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Carpal Tunnel Syndrome

By John (Jack) McCarthy, M.D. 
Hand and Upper Extremity Surgeon
Drs. Gross, Iwersen, Kratochvil & Klein, P.C.

John (Jack) McCarthy, M.D.

INTRODUCTION:

Carpal tunnel syndrome remains the most common diagnosis presenting to hand surgeon’s offices for treatment. It will involve approximately one percent of the adult population with significantly greater involvement with women than men. It is most present during the middle age years, but can be seen at the extremes with my personal surgical experience from 16 to 98 years old.

The main complaints patients have are a combination of numbness and pain. It will involve the digits on the radial side of the hand (thumb, index, long and part of the ring finger) greater than the small finger. It is actually most symptomatic at rest rather than at work activities.

It is often difficult to find the cause for carpal tunnel problems. Suffice it to say, it has been extensively evaluated in jobs that demand forceful repetitive use and these do have slightly increased risk of developing carpal tunnel syndrome.

There has been considerable efforts to evaluate this with the use of CRT or computer activities, as well as other jobs. No specific dose causation studies have been documented. Suffice it to say to date, it is something we continue to treat often with occupational modifications.

There are multiple additional causes of carpal tunnel syndrome including pregnancy, thyroid disease, and fractures. It is also associated with multiple medical conditions such as kidney disease, congestive heart failure, rheumatoid arthritis and other inflammatory arthritides.

The carpal tunnel itself is a bony box located at the level of your wrist. The median nerve passes through this bony box with 9 tendons. The bones of the wrist actually create the bottom three sides of the carpal tunnel and the transverse ligament creates the top. Either with a fracture and/or with significant tendon irritation, one will see swelling of the flexor tendons or a collapse of the bony structures such as to cause increased pressure within the carpal tunnel. This increased pressure does cause resulting dysfunction of the median nerve usually presenting with pain and numbness.

The treatment of carpal tunnel syndrome is a stepwise process managed depending on the patient’s symptoms.

Our current treatment plan for those that present with mild symptoms of relatively new onset is a multiple venue plan. Specifically, we will encourage patients to use a simple wrist brace that holds the wrist in a neutral or non-flexed position, a home exercise program which we have written out and given to them, and

often we will use anti-inflammatories both to manage the pain, as well as to potentially diminish the amount of swelling. There is limited indication for supplementation such as Vitamin B6, which when done in mild moderation for a reasonable trial period, is acceptable.

When a patient goes beyond these endeavors additional studies such as nerve conduction tests are often indicated. These are done usually by a Neurologist or Physiatrist who documents the level of, as well as, the severity of carpal tunnel syndrome.

One can consider with persistent carpal tunnel syndrome a cortisone injection. This can be helpful especially in the mild cases. In the more severe cases it is successful at postponing potential need for surgical intervention. Therefore, it will often be used during the peak of a person’s work year to allow postponing of surgery if symptoms persist.

The biggest gains have been seen in surgical intervention. We have attached three articles of significance concerning the development of the endoscopic carpal tunnel surgery.

The first was a landmark study written by Dr. Agee in 1990 which was a prospective double-blinded study where we were study participants. This study documented that the endoscopic procedure was successful in shortening the rehabilitation process and was very successful at relieving carpal tunnel symptoms. This, as well as a subsequent study done on a 1,000 patients documented that this was a safe, as well as effective procedure.

The second study is a study that was published this month in the Journal of Bone and Joint Surgery over 10 years later, again documenting the benefits of endoscopic carpal tunnel surgery. Suffice it to say, that this technique has stood the test of time and like many endoscopic procedures for abdominal surgery and/or arthroscopic procedures for orthopedic surgery, one could see substantial improvements. I often compared the endoscopic procedure to the endoscopic cholecystectomy versus the open cholecystectomy (gallbladder surgery).

Finally, there was a study published this spring through our office on “Bilateral Endoscopic Carpal Tunnel Releases: Simultaneous Versus Staged Operative Intervention”. Significant gains are noted both in patient care, as well as rehabilitation. As you would guess, patient’s most significant concern is bathroom functions and indeed, it is now well over 200 patients and no patients even with bilateral surgery has needed assistance for their day-to-day cares. There are significant limitations especially in that first 2 to 3 days as far as activities and/or work, but the rehabilitation does progress very quickly.

I think carpal tunnel syndrome has made substantial gains in the last 15 years. These have been incorporated into our practice and are well documented in the attached literature.

This Page Updated On:   10/08/2002 07:58 AM