Carpal tunnel syndrome is a frequent and often neglected condition that causes irreversible damage if not treated promptly. It occurs in adulthood and more commonly in people over 50. It is estimated that nearly 1 in 20 adults in Canada suffers from carpal tunnel. It affects both men and women, but women are 4 times more likely than men to suffer from it.
It occurs when the median nerve that passes through the wrist is compressed in its channel, the carpal tunnel. Compression affects the sensory and motor function of the hand, which can cause numbness, pain, and the inability to perform certain movements. In the majority of cases, the disease is bilateral, meaning it affects both hands.
Several causes can be at the root of the problem, including repeated bending movements, hormonal imbalances, a structural or bone anomaly, or certain chronic illnesses.
Diabetes, smoking, pregnancy, osteoarthritis, hyperthyroidism, excess weight, menopause and radius fractures are among the most common risk factors.
The main symptoms of carpal tunnel syndrome, in no particular order, include:
– Pain or burning sensation in the hand, fingers, or forearm.
– Numbness and tingling in the hand, especially in the thumb, index, and middle fingers. Symptoms may worsen at night, leading to night awakenings. Patients often need to shake their hands to relieve the numbness.
– Worsening of symptoms with manual activity or driving.
– Swollen feeling in the fingers and hand.
– Weakness, clumsiness, and loss of dexterity.
Numbness and tingling in the palm of the hand or fingers are usually the first signs of the disorder. These symptoms often occur at night or early in the morning, causing insomnia or nocturnal awakenings. Some individuals may also experience itching or burning pain. Shaking the affected hand is a common way to alleviate the numbness.
Symptoms can also be triggered by activities such as driving, prolonged phone use, or reading the newspaper during the day.
Over time, as the condition progresses, there may be a loss of sensitivity in the fingers. Initially, this loss of sensitivity may be temporary but can eventually become permanent. Affected individuals may lose the sense of touch in the thumb, forefinger, middle finger, and half of the fourth finger. As the condition worsens, muscle atrophy may occur, leading to a weakening of the muscles from the base of the thumb to the palm of the hand. This can result in a decrease in manual dexterity and a reduced strength in the thumb-index pinch. Manipulating small items such as coins or buttoning clothes can become difficult, and individuals may experience increased clumsiness, often dropping pens and having trouble with writing.
The diagnosis is based mainly on clinical examination and symptom description. Various challenge tests, including the Tinel sign, Durkan compression test, limb elevation test and Phalen maneuver, can also be used to assess symptoms and measure the severity of the syndrome. The Scratch Collapse Test is very useful for confirming nerve damage. Electromyography (EMG) and nerve conduction tests are complementary tests sometimes recommended to provide differential diagnosis and to measure the severity of nerve damage. They also make it possible to confirm the site of nerve compression accurately.
All patients presenting with hand numbness in the area corresponding to the median nerve (major index thumb) should be examined not only for carpal tunnel syndrome, but also for compression of this nerve in the elbow, under the lacertus fibrosis. The scratch collapse test is a very little-known but very useful physical examination maneuver for the diagnosis of nerve compressions such as CTS or lacertus fibrosis syndrome.
Indeed, between 33 and 50% of patients with median nerve compression in the carpal tunnel also have a similar compression even higher, at the elbow and forearm. If this compression is not identified and treated, many symptoms may persist after carpal tunnel surgery. Ignorance of this pathology is a common cause of the failure of carpal tunnel surgery.
Beyond maintaining a healthy lifestyle and controlling chronic diseases, several measures can help to relieve symptoms. Conservative management includes stretching and nerve movement exercises, night splinting, prevention of incorrect or non-ergonomic postures, and reduction or elimination of repetitive movements.
Wearing a night orthosis can be recommended for four to six weeks. If, at the end of this period, symptoms are still present or if signs reappear when the orthosis is abandoned, surgery is required. Orthotics are not a permanent solution to the problem and can, on the contrary, adversely affect the treatment protocol.
Cortisone injections, preferably performed under ultrasound monitory, are sometimes performed to temporarily relieve the pressure inside the carpal tunnel. They can also be used as therapeutic tests when the diagnosis is uncertain. These injections may mask the symptoms of compression. They should not be repeated to avoid the development of irreversible neurological damage.
Two types of surgery are available when first-line treatment is not enough to improve symptoms.
The conventional or “open” decompression method involves making a 3-4 cm incision in the palm of the hand to cut the transverse carpal ligament and reduce pressure on the median nerve. This is the most common method in the Canadian public health system. Unfortunately, this method is invasive and unnecessarily sacrifices many structures interposed between the skin and the ligament that is the target of the surgery, which leads to a convalescence of several months.
Dr. Brutus favors a newer, less invasive alternative method called endoscopic decompression. This technique makes it possible to selectively cut the ligament using miniaturized instruments introduced by a mini-incision made in the forearm. The procedure is done in minutes under local anesthetic and only requires dissolvable stitches. Unlike the conventional method, the skin and muscles of the hand are not damaged. The pain is minimal and the relief of symptoms is fast. This method also makes it possible to treat both hands in one session, which considerably shortens the convalescence period.
Endoscopic release offers significant comfort and productivity benefits. Because of its less invasive nature, it provides rapid symptom relief, improved motor recovery and a much faster return to normal activities.
Endoscopic release provides rapid relief from numbness and tingling. The duration for complete recovery and resumption of activities varies from a few days to a few weeks, depending on the patient. Recovery does not require rehabilitation.
The average duration of a work stoppage is 14 days for patients treated by the endoscopic method, compared to 32 days for patients operated on “openly.” The average time to resume driving is 3 days after endoscopic decompression, compared to 28 days with the conventional procedure. In addition, scar pain is considerably reduced by the endoscopic technique, which limits the inconvenience associated with taking narcotic painkillers.
In general, the satisfaction rate among patients who have undergone endoscopic decompression is much higher. According to a study conducted in patients who had experienced both methods, 95% of them preferred the endoscopic method.
Endoscopic decompression using the Smart Release system is the most effective and rapid way to treat carpal tunnel syndrome.
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Preview - Self help book for carpal tunnel syndrome: The essential guide to a quick recovery
Dr. Jean-Paul Brutus and Nathalie Brisebois (Occupational Therapist) answer the most frequently asked questions about carpal tunnel syndrome and offer advice to treat the disease without surgery.