Carpal Tunnel Syndrome

A picture showing the front aspect of the left hand, demonstrating the median nerve distribution. There are red circles around the median nerve compression area at the carpal tunnel.

Carpal tunnel syndrome is a very common cause of numbness and pain. Proper understanding of the symptoms of this problem and their cause can minimize morbidity for the patient.

Carpal tunnel syndrome is median nerve compression at the wrist.

Anatomy of Carpal Tunnel Syndrome

The anatomic boundary bound by the wrist or carpal bones in the back or dorsal side and the transverse carpal ligament in the front or palmar side makes up the carpal tunnel. All the tendons that flex the wrist and fingers and the median nerve go through this space. If increased pressure is present, for whatever reason, it presses on both the flexor tendons and the median nerve. The increased pressure does not bother the tendons at all, but the median nerve is very sensitive to increased pressure.

A labeled cross-sectional picture of the wrist at the carpal tunnel.
Carpal Tunnel Anatomy

The increased pressure on the median nerve causes numbness and/or pain in the distribution of the median nerve.

A picture showing the front aspect of the left hand, demonstrating the median nerve distribution. There are red circles around the median nerve compression area at the carpal tunnel.
Carpal Tunnel Syndrome Numbness Distribution

If untreated, there can be permanent loss of muscle in the thenar eminence. The thenar eminence is the muscle group in the palm at the base of the thumb.

Symptoms of Carpal Tunnel Syndrome

Pain and numbness along the palm of the hand and the thumb, index, long, and half of the ring finger is the usual case. It usually comes on slowly, but can happen after a wrist fracture; in which case it is very acute. It is typically worse at night and with activities. Carpal Tunnel Syndrome aligns with repetitive activities, such as typing on a computer, but not always. 

Often, especially in the early stages, the symptoms can be better by shaking the hand out.

Physical Examination 

Firstly, the hand is examined for any evidence of muscle wasting.  A thorough exam will check for other causes of numbness, such as from the neck or the ulnar nerve. The hand is checked for sensation with light touch and two-point discrimination tests. 

The Tinel sign and Phalen’s test evaluates the median nerve.

In the Tinel sign, you gently tap over the median nerve and if irritation is present, you will feel electric shocks in the distribution of the nerve. This is a positive test.

In Phalen’s test, you place both of the back of your hands together with the wrists flexed and hold it for at least one minute.

A picture of a woman holding both of her wrists flexed with the back of the hands together.

A positive test will result in feeling numbness and/or electric shocks in the distribution of the median nerve.

Diagnostic Tests

The two most utilized tests to diagnose carpal tunnel syndrome are the nerve conduction study and ultrasound.

In the nerve conduction study, a small needle electrode penetrates just before and just after the site of compression and the speed of conduction is compared to that of normal values. In carpal tunnel syndrome, the speed will be less.

More recently, diagnosing carpal tunnel syndrome with great accuracy has been done by ultrasound. The benefits of ultrasound are that it is completely non-invasive, and relatively cheap.

Treatment 

If the symptoms are severe and relatively acute, icing the wrist will be of benefit. Resting the wrist in a splint, especially at night, is the mainstay of treatment. 

If these treatments are ineffective then the treatment of choice is surgery. The goal of the surgery is to simply release the transverse carpal ligament. This is possible either through an open incision, or endoscopically.

I have use the endoscopic carpal tunnel release in thousands of cases and I found it very effective with minimal pain and risks.

In summary, carpal tunnel syndrome is a common condition that can be successfully treated with minimal morbidity.

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