Carpal Tunnel Syndrome
with Dr. Eric Gaenslen, Surgeon
Carpal Tunnel Syndrome is a common problem caused by compression of a nerve (the median nerve) at the wrist. It is characterized by pain, numbness, tingling, and weakness in the hand and wrist. It is one of the most common orthopaedic disorders, affecting approximately 7% of the population, with approximately 250,000 carpal tunnel release surgeries performed annually in the U.S.
Dr. Eric Gaenslen, an orthopaedic hand and upper extremity surgeon with
Advanced Healthcare, said carpal tunnel syndrome is the most common reason patients present to his office.
Who is at risk?
Gender plays a strong role in carpal tunnel syndrome, with approximately 75% of cases being present in women. Others at higher risk for the development of carpal tunnel syndrome are patients who smoke or excessively consume alcohol and patients with diabetes, rheumatoid arthritis, and hypothyroidism. Carpal tunnel syndrome is also more common with increasing age.
The link between ones occupation and the development of carpal tunnel syndrome is controversial. Persons whose job involves a combination of high gripping force and repetition; high vibration exposure; and frequent or prolonged cold exposure are felt to be at higher risk.
Symptoms of Carpal Tunnel Syndrome
The earliest symptoms of carpal tunnel syndrome are usually those of tingling and numbness involving the thumb, index, long, and ring finger (although commonly only some of those digits are involved). As the duration and severity of the nerve compression progress the patient may experience pain and weakness in the hand and wrist. Less commonly, symptoms may radiate up toward the elbow. Finally, the symptoms may interfere with sleep, making it difficult for the patient to fall asleep or waking them in the middle of the night.
Unfortunately, he said, some patients wait to long to have their symptoms evaluated and permanent damage to the nerve can occur from the combination of severe and prolonged nerve compression. "This is more often true in patients with diabetes, whose symptoms are sometimes blunted (by underlying neuropathy) until it is very advanced.
Dr. Eric Gaenslen, Orthopaedic Hand and Upper Extremity Surgeon
Advanced Healthcare
"I recently had a patient with very symptomatic carpal tunnel syndrome in her right hand. She had a history of a prior stroke with quite a bit of left sided weakness requiring her to use a cane in her right hand in order to walk. I performed her carpal tunnel release endoscopically to speed her ability to regain use of her cane and get back on her feet."
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Evaluation of the Patient
In addition to taking a history and performing a physical examination, physicians may order an electrical test of patients with suspected carpal tunnel syndrome. The test, commonly called an EMG/NCS (electromyograph/nerve conduction study), involves stimulating areas on the skin and recording the response and speed of transmission of nerve signal in the hand and upper extremity. It is very useful to assess the severity of carpal tunnel syndrome and to rule out other causes of similar symptoms, such as a pinched nerve at the neck.
Avoiding Surgery
Patients with carpal tunnel syndrome can sometimes control their symptoms for many years by wearing a brace or splint to keep the wrist in a "neutral" position. This is often particularly helpful at night. Taking anti-inflammatory medications, and cortisone injections into the carpal tunnel may also help. Rarely, patients may find relief with high doses of Vitamin B6, though research has not proven this to be of benefit.
For those whose occupations or other activities aggravate their symptoms, there are special shock absorbing gloves, similar to fingerless bicycling gloves, which can dissipate some of the force and vibration across the wrist.
Carpal Tunnel Release Surgery
Carpal tunnel release can be performed by one of two methods, and is done on an outpatient basis. The first is with a traditional open incision, usually about an inch in length at the base of the palm. The second is with the use of an endoscope. With endoscopic carpal tunnel surgery a small incision is made just above the wrist and in the palm. The scope is passed through one of the incisions to visualize the ligament, which forms the "roof" of the carpal tunnel. The other incision allows the passage of a specialized knife used to cut the ligament. There are advantages and disadvantages to each method, and not everyone is a candidate for the endoscopic technique.
"Regardless of which technique is used, cutting the ligament overlying the carpal tunnel relieves the increased pressure within the tunnel (and on the nerve), and allows the tunnel to expand. It is often dramatic how tight and thick the ligament can be," Dr. Gaenslen said.
Following surgery, the hand and wrist are wrapped in a soft dressing incorporating a small splint, approximately the size of the splint many patients wear before surgery. "The fingers and thumb are immediately free to move," he said.
The Recovery
Dr. Gaenslen said many patients experience almost immediate relief of the most annoying symptom. "The first symptom to get better is the pain that often wakes them at night. This occurs almost immediately. The tingling and numbness are the next symptoms to resolve and this depends somewhat on how severe the nerve compression was before surgery. The more severe and prolonged the compression, the longer it may take for these symptoms to abate. Strength is usually the last symptom to improve." Depending on the severity most patients are nearly fully recovered in 6 to 12 weeks.
Dr. Gaenslen usually prescribes a short course of therapy following carpal tunnel release surgery. The therapists instruct the patient on scar message, stretching, and gentle strengthening exercises. Most of these exercises can be done at home.
The time off from work will depend on the type of work the person does. For patients whose job does not involve extensive or heavy reliance on the operated hand, they may be back to work in less than a week. For patients doing heavier or more repetitive activities with their hands, they are usually back to some form of light duty by 6 weeks, transitioning back toward their regular duties by 3-4 months.
