Carpal Tunnel Syndrome: mild disorder and chronic pains
By Dr. Sanjay Saureen, Specialist Orthopedic Surgeon at Prime Hospital
Carpal Tunnel Syndrome (CTS) is a disorder that increases pressure on the median nerve passing through the hand, down to the carpal tunnel in the palm. CTS is caused by the compression of the median nerve in the wrist and ligaments that help the fingers move. Associated side effects include pains, tingling, numbness, and in advance cases, weakness of the hand muscles. Media statistics show that CTS usually begins in early adulthood, while females are likely to develop the disease between the ages of 29 to 69.
Despite there being no apparent and clearly definitive reasons for being diagnosed with CTS, there are specialized studies that refer to there being a host of risks factors that may accelerate the risk of developing the disease, including the following:
- Hypothyroidism (there is tentative evidence that hypothyroidism increases the risk)
- Repetitive wrist work including the overuse of computers and smart phones (using vibrating tools and conducting work that requires manual dexterity and a strong grip)
- Diabetes (and pre-diabetes; associated with impaired glucose tolerance)
- Inflammatory Arthritis
- Fractures (of the wrist)
- Pregnancy (during pregnancy women experience CTS due to hormonal changes - high progesterone levels- and water retention - which swells the synovium - which are common during pregnancy)
- Aging (as a manifestation of physiologic aging)
- Genetics plays a role (biological factors such as genetic predisposition and anthropometric features have significantly stronger causal associations with CTS, than occupational/environmental factors such as repetitive hand use and stressful manual work)
Transient and lasting symptoms
The main symptoms associated with CTS originate from the irritation in the median nerve passing through the Carpal Tunnel in the wrist, which is mainly responsible for controlling a large part of the motion of the thumb and conveying the sensation into the thumb and first three fingers (index, middle, and ring finger.) The disease progresses quite slowly, and the symptoms start gradually, and might vary case by case. However, they exacerbate during the night or early on in the morning. The symptoms primarily influence the thumb, index finger, middle finger, and the thumb side of the ring fingers and manifest as follows:
- Pain and tingling “pins and needles”
- Numbness in the fingers
- Weakness in the thumb, index and middle fingers
- Inability to move the hand easily and weak grip and strength; after a long period of time, the muscles at the base of the thumb may waste away
- Swelling in the wrist – and occasionally sclerosis – might occur
The same symptoms might happen in one or both hands, inter alia, with other signs including:
- Dull pain in the hand, forearm, or shoulder
- Burning or tingling sensation in the radial side of the hands and/ or wrist
- Ache and discomfort possibly felt more proximally in the forearm or even the upper arm
- Dry skin or a discoloration of the hand color
- Impaired tactility and difficulty in distinguishing between hot and cold
- Possible weakness and atrophy of the thumb base muscles if the condition remains untreated, because the muscles are not receiving sufficient nerve stimulation
There is no consensus reference standard as to the diagnosis of CTS. However, physicians typically tend to diagnose CTS using a combination of described symptoms and the clinical findings which are confirmed later through electromyography or what is referred to as electrophysiological testing, radiographic testing (X-Ray), Computerized Tomography (CT), and Magnetic Resonance Imaging (MRI). Blood chemistry testing (Sodium - Na+ test) is also performed to rule out other diseases with similar symptoms.)
Therapies … are they good?
The treatment of Carpal Tunnel Syndrome varies according to the degree of the injury and the severity of the symptoms. However, they generally fall
under three major categories:
1. Maintenance Therapy (Conservative Treatment):
Maintenance therapy typically involves the use of a wrist splint and hand brace for several weeks to fix the wrist in a straight position and prevent nerve compression. Many health professionals suggest that, for the best results, one should in the beginning wear braces at night only and, if possible, during the activity primarily causing stress on the wrists during the day as well. Maintenance therapy is prescribed in very mild cases or for pregnant women. In addition to splints and braces, a prescription could be given with medications including non-steroidal anti-inflammatory drugs (NSAIDs) as an initial therapy, like Brufen and Vitamin B6 with a daily 200 mg dosage.
2. Corticosteroid Therapy:
Some cases of CTS can be treated using a corticosteroid injection around the nerve, which can be effective for temporary relief from symptoms while a person develops a long-term strategy that fits his or her lifestyle. The injections are done under local anesthesia using Ultrasound Imaging (UI) to ensure injection is in the correct place, to avoid any other injuries occurring during the procedure. This treatment is not appropriate for extended periods, however. Local steroid injections are only used until other treatment options can be identified.
3. Surgery - “Carpal Tunnel Release/ Release of Transverse Carpal Ligament:”
Physicians typically tend to only resort to surgery in advanced cases, where a 4-cm long incision is made in the palm of the hand, to incise the nerve compressing ligament in a simple operation under local or regional anesthesia, with or without sedation. The operation can also be conducted under general anesthesia. The success rate of this surgery goes up to 85 to 90 per cent, which makes it the best and the most viable option currently available. The surgery is recommended when there is static (constant, not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting or other conservative interventions no longer control intermittent symptoms. It is more beneficial in the short term to alleviate symptoms (up to 6 months) than wearing an orthosis for a minimum of 6 weeks.
4. Is prevention feasible?
There are no effective preventative methods for CTS, due to there being no clear true triggers as of yet. Nevertheless, maintaining hygienic habits and a healthy lifestyle contribute towards limiting the risk factors and preventing the injury. There are several recommended practices, the most important of which are maintaining a good posture and having sufficient rest during work while moving the arms and legs, straightening the back, and regularly keeping the hands and wrists straight, particularly for those who work long hours in front of computers, or those whose work involves strenuous manual labor.