Carpal Tunnel Syndrome

THE CLINICAL SYNDROME

Carpal tunnel syndrome is the most common entrapment neuropathy encountered in clinical practice. It is caused by compression of the median nerve as it passes through the carpal canal at the wrist. The most common causes of compression of the median nerve at this anatomic location include flexor tenosynovitis, rheumatoid arthritis, pregnancy, amyloidosis, and other space-occupying lesions that compromise the median nerve as it passes through this closed space. This entrapment neuropathy presents as pain, numbness, paresthesias, and associated weakness in the hand and wrist that radiates to the thumb, index finger, middle finger, and radial half of the ring finger. These symptoms may also radiate proximal to the entrapment into the forearm. Untreated, progressive motor deficit and, ultimately, flexion contracture of the affected fingers can result. The onset of symptoms usually occurs after repetitive wrist motions or due to repeated pressure on the wrist such as resting the wrists on the edge of a computer keyboard. Direct trauma to the median nerve as it enters the carpal tunnel may result in a similar clinical presentation.

Poor positioning of the hand and wrist during keyboarding can result in carpal tunnel syndrome.

SIGNS AND SYMPTOMS

Physical findings include tenderness over the median nerve at the wrist. A positive Tinel’s sign over the median nerve as it passes beneath the flexor retinaculum is usually present. A positive Phalen’s test is highly suggestive of carpal tunnel syndrome. Phalen’s test is performed by having the patient place the wrists in complete unforced flexion for at least 30 seconds. If the median nerve is entrapped at the wrist, this maneuver will reproduce the symptoms of carpal tunnel syndromes. Weakness of thumb opposition and wasting of the thenar eminence are often seen in advance carpal tunnel syndrome, although because of the complex motion of the thumb, subtle motor deficits may easily be missed. Early in the course of the evolution of carpal tunnel syndrome, the only physical finding other than tenderness over the median nerve may be the loss of sensation on the above mentioned fingers.

A positive Phalen's test is highly indictive of carpal tunnel syndrome.

Carpal tunnel syndrome is often misdiagnosed as arthritis of the carpometacarpal joint of the thumb, cervical radiculopathy, or diabetic polyneuropathy. Patients with arthritis of the carpometacarpal joint of the thumb will have a positive Watson’s test and radiographic evidence of arthritis. Most patients suffering from a cervical radiculopathy will have reflex, motor, and sensory changes associated with neck pain, whereas patients with carpal tunnel syndrome will have no reflex changes and motor and sensory changes will be limited to the distal median nerve. Diabetic polyneuropathy will generally present as symmetrical sensory deficit involving the entire hand rather than limited just to the distribution of the median nerve. It should be remembered that cervical radiculopathy and median nerve entrapment may coexist as the “double crush” syndrome. Furthermore, because carpal tunnel syndrome is commonly seen in patients with diabetes, it is not surprising that diabetic polyneuropathy is usually present in diabetic patients with carpal tunnel syndrome.

TREATMENT

Mild cases of carpal tunnel syndrome will usually respond to conservative therapy, and surgery should be reserved for more severe cases. Initial treatment of carpal tunnel syndrome should consist of simple analgesics, nonsteroidal anti-inflammatory drugs, or cyclooxygenase inhibitors and splinting of the wrist. At a minimum, the splint should be worn at night, but 24 hours a day is ideal. Avoidance of repetitive activities thought to be responsible for evolution of carpal tunnel syndrome (e.g., keyboarding, hammering) will also help ameliorate the patient’s symptoms. If the patient fails to respond to these conservative measures, a next reasonable step is injection of the carpal tunnel with local anesthetic and steroid.

Proper needle placement for injection of the carpal tunnel.

Carpal tunnel injection is performed by placing the patient in a supine position with the arm fully abducted at the patient’s side and the elbow slightly flexed with the dorsum of the hand resting on a folded towel.

For patients in whom these treatment modalities fail, surgical release of the median nerve at the carpal tunnel is indicated. Endoscopic technique are showing promise and appear to result in less postoperative pain and dysfunction.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue. Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.