition, but it can hinder a person's life if it is left untreated.The median nerve can become severely damaged and result in total loss of movement within that hand.


==Prevention==
==Prevention==

Revision as of 04:09, 1 June 2010

Carpal tunnel syndrome
SpecialtyNeurology, orthopedic surgery Edit this on Wikidata

Template:Two other uses

Carpal Tunnel Syndrome (CTS), is associated by symptoms and signs, which are caused by compression of the median nerve travelling through the carpal tunnel.[1] Carpal Tunnel Syndrome affects the hands since it is an upper limb neuropathy that results in motor and sensory disturbance of the median nerve.[2]

This condition affects individuals by causing pain, paresthesias, and sometimes weakness in the median nerve distribution. Pain, numbness and tingling sensations can occur from the arm and extend to the shoulder and neck area. Some useful treatments for CTS include use of night splints, corticosteroid injections and ultimately with surgery.

Most cases of Carpal Tunnel Syndrome have been found to be without a specific cause and certain individuals may be genetically predisposed to this condition.

History

The condition known as Carpal Tunnel Syndrome has had major appearances throughout the years but it was most commonly heard of in the years following World War II.[3] Individuals who had suffered from this condition have been depicted in surgical literature for the mid 1800’s.[3] In 1854, Sir James Paget was the first to report median nerve compression at the wrist in a distal radius fracture.[4] Following the early 1900’s there were various cases of median nerve compression underneath the transverse carpal ligament.[4] Carpal Tunnel Syndrome was most commonly noted in medical 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 of patients in the 1950s and 1960s.[5] Carpal Tunnel Syndrome, a disabling overuse injury to the hand is one of the most frequent work injuries reported by the medical profession [6]

Anatomy

Main article: Carpal tunnel

The carpal tunnel is an anatomical compartment located at the base of the wrist. Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. The nerve and the tendons provide function, feeling, and movement to some of the fingers. The finger and wrist flexor muscles including their tendons originate in the forearm at the medial epicondyle of the elbow joint and attach to the Metaphalangeal (MP), Proximal Interphalangeal (PIP), and Distal Interphalangeal bones of the fingers and thumb (BSI). The carpal tunnel is approximately as wide as the thumb and its boundary lies at the distal wrist skin crease and extends up the arm towards the elbow for approximately 3cm.[2]

The median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both. Simply flexing the wrist to 90 degrees will decrease the size of the canal.

Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the distribution of the median nerve distal to the transverse carpal ligament. There is a superficial sensory branch of the median nerve, which branches proximal to the TCL and travels superficial to it. This branch is therefore spared, and it innervates the palm towards the thumb.[7]

Symptoms

Carpal tunnel syndrome produces a series of symptoms from mild to extreme. These symptoms worsen over time and patients that have been diagnosed with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, particularly the index and middle fingers, which are affected by the median nerve. Individuals also experience pain in the hands or wrists and some report to have lost gripping strength. Pain also develops in the arm and shoulder and swelling of the hand, which increases at night.[8]

Numbness and paresthesias in the median nerve distribution are the neuropathic symptoms (NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar muscles may occur if the condition remains untreated.[9]

Causes

Most cases of CTS are of unknown causes, or idiopathic. Carpal Tunnel Syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can lead to CTS include obesity, hypothyroidism, arthritis, diabetes, and trauma.[10]

Other causes of this condition include intrinsic factors that exert pressure within the tunnel, and extrinsic factors (pressure exerted from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformation, and overuse factors.[11] It is unclear whether there is a close relationship between work and CTS or if it’s due to underlying medical problems.

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

The relationship between work and CTS is controversial; in many locations workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation.[12] In the USA Carpal tunnel syndrome results in an average of $30,000 in lifetime costs (medical bills and lost time from work).[13]

Some speculate that carpal tunnel syndrome is provoked by repetitive jacking and manipulating activities and that the exposure can be cumulative. It has also been stated that symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations,[14] but it is unclear if this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms.

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 postures were 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 that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. It has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. While addressing these factors has been found to improve comfort in some studies,[15] there is no evidence that they affect the natural history of carpal tunnel syndrome.

CTS is found mostly in the working adult population for this reason it is very likely to be associated with the workplace whether or not it is caused by the work itself. When a single muscle acts performs more than one task, for example twisting and flexing of the wrist muscles, the increased muscle load plays an important role in the development of musculoskeletal disorders. Despite the findings that the association between work and CTS is high, there is still a deficit of knowledge regarding the pattern and the causality of this relation. Extensive research needs to be conducted in order to establish the relationship between the ergonomics of work and work-related injuries including CTS [16]

Carpal tunnel syndrome associated with other diseases

A variety of patient factors can lead to CTS including heredity, size of the carpal tunnel, associated local and systematic diseases and certain habits contribute to its etiology[17] Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging.[18]

Examples include:

  • May be associated with excessive typing.
  • Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons.
  • With pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium.
  • During pregnancy women experience CTS due to hormonal changes and water retention which is 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, particularly with a combination of forceful and repetitive activities [19]
  • Acromegaly, a disorder of growth hormones, compresses the nerve by the abnormal growth of bones around the hand and wrist.
  • 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 who are classified as obese (BMI > 29) are 2.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS.[20]
  • Double crush syndrome is a debated hypothesis that compression or irritation of nerve branches contributing to the median nerve in the neck, or anywhere above the wrist, increases sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really exists.[21]
  • Heterozygous mutations in a gene, SH3TC2, associated with Charcot-Marie-Tooth, confer susceptibility to neuropathy, including the carpal tunnel syndrome.[22]

The common causes of carpal tunnel syndrome can be remembered using the mnemonic, MEDIAN TRAP for Myxoedema, Edema, Diabetes mellitus, Idiopathic, Acromegaly, Neoplasm, Trauma, Rheumatoid arthritis, Amyloidosis and Pregnancy.[23]

Diagnosis

The reference standard for the diagnosis of carpal tunnel syndrome is electrophysiological testing. Patients with intermittent numbness in the distribution of the median nerve along with positive Phalen's, Durkan's and eletrophysiological tests have at worst, a very mild case of carpal tunnel syndrome. A predominance of pain rather than numbness is unlikely to be due to carpal tunnel syndrome no matter the result of electrophysiological testing.

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 this position and awaiting symptoms.[24] A positive test is one that results in numbness in the median 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 as pain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion. Only this test has been shown to correlate with CTS severity when studied prospectively.[25]
  • Tinel's sign, a classic, though less specific test, is a way to detect irritated nerves. Tinel's is performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tingling or "pins and needles" in the nerve distribution.• Tinel’s sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive, but slightly more specific than Phalen’s sign.[26]
  • Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed.[27][28]

Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will sometimes be tested electrodiagnostically with nerve conduction studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. When the median nerve is compressed, as in CTS, it will conduct more slowly than normal and more slowly than other nerves. There are many electrodiagnostic tests used to make a diagnosis of CTS, but the most sensitive, specific and reliable test is the Combined Sensory Index (also known as Robinson index).[29]

Nerve conduction studies (NCS) are a sensitive measure of detecting compression of the median nerve. Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. Compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities [30]

The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear.[31][32][33]

Frequency

Carpal tunnel syndrome affects everyone in the world, not just here(?) in the United States. Within the U.S., an approximation of 50 out of 1000 people within the general public will suffer from the effects of carpal tunnel syndrome. With more and more technological gadgetry being released, it would not be surprising to see a sharp increase in that number within the next few years. On an international level, CTS is reported, but nothing too different in comparison to the U.S. results. Whites are of the highest risk of being diagnosed with CTS than other races such as Non-White South Africans. [34] Surprisingly, women suffer more from CTS than men with a ratio of 3:1 in between the ages of 45-60 years of age. Considering that more and more children are beginning to use the computer a lot more for learning, only 10% of reported cases of CTS are younger 30 years of age. [34]

Being diagnosed with CTS is not a life-threatening condition, but it can hinder a person's life if it is left untreated.The median nerve can become severely damaged and result in total loss of movement within that hand.

Prevention

A 2007 study conducted by Lozano-Calderon et al the Department of Orthopaedic Surgery at Massachusetts General Hospital states that carpal tunnel syndrome is primarily determined by genetics and structure.[35] Therefore, carpal tunnel syndrome is probably not preventable. [original research?] However, others[who?] think it is preventable by developing healthy habits like avoiding repetitive stress, practicing healthy work habits like using ergonomic equipment and taking proper breaks, and early passive treatment like taking turmeric (anti-inflammatory), omega-3 fatty acids, and B vitamins. Those who favor activity as a cause of carpal tunnel syndrome speculate that activity-limitation might limit the risk of developing carpal tunnel syndrome, but there is little or no data to support these concepts[35] and they stigmatize arm use in ways that risks increasing illness.[36][37] Having the preconception that using the arms will greatly increase the probability of obtaining CTS is nonsensical. It is hard to determine where an idiopathic condition originates from, especially with something as common as CTS.

Treatment

There have been numerous scientific papers evaluating treatment efficacy in CTS. It is important to distinguish treatments that are supported in the scientific literature from those that are advocated by any particular device manufacturer or any other party with a vested financial interest. Generally accepted treatments, as described below, may include splinting or bracing, steroid injection, activity modification, physical or occupational therapy (controversial), medications, and surgical release of the transverse carpal ligament.

Immobilizing braces

A rigid splint can keep the wrist straight.

A wrist splint helps limit numbness by limiting wrist flexion. Night splinting helps patients sleep. There is no evidence that wrist splinting is disease modifying.

The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but many people are unwilling to use braces. In 1993, The American Academy of Neurology recommend a non-invasive treatment for the CTS at the beginning (except for sensitive or motor deficit or grave report at EMG/ENG): a therapy using splints was indicated for light and moderate pathology.[38] Current recommendations generally don't suggest immobilizing braces, but instead activity modification and non-steroidal anti-inflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve.[39][40][41]

Many health professionals suggest that, for best results, one should wear braces at night and, if possible, during the activity primarily causing stress on the wrists.[42][43]

Active medical devices

Newer types of treatments are emerging which are both palliative and physiologically modifying. These are active medical devices. While braces or splints have been used palliatively, the newer designs attempt to influence the pathophysiology of carpal tunnel syndrome and attempt to reverse its causes.

The newest of these is the Carpal Therapist which is an electrically powered massaging device worn on the wrist and arm. The principle is that manipulative therapy, which is generally effective in alleviating symptoms of carpal tunnel syndrome, can be reproduced mechanically. Therefore, deep tissue massaging is produced by the device in a particular pattern in order to attenuate the tendons and to drain interstitial fluid from the inflamed carpal tunnel. This combined effect reduces the pressure inside the carpal tunnel and therefore alleviates the symptoms caused by median nerve compression.

Another active medical device is The Carpal Solution. It is composed of a series of adhesive tape strips, which, when applied in a certain orientation, reportedly initiates stretching and re-shaping of the wrist’s anatomy. The re-shaping produces less strain inside the carpal tunnel, and therefore relieves the pressure on the median nerve.

Yet another device called WristTrac is a brace with a built-in traction system. The hand is placed into the brace and a knob is used to manually increase tension (traction) on the wrist. This presumably results in stretching of the wrist tendons, which in turn attenuates them within the carpal tunnel. It is thought that this results in less inflammatory pressure and therefore reduced pain.

However none of these three devices have ever been discussed, reviewed or reported upon in a peer reviewed medical journal. Nor has any well respected or tangible paper or experiment described their efficacy or relationship to anatomy of the carpal tunnel. In short there is no study or paper that shows that these over the counter devices work. Indeed the natural history of carpal tunnel symptoms may be of exacerbations and remissions and often something may seem to work when in fact it has no real long term effect.

Localized steroid injections

Steroid injections can be quite effective for temporary relief from symptoms of CTS for a short time frame while a patient develops a longterm strategy that fits with his/her lifestyle.[44] In certain patients, an injection may also be of diagnostic value. This treatment is not appropriate for extended periods, however. In general, medical professionals only prescribe local steroid injections until other treatment options can be identified. For most patients, surgery is the only option that will provide permanent relief.[45]

Physiotherapy

There is little evidence to support the use of physiotherapy or occupational therapy techniques for carpal tunnel syndrome. They seem to be oriented primarily towards non-specific activity related pain rather than the numbness of carpal tunnel syndrome. The following comments regarding physical therapy seem to apply more to such chronic activity related pains than to verifiable idiopathic median nerve compression at the carpal tunnel.

Physiotherapy offers several ways to treat and control carpal tunnel syndrome. This procedure should be directed specifically towards the pattern of pain / symptoms and dysfunction assessed by the therapist. As such, it may include a range of modalities ranging from soft tissue massage, conservative stretches and exercises and techniques to directly mobilize the nerve tissue. It can also include the aforementioned immobilizing braces.

Clinically, sometimes a patient will present with a hand that is very inflamed and swollen with severe symptoms of pain, tingling and numbness and almost a fear of use because of the pain. In these cases a physiotherapist may focus on techniques to reduce the pain and inflammation, and exercises to encourage improved circulation. A comprehensive review of effectiveness of hand therapies in carpal tunnel management demonstrates that there is some valid scientific evidence for a range of therapeutic modalities.[46] For instance, Body Awareness Therapy such as the Feldenkrais method has positive effects in relation to fibromyalgia and chronic pain.[47] Structured exercise programs using these therapies to reduce wrist pain have been developed.

Occupational therapy

Occupational therapy offers ergonomic suggestions to prevent worsening of the symptoms. Occupational therapies facilitate hand function through remedial adaptive approaches.

Any forceful and repetitive use of the hands and wrists can cause upper extremity pain. More frequent rest can be useful if it can be orchestrated into one's schedule. It has been shown that taking multiple mini-breaks during the stressful activity is more effective than taking occasional long breaks.[citation needed] There are computer applications that aid users in taking breaks. All of these applications have recommended defaults, following the most effective average break configuration—a 30 sec. pause every 3 to 5 minutes (the more severe the pain, the more often one should take this break). There are also programs that automatically click the mouse. Before investing in these types of programs, it's best to consult with a doctor and research whether computer use is causing or contributing to the symptoms, as well as getting a formal diagnosis.

More pro-active ways to reduce stress on the wrists, which alleviates wrist pain and strain, involve adopting a more ergonomic work and life environment. Switching from a QWERTY computer keyboard layout to a more optimised ergonomic layout 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.[48][49]

It is also important that one's body be aligned properly with the keyboard. This is most easily accomplished by bending ones elbows to a 90 degree angle and making sure the keyboard is at the same height as the elbows. Also it is important not to put physical stress on the wrists by hanging the wrist on the edge of a desk, or exposing the wrists to strong vibrations (e.g. manual lawn mowing). Position the computer monitor directly in front of your seat, so the neck is not twisted to either side when viewing the screen.[citation needed]

Exercises that relax and strengthen the muscles of the upper back can reduce the risk of a double crush of the median nerve.

Massage is one of the most overlooked methods for treatment of the symptoms of CTS. The use of myofascial release and active stretch release can erase the pain, numbness, tingling and burning in minutes. Then following up with the stretches and exercises afore mentioned will lengthen the relief attained by these release techniques.

Medication

Using an over-the-counter anti-inflammatory such as aspirin, ibuprofen or naproxen can be effective as well for controlling symptoms. Pain relievers like paracetamol will only mask the pain, and only an anti-inflammatory will affect inflammation.[clarification needed] Non-steroidal anti-inflammatory medications theoretically can treat the swelling and thus the source of the problem. Oral steroids such as prednisone do the same, but are generally not used for this purpose because of significant side effects. Use of non-steroidal anti-inflammatory drugs may worsen asthma symptoms in some with a history of asthma, making the use of steroids such as prednisone the safer option for treating CTS. The most common complications associated with long-term use of anti-inflammatory medications are gastrointestinal irritation and bleeding. Also, some anti-inflammatory medications have been linked to heart complications. Use of anti-inflammatory medication for chronic, long-term pain should be done with doctor supervision.

A more aggressive pharmaceutical option is an injection of cortisone, to reduce swelling and nerve pressure within the carpal tunnel. Methylcobalamin (vitamin B12) has been helpful in some cases of CTS. [50]

Carpal tunnel release surgery

Scars from carpal tunnel release surgery. Two different techniques were used. The left scar is 6 weeks old, the right scar is 2 weeks old. Also note the muscular atrophy of the thenar eminence in the left hand, a common sign of advanced CTS

Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is recommended when there is static (constant, not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms.[51] In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment.[52]

Procedure

In carpal tunnel release surgery, the goal is to divide the transverse carpal ligament in two. This is a wide ligament that runs across the hand, from the scaphoid bone to the hamate bone and pisiform. It forms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the ring finger) it no longer presses down on the nerve inside, relieving the pressure.[53]

There are several carpal tunnel release surgery variations: each surgeon has differences of preference based on their personal beliefs and experience. All techniques have several things in common, involving brief outpatient procedures; palm or wrist incision(s); and cutting of the transverse carpal ligament.

The two major types of surgery are open carpal tunnel release and endoscopic carpal tunnel release. Most surgeons historically have performed the open procedure, widely considered to be the gold standard. However, since the 1990s, a growing number of surgeons now offer endoscopic carpal tunnel release.

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 the transverse carpal ligament.

Endoscopic techniques 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 carpal ligament. The endoscopic methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open method does.[citation needed]

Many studies have been done to determine whether perceived benefits of a limited endoscopic or arthroscopic release are significant. Brown et al. conducted a prospective, randomized, multi-center study and found no significant differences between the two groups with regard to secondary quantitative outcome measurements.[1] However, the open technique resulted in more tenderness of the scar than the endoscopic method. A prospective randomized study done in 2002 by Trumble revealed that good clinical outcomes and patient satisfaction are achieved more quickly with the endoscopic method. Single-portal endoscopic surgery is a safe and effective method of treating carpal tunnel syndrome. There was no significant difference in the rate of complications or the cost of surgery between the two groups. However, the open technique caused greater scar tenderness during the first three months after surgery, and a longer time before the patients could return to work. [2]

Some surgeons have suggested that in their own hands endoscopic carpal tunnel release has been associated with a higher incidence of median nerve injury, and for this reason it has been abandoned at several centers in the United States. At the 2007 meeting of the American Society for Surgery of the Hand, a former advocate of endoscopic carpal tunnel release, Thomas J. Fischer, MD, retracted his advocacy of the technique, based on his assessment that the benefit of the procedure (slightly faster recovery) did not outweigh the risk of injury to the median nerve. Despite these views, many other surgeons have embraced limited incision methods. It is considered to be the procedure of choice for many of these surgeons with respect to idiopathic carpal tunnel syndrome. Supporting this are the results of some of the previously mentioned series which cite no difference in the rate of complications for either method of surgery. Thus, there has been broad support for either surgical procedure using a variety of devices or incisions. The primary goal of any carpal tunnel release surgery is to divide the transverse carpal ligament and the distal aspect of the volar ante brachial fascia, thereby decompressing the median nerve. [3]

All of the surgical options (when performed without complication) typically have relatively rapid recovery profiles (weeks to a few months depending on the activity and technique), and all usually leave a cosmetically acceptable scar.

Efficacy

Surgery to correct carpal tunnel syndrome has a high success rate. Up to 90% of patients were able to return to their same jobs after surgery.[54][55][56] In general, endoscopic techniques are as effective as traditional open carpal surgeries,[57][58] though the faster recovery time typically noted in endoscopic procedures is felt by some to possibly be offset by higher complication rates.[59][60] Success is greatest in patients with the most typical symptoms. The most common cause of failure is incorrect 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 recurrence usually results from a misdiagnosis of another problem. Complications can occur, but serious ones are infrequent to rare.

Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic or plastic surgeon. Some neurosurgeons and general surgeons also perform the procedure.

Long term recovery

Most people who find relief of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage".[61] Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. irreversible numbness, muscle wasting and weakness.

While outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. One study showed that mental status parameters, alcohol use, yield much poorer overall results of treatment.[62]

Many mild carpal tunnel syndrome sufferers either change their hand use, pattern, or posture at work or find a conservative, non-surgical treatment that allows them to return to full activity without hand numbness or pain, and without sleep disruption. Some find relief by adjusting their repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods of performing the movements. Other people end up prioritizing their activities and possibly avoiding certain hand activities so that they can minimize pain and perform the essential tasks. Keyboard re-mapping software can help people whose condition is aggravated by one-handed key strokes involving a combination of the Control, Shift, or Alt keys and an alpha-numeric key. Programs such as Autohotkey allow a person to disable key combinations while they train themselves to use two hands to perform the offending key strokes.

Recurrence of carpal tunnel syndrome after successful surgery is rare.[63] If a person has hand pain after surgery, it is most likely not due to carpal tunnel syndrome. It may be the case that a person who has hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpal tunnel release has had no positive effect upon the patient's symptoms.

References

  1. ^ Scott KR. "Treatment of Carpal Tunnel Syndrome".
  2. ^ a b Walker JA. "Management of patient with carpal tunnel syndrome". Nursing Standard. 24 (19): 44–48.
  3. ^ a b {{cite book |author=Amadio PC |title=History of carpal tunnel syndrome |book=Carpal Tunnel Syndrome |pages=3-9 |year=2007 Cite error: The named reference "Amadio_2007" was defined multiple times with different content (see the help page).
  4. ^ a b Fuller DA. "Carpal Tunnel Syndrome".
  5. ^ Kao SY (2003). "Carpal tunnel syndrome as an occupational disease". The Journal of the American Board of Family Practice / American Board of Family Practice. 16 (6): 533–42. doi:10.3122/jabfm.16.6.533. PMID 14963080.
  6. ^ Hamill, J., Knutzen, K.M. (2009). Injury Potential of the Hand and Fingers. Biomechanical Basis of Human Movement (3rd Ed.), carpal tunnel syndrome (pp.171-173).
  7. ^ Norvell JG. "Carpal Tunnel Syndrome".
  8. ^ "National Institute of Neurological Disorders and Stroke".
  9. ^ "Neuropathic symptoms and musculoskeletal pain in carpal tunnel syndrome: Prognostic and therapeutic implications". Surgical Neurology. 2 (47): 115–17.
  10. ^ "Carpal Tunnel Syndrome". The New England Journal. 346 (23): 1807–12.
  11. ^ "Two rare causes of carpel tunnel syndrome". Irish Journal of Medical Science. 173 (1): 70.
  12. ^ Derebery J (2006). "Work-related carpal tunnel syndrome: the facts and the myths". Clin Occup Environ Med. 5 (2): 353–67, viii. PMID 16647653.
  13. ^ Office of Communications and Public Liaison (December 18, 2009). "National Institute of Neurological Disorders and Stroke".
  14. ^ Werner R (2006). "Evaluation of work-related carpal tunnel syndrome". J Occup Rehabil. 16 (2): 207–22. doi:10.1007/s10926-006-9026-3. PMID 16705490.
  15. ^ Cole D, Hogg-Johnson S, Manno M, Ibrahim S, Wells R, Ferrier S (2006). "Reducing musculoskeletal burden through ergonomic program implementation in a large newspaper". Int Arch Occup Environ Health. 80 (2): 98–108. doi:10.1007/s00420-006-0107-6. PMID 16736193.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ Fagarasanu, M., and Kumar, S. (2003). Carpal tunnel syndrome due to keyboarding and mouse tasks: a review. International Journal of Industrial Ergonomics, 31 (2) 119-136. doi:10.1016/S0169-8141(02)00180-4
  17. ^ Scott, K.R., Kothari, M.J. (2009, October 5). Treatment of Carpal Tunnel Syndrome. Retrieved January, 2010, from UpToDate website: http://www.uptodate.com/patients/content/topic.do?topicKey=~wx2xecoDuYz0gp&selectedTitle=1~107&source=search_result
  18. ^ Stevens JC, Beard CM, O'Fallon WM, Kurland LT (1992). "Conditions associated with carpal tunnel syndrome". Mayo Clin Proc. 67 (6): 541–548. PMID 1434881.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Katz, J.N., Simmons, B.P. (2002). Carpal Tunnel Syndrome. The New England Journal of Medicine, 346 (23) 1807-1812. Retrieved from: http://www.endo.gr/cgi/content/full/346/23/1807
  20. ^ Werner RA, Albers JW, Franzblau A, Armstrong TJ (1994). "The relationship between body mass index and the diagnosis of carpal tunnel syndrome". Muscle Nerve. 17 (6): 632–636. doi:10.1002/mus.880170610. PMID 8196706.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ^ Wilbourn AJ, Gilliatt RW (1997). "Double-crush syndrome: a critical analysis". Neurology. 49 (1): 21–27. PMID 9222165.
  22. ^ http://content.nejm.org/cgi/content/full/NEJMoa0908094
  23. ^ "Carpal tunnel syndrome: Causes". LifeHugger. Retrieved 2009-12-14.
  24. ^ Cush JJ, Lipsky PE (2004). Approach to articular and musculoskeletal disorders, In: Harrison's Principles of Internal Medicine (16th ed.). McGraw-Hill Professional. p. 2035. ISBN 0-07-140235-7.
  25. ^ Scott, K.R., Kothari, M.J. (2009, October 5). Treatment of Carpal Tunnel Syndrome. Retrieved January, 2010, from UpToDate website: http://www.uptodate.com/patients/content/topic.do?topicKey=~wx2xecoDuYz0gp&selectedTitle=1~107&source=search_result
  26. ^ Scott, K.R., Kothari, M.J. (2009, October 5). Treatment of Carpal Tunnel Syndrome. Retrieved January, 2010, from UpToDate website: http://www.uptodate.com/patients/content/topic.do?topicKey=~wx2xecoDuYz0gp&selectedTitle=1~107&source=search_result
  27. ^ González del Pino J, Delgado-Martínez AD, González González I, Lovic A (1997). "Value of the carpal compression test in the diagnosis of carpal tunnel syndrome". J Hand Surg [Br]. 22 (1): 38–41. PMID 9061521. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help)CS1 maint: multiple names: authors list (link)
  28. ^ Durkan JA (1991). "A new diagnostic test for carpal tunnel syndrome". J Bone Joint Surg [Am]. 73: 535–538. PMID 1796937. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help)
  29. ^ Robinson LR (2007). "Electrodiagnosis of Carpal Tunnel Syndrome". Phys Med Rehabil Clin N Am. 18 (4): 733–746. PMID 17967362.
  30. ^ Scott, K.R., Kothari, M.J. (2009, October 5). Treatment of Carpal Tunnel Syndrome. Retrieved January, 2010, from UpToDate website: http://www.uptodate.com/patients/content/topic.do?topicKey=~wx2xecoDuYz0gp&selectedTitle=1~107&source=search_result
  31. ^ Wilder-Smith E, Seet R, Lim E (2006). "Diagnosing carpal tunnel syndrome—clinical criteria and ancillary tests". Nat Clin Pract Neurol. 2 (7): 366–74. doi:10.1038/ncpneuro0216. PMID 16932587.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  32. ^ Bland J (2005). "Carpal tunnel syndrome". Curr Opin Neurol. 18 (5): 581–5. doi:10.1097/01.wco.0000173142.58068.5a. PMID 16155444.
  33. ^ Jarvik J, Yuen E, Kliot M (2004). "Diagnosis of carpal tunnel syndrome: electrodiagnostic and MR imaging evaluation". Neuroimaging Clin N Am. 14 (1): 93–102, viii. doi:10.1016/j.nic.2004.02.002. PMID 15177259.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  34. ^ a b Ashworth-Nigel. "Carpal Tunnel Syndrome". {{cite journal}}: Cite journal requires |journal= (help); Unknown parameter |updated= ignored (help)
  35. ^ a b Lozano-Calderón, Santiago (2008). "The Quality and Strength of Evidence for Etiology: Example of Carpal Tunnel Syndrome". J. Hand Surg. 33 (4): 525–538. doi:10.1016/j.jhsa.2008.01.004. ISSN 0363-5023. Retrieved 2009-07-29. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  36. ^ Scangas, George (2008). "Disparity Between Popular (Internet) and Scientific Illness Concepts of Carpal Tunnel Syndrome Causation". J. Hand Surg. 33 (7): 1076–1080. doi:10.1016/j.jhsa.2008.03.001. ISSN 0363-5023. Retrieved 2009-07-29. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  37. ^ Anthony, Shawn (2008). "Stigmatization of Repetitive Hand Use in Newspaper Reports of Hand Illness". HAND. 3 (1): 30–33. doi:10.1007/s11552-007-9052-4. Retrieved 2009-07-29. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  38. ^ American Academy of Neurology (2006). "Quality Standards Subcommittee: Practice parameter for carpal tunnel syndrome". Eura Medicophys. Neurology (43): 2406–2409. PMID 16557211.
  39. ^ American Academy of Orthopaedic Surgeons (1996). "Clinical Guideline on wrist pain. National Guideline clearinghouse". {{cite journal}}: Cite journal requires |journal= (help)
  40. ^ Katz JN, Simmons BP (2002). "Carpal tunnel syndrome". NEJM. 346: 1807–1812. doi:10.1056/NEJMcp013018. PMID 12050342.
  41. ^ Harris JS (1998). "ed. Occupational Medicine Practice Guidelines: evaluation and management of common health problems and functional recovery in workers". Beverly Farms, Mass.: OEM Press. ISBN 978-1-883595-26-5.
  42. ^ Premoselli S, Sioli P, Grossi A, Cerri C (2006). "Neutral wrist splinting in carpal tunnel syndrome: a 3- and 6-months clinical and neurophysiologic follow-up evaluation of night-only splint therapy". Eura Medicophys. PMID 16767058.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  43. ^ Michlovitz SL (2004). "Conservative interventions for carpal tunnel syndrome". J Orthop Sports Phys Ther. 34 (10): 589–600. PMID 15552705.
  44. ^ Marshall S, Tardif G, Ashworth N (2007). "Local corticosteroid injection for carpal tunnel syndrome". Cochrane database of systematic reviews (Online) (2): CD001554. doi:10.1002/14651858.CD001554.pub2. PMID 17443508.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  45. ^ Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, Li-Tsang CW, Wong LK, Boet R (2005). "A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome". Neurology. 64 (12): 2074–8. doi:10.1212/01.WNL.0000169017.79374.93. PMID 15985575.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  46. ^ Muller M, Tsui D, Schnurr R, Biddulph-Deisroth L, Hard J, MacDermid J (2004). "Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review". J Hand Ther. 17 (2): 210–28. doi:10.1197/j.jht.2004.02.009. PMID 15162107.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  47. ^ Gard G (2005). "Body awareness therapy for patients with fibromyalgia and chronic pain". Disabil Rehabil. 27 (12): 725–8. doi:10.1080/09638280400009071. PMID 16012065.
  48. ^ Lincoln A, Vernick J, Ogaitis S, Smith G, Mitchell C, Agnew J (2000). "Interventions for the primary prevention of work-related carpal tunnel syndrome". Am J Prev Med. 18 (4 Suppl): 37–50. doi:10.1016/S0749-3797(00)00140-9. PMID 10793280.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  49. ^ Verhagen AP, Karels CC, Bierma-Zeinstra SMA; et al. (2009). "WITHDRAWN: Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults". Cochrane Database Syst Rev (3): CD003471. doi:10.1002/14651858.CD003471.pub4. PMID 19588342. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  50. ^ Sato Y, Honda Y, Iwamoto J, Kanoko T, Satoh K (2005). "Amelioration by mecobalamin of subclinical carpal tunnel syndrome involving unaffected limbs in stroke patients". J Neurol Sci. 231 (1–2): 13–8. doi:10.1016/j.jns.2004.12.005. PMID 15792815.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  51. ^ Hui AC, Wong SM, Tang A, Mok V, Hung LK, Wong KS (2004). "Long-term outcome of carpal tunnel syndrome after conservative treatment". Int J Clin Pract. 58 (4): 337–9. doi:10.1111/j.1368-5031.2004.00028.x. PMID 15161116.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  52. ^ Kouyoumdjian JA, Morita MP, Molina AF, Zanetta DM, Sato AK, Rocha CE, Fasanella CC (2003). "Long-term outcomes of symptomatic electrodiagnosed carpal tunnel syndrome". Arq Neuropsiquiatr. 61 (2A): 194–8. PMID 12806496.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  53. ^ A patient's guide to endoscopic carpal tunnel release
  54. ^ Schmelzer RE, Della Rocca GJ, Caplin DA (2006). "Endoscopic carpal tunnel release: a review of 753 cases in 486 patients". Plast Reconstr Surg. 117 (1): 177–85. doi:10.1097/01.prs.0000194910.30455.16. PMID 16404264.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  55. ^ Quaglietta P, Corriero G (2005). "Endoscopic carpal tunnel release surgery: retrospective study of 390 consecutive cases". Acta Neurochir Suppl. 92: 41–5. doi:10.1007/3-211-27458-8_10. PMID 15830966.
  56. ^ Park SH, Cho BH, Ryu KS, Cho BM, Oh SM, Park DS (2004). "Surgical outcome of endoscopic carpal tunnel release in 100 patients with carpal tunnel syndrome". Minim Invasive Neurosurg. 47 (5): 261–5. doi:10.1055/s-2004-830075. PMID 15578337.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  57. ^ Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet HC, Bouter LM (2004). "Surgical treatment options for carpal tunnel syndrome". Cochrane Database Syst Rev (4): CD003905. doi:10.1002/14651858.CD003905.pub2. PMID 15495070.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  58. ^ McNally SA, Hales PF (2003). "Results of 1245 endoscopic carpal tunnel decompressions". Hand Surg. 8 (1): 111–6. doi:10.1142/S0218810403001480. PMID 12923945.
  59. ^ Thoma A, Veltri K, Haines T, Duku E (2004). "A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression". Plast Reconstr Surg. 114 (5): 1137–46. doi:10.1097/01.PRS.0000135850.37523.D0. PMID 15457025.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  60. ^ Chow JC, Hantes ME (2002). "Endoscopic carpal tunnel release: thirteen years' experience with the Chow technique". J Hand Surg [Am]. 27 (6): 1011–8. doi:10.1053/jhsu.2002.35884. PMID 12457351.
  61. ^ Olsen KM, Knudson DV (2001). "Change in strength and dexterity after open carpal tunnel release". Int J Sports Med. 22 (4): 301–3. doi:10.1055/s-2001-13815. PMID 11414675.
  62. ^ Katz JN, Losina E, Amick BC 3rd, Fossel AH, Bessette L, Keller RB (2001). "Predictors of outcomes of carpal tunnel release". Arthritis Rheum. 44 (5): 1184–93. doi:10.1002/1529-0131(200105)44:5<1184::AID-ANR202>3.0.CO;2-A. PMID 11352253.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)
  63. ^ Ruch DS, Seal CN, Bliss MS, Smith BP (2002). "Carpal tunnel release: efficacy and recurrence rate after a limited incision release". J South Orthop Assoc. 11 (3): 144–7. PMID 12539938.{{cite journal}}: CS1 maint: multiple names: authors list (link)

See also

Carpal Tunnel Syndrome Sufferers

Retrieved from "https://en.wikipedia.org/w/index.php?title=Carpal_tunnel_syndrome&oldid=365360985"