What is New About Carpal Tunnel Syndrome?

Sunset in the prairies. (Dr. Noorali Bharwani)
Sunset in the prairies. (Dr. Noorali Bharwani)

August seems to be my favourite month. Many good things and some not so good have happened during this month. One of the good things was starting this column 16 years ago. A by-product of these columns has been publication of my two books. Hopefully, there will be more.

OK, let us get back to what we are going to discuss today – carpal tunnel syndrome.

Last time I wrote about carpal tunnel syndrome was in 2003. This is a good time to review the subject again as I saw an article in the Canadian Medical Association Journal (CMAJ August 5, 2014).

Carpal tunnel syndrome was first described in 1853. It is a common, painful disorder of the wrist and hand. It is caused by pressure on the median nerve in the wrist. The median nerve travels from the forearm into the hand through a “tunnel” in the wrist.

The CMAJ article says the condition is not as common as thought. “A prospective long-term study of a general working-age population (16 to 74 yr) showed that the overall incidence of carpal tunnel syndrome over a 66-month period was 103 per 100 000 people per year,” says the article.

Who is at risk?

Individuals who are working in areas where there is exposure to excess vibration, use of increased hand force and repetitious movements increase the risk of carpal tunnel syndrome. In an analysis of 37 studies it was found that factors significantly associated with increased risk included vibration, increased hand force and repetition.

What about somebody spending many hours using computer keyboard?

The authors of the article say that the association between carpal tunnel syndrome and use of a computer keyboard or mouse is unclear. The authors reviewed eight epidemiologic studies and came to the conclusion that the evidence is insufficient to confirm that computer work causes carpal tunnel syndrome.

The review also found no evidence of an association with repetitive, low-force noncomputer work.

Personal characteristics that increase a patient’s risk include increase in age, sex (women were at higher risk than men) and obesity.

Is there a good treatment for carpal tunnel syndrome?

After 160 years, one would think we would have found a good treatment for this ailment. Let us see what we have.

Initial management may include occupational therapy and wrist splinting. A study found that eight weeks of splinting and education sessions with an occupational therapist was helpful in 63 per cent of the patients. These patients did not require surgery.

These patients showed improvement in symptom severity, functional status, pain perception and grip strength. The article says if symptoms do not improve within eight weeks, referral to a surgical specialist should be considered.

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Carpal Tunnel Syndrome

A young lady wants to know about carpal tunnel syndrome. What is it? Who gets it? How is it managed?

Carpal tunnel syndrome was first described in 1853. It is a common, painful disorder of the wrist and hand. It is caused by pressure on the median nerve in the wrist. The median nerve travels from the forearm into the hand through a “tunnel” in the wrist.

The cause of the pressure can be multifactorial. Some common causes and associated conditions are:
-repetitive and forceful grasping with the hands
-repetitive bending of the wrist
-broken or dislocated bones in the wrist which produce swelling
-arthritis, especially the rheumatoid type
-thyroid gland imbalance
-sugar diabetes
-hormonal changes associated with menopause
-pregnancy

Although any of the above may be present, most cases have no known cause.

It can occur at any age. The condition occurs most often in people 30 to 60 years old, and it is 5 times more common in women. It affects the dominant hand more frequently. It may affect both hands.

The symptoms start with pins and needles in three and half fingers (thumb, index finger, middle finger and half of ring finger) that are supplied by the sensory branch of the median nerve.

This may be followed by pain in the distribution of the median nerve, from the tip of the fingers to the neck. Symptoms may be worse at night and wake the patient from sleep. Relief is obtained by dangling the arm over the side of the bed.

Eventually, the median nerve supplying the small muscles of the hand may be affected. This produces wasting and weakness of the hand. There may be tendency to drop things.

A good history and physical examination is very important. Sometimes the condition may be confused with other problems affecting the shoulder and the neck. Therefore, nerve conduction study of the median nerve can provide more information.

The nerve conduction study helps localize the site of the entrapment and estimate the severity of damage. In less than 10 percent of the patients the test may be falsely negative. Clinical correlation is required to come to a final diagnosis.

Non-surgical treatment of carpal tunnel syndrome is: avoidance of the use of the wrist, placement of a wrist splint in a neutral position for day and night use, and anti-inflammatory medications.

Splinting can be combined with steroid injections. In one study, 80 percent had immediate relief of symptoms. But after one year only 20 percent were free of symptoms.

Ergonomic redesign of work stations is widely practiced for prevention and for relief of symptoms.

Surgical treatment involves a small incision on the palmar aspect of the wrist and the hand. The incision is deepened to divide the ligament to open the tunnel. Thus the pressure on the nerve is released.

The surgery requires no hospitalization and is done under local or regional anesthetic. No genera anesthetic is required. Studies have shown that surgical treatment relieves symptoms in 82 to 98 percent of the patients.

Relief of symptoms and return to normal level of physical activities may take few days to several months – depending on the damage to the nerve and the type of activity. Physiotherapy may become necessary.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!