Carpal Tunnel Syndrome
Today there are few people in the United States who have
never heard of carpal tunnel syndrome. Most have a
friend or family member who has had carpal tunnel syndrome and
many have had a carpal tunnel release operation themselves.
As with any common entity there are all sorts of tales told
about carpal tunnel syndrome, various ways to treat it, and
even some real horror stories about bad outcomes.
Carpal
tunnel syndrome (CTS) has long been regarded in the medical
community as a “simple problem” and unfortunately there
have been very few comprehensive publications in either the
medical or the lay literature to clear up some of the
misinformation that surrounds carpal tunnel syndrome.
History
Carpal
tunnel syndrome was a term first used in the 1930’s to describe an
entrapment neuropathy of the median nerve at the wrist. There is
nothing new whatsoever about carpal tunnel syndrome. Human
beings have had carpal tunnel syndrome for as long as there have been
carpal tunnels. The first open carpal tunnel release was
described in 1947 and nothing changed very much for 50 years until the
advent of the endoscopic procedure in 1990. Along about the same
time, the media publicized the fact that some individuals involved in
repetitive-type work activities, such as those who work on computers
all day, have an increased incidence of carpal tunnel syndrome.
In point of fact, most people who come in the hand surgeon’s office
with carpal tunnel syndrome are perplexed as to why they have this
disease because they do not engage in classical repetitive-type work
activities.
Anatomy
Carpal
tunnel syndrome is easily understood if one begins with the anatomy.
The carpal tunnel is formed by a semi-circle of carpal bones on three
sides. The fourth side that forms the carpal tunnel is the transverse
carpal ligament. The ligament cannot stretch. Thus the
carpal tunnel is a defined space that cannot enlarge. There is
only so much room in that opening. Through that opening passes the
median nerve, nine tendons, and spongy tissue around the tendons
called tenosynovium. We start our lives with that extra space.
When we run out of extra space due to the swollen tenosynovium, then pressure
is placed on the nerve. When this happens, one begins to develop
carpal tunnel symptoms.
Symptoms
Classic textbook carpal tunnel syndrome
symptoms are tingling and numbness in the thumb, index and middle
finger (median nerve distribution), aching in the forearm which can
radiate to the shoulder, and clumsiness or weak grip. Only about
one or two patients out of ten presents with a classic textbook carpal
tunnel picture. Some present with tingling in all fingers while
others present with tingling only in the thumb or the middle finger.
Some present with aching and pain in the hand while others have
radiating pain just medial to the back.
Diagnosis and Treatment
A
nerve test is done to confirm the diagnosis. Once the patient
has been diagnosed with carpal tunnel syndrome, a decision versus
treatment must be made. One must keep in mind what is going on
with the
nerve. The nerve is being squeezed. If one has a wedding
band on the ring finger and the hand is crushed between two objects,
then the entire hand begins to swell and the ring acts as a tourniquet
cutting off the flow of blood to the finger. It is easy to
understand that the ring has to be cut off the finger or else the
finger will die. Likewise the nerve is being pinched. The
nerve fibers are being pinched and they will be deprived of blood flow
and undergo irreversible changes and ultimately die unless the
pressure is released before those irreversible changes take place.
Thus
the goal of treating carpal tunnel syndrome is not simply to reduce
the pressure on the nerve so that the symptoms are tolerable and the
patient can live with it, but rather to alleviate the pressure
entirely. Waiting “until it gets too bad” is not advised and
one may actually end up with permanent nerve damage.
Treatment Myths
Make
no mistake; carpal tunnel is big business. Countless millions of
dollars have been wasted on gimmicks and gadgets trying to prevent
carpal tunnel, treat carpal tunnel, and avoid surgery. Almost
all of them do not work. Rarely do ergonomic devices work.
“Therapy” and “exercises” do not work. Think about it,
repetitive motion contributed to the carpal tunnel to begin with in
many cases. It’s not a problem
that can be exercised away. Magic lasers waved over the hand have not
been proven effective by scientific evaluation. There is no
evidence to suggest that they actually decrease the flexor
tenosynovium. Splints worn during the day decrease the muscle
pumping action of the hand, cause more swelling in the hand, and
increase carpal tunnel symptoms. Splints can be helpful at night
for positioning the hand to avoid sleeping in marked flexion which
puts increased pressure on the nerve. Vitamin B-6 is almost
always ineffective. Topical creams by “renowned doctors”
don’t work. Magnets don’t work for carpal tunnel syndrome.
Dietary supplements don’t work.
Steroid
injections are only temporary and can cause permanent injury to the
nerve if the needle is accidentally placed in the nerve, which usually
happens on the third or fourth injection.
An
open carpal tunnel release works, but it can cause weeks or months of
pain and inability to work.
What’s
the answer?
So
why do carpal tunnel sufferers, employers, and insurance carriers fall
for all of these worthless remedies? Simple. In the United
States, one can sell just about anything if it’s packaged right,
even if it
is worthless. Carpal tunnel is big business.
Unfortunately,
that means a lot of hard-earned money is being wasted and people are
going untreated. Not only are they suffering, but also they risk
permanent damage to the nerve the longer the condition persists.
There
is an excellent treatment however. It’s not magic. It is
a quantum leap forward in the treatment of carpal tunnel. It is
the first major breakthrough in 50 years. It will almost
certainly be the standard by which all other treatments are measured
in years to come. Tens of thousands of people have been
effectively treated in this manner, which requires about eight days of
inconvenience; afterwards one can do whatever they choose to do.
This is the treatment that informed people choose.
Certain diseases and other situations can significantly contribute to the development of carpal tunnel syndrome.
These include:
Can I wait until it gets
worse?
Maybe it will just go away.
Doing nothing can possibly lead to irreversible damage.
If you have CTS, the nerve that provides sensation to the hand
and function to the thumb is being "pinched." After
remaining in the pinched stage for a period of time, permanent
injury to the nerve will result. There is no treatment
that can fully restore hand function and sensation once
permanent damage is sustained.
Is surgery always
necessary?
No. The hand surgeon will first examine your hands and
review your symptoms. If you have something other than
carpal tunnel syndrome, the doctor will suggest the
appropriate treatment. If CTS is suspected, he will
first prescribe non-operative treatment with splinting and
anti-inflammatory drugs. A test conducted on the nerve
will positively determine whether or not it is pinched and if
you have carpal tunnel syndrome.
What then?
If all your symptoms go away with splinting and medication,
then surgery will not be necessary. If not, then the
"carpal tunnel release" surgery is recommended.
The procedure is performed on an outpatient basis. No
hospital stay is required. With the new endoscopic
technique the recovery period is about 10 days compared with
several weeks or months with the old technique of cutting
through the palm to reach the tight ligament.
What about cost?
The cost of the new endoscopic surgery is comparable to the
traditional open carpal tunnel release surgery.
Actually, when considering the additional cost of therapy
often necessary after the traditional surgery and the loss of
work due to a lengthy recovery time, the new endoscopic
surgery may in fact be less costly.
Why us?
Dr. Neff is extensively trained in hand and upper extremity
surgery. Most orthopaedic surgeons are not trained in the newest
techniques of true endoscopic carpal tunnel release. Special training,
cadaver surgery, and special certification is necessary before the surgeon
should state to the public that he or she is trained and capable of expertly and
safely performing the newest endoscopic carpal tunnel release techniques.
What do I have to do now?
Call for appointment today 515-222-3151 or Toll Free 877-348-9341.
Do I have a choice of
surgeries?
Yes. You can either have the traditional carpal tunnel release
surgery in which a longitudinal incision is performed in the
palm of the hand or have it done through the new endoscopic
technique. Both are effective, but with the traditional
technique, the wound in the palm remains tender for several
weeks or months and prevents a quick return to work or
recreational activities. With the traditional technique,
normal tissues are divided in the palm, whereas, with the
endoscopic technique these structures are not injured.
Read
CTS articles from the Journal of Hand Surgery
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