Monday, January 9, 2012

Carpal Tunnel Syndrome

Recently, Avtar Ji came over after his jog and told me ‘Doctor Saab – I’ve been having some pins and needles over my right hand la. My Sinseh said it’s due to ‘angin’ but it has not gone off with massages la’
Chatting a while more and gleaning out some more information, I possibly felt it was median nerve compression at the carpal tunnel – the Carpal Tunnel Syndrome. Examination and work up confirmed this and over 1 week I was able to get him better.
The carpal tunnel is located in the hand and not the wrist. Compression of the median nerve as it runs under the transverse carpal ligament forming the roof of the tunnel is a common cause of numbness of the outer 3 fingers (thumb, index and middle) and pain over the hand.
Many conditions can cause increased pressure within the carpal tunnel and lead to carpal tunnel syndrome although there is often no identifiable cause in spite of detailed evaluation.
At the early stage, patients usually complain of numbness, pain (usually a burning pain), and tingling in the thumb, index, and middle fingers although some patient feel it moving from hand to the lower forearm. As the condition progresses, Some claim to being clumsy and often dropping objects – especially claiming to find it difficult to feel and handle small objects while others complain of frank weakness.
The relationship between work and carpal tunnel syndrome is unclear. Positions of extreme wrist flexion and extension  - this in movement of the wrist to its limit upwards and downwards are known to increase pressures within the carpal canal and apply pressure on the nerve. Poor office ergonomics particularly with computer use are described as predisposing.
Diagnosis is made easy by a good history. Clinical examination centers on confirming that the level of compression is at the hand as occasionally the compression of the nerve may be at the elbow and at times neck problems can cause symptoms that mimic carpal tunnel syndrome. A trained doctor would comfortably make a diagnosis from examination alone. Confirmatory tests include nerve conduction studies that track and test the speed of conduction of impulses along the nerve.  
I often teach simple exercises to glide the median nerve. This involves movement of the wrist from one extreme to the other – from dorsiflexion to palmar flexion.
Usage of a splint keeping the wrist in a neutral position is also helpful. Early symptoms are predominant at night and splints are often used during sleep.
Office ergonomics and proper wrist positioning while at the computer often improves symptoms. The wrist should never be kept in extremes of flexion or extension while typing – simple gadgets such as a silicon rest pad or an ergonomically designed keyboard may help.
Medications and Injectables
Anti inflammatories are often used to combat acute pain although carpal tunnel syndrome is not inflammatory by definition.

Steroid injection into the carpal tunnel is often helpful in early cases where splints and exercises have failed.
More advanced cases, particularly those that involve muscle weakness and loss of dexterity and also in cases where conservative management have failed usually require surgery.
The goal of surgery is to take pressure off the nerve at the wrist. This involves releasing the carpal tunnel ligament which form the roof of the tunnel. Post surgery  movement of the fingers and wrist is encouraged and I often advise the use of a splint at night for 2 weeks. Return to heavy activity is at 6 weeks althought basic activities can be done based on comfort of hand use. Some people experience immediate relief in their hand once the pressure on the nerve is eliminated with surgery – these are often those who have had a short duration of symptoms. Other people do not experience immediate relief due to more long-standing and severe pressure on the nerve.
Risks following surgery is rare. The ones documented in literature include wound infection, stiffness at the wrist and residual pain. There are minimized further by rehabilitation and pain relief medication post operation.