CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome is a common condition that causes pain, numbness, tingling, and weakness in the hand and wrist. The condition occurs when the median nerve is compressed at the wrist. This nerve provides sensation to the thumb, index, and middle fingers, and to half of the ring finger. In most patients, carpal tunnel syndrome gets worse over time, so early diagnosis and treatment are important.

Anatomy
The carpal tunnel is a narrow passageway in the wrist, about an inch wide. The floor and sides of the tunnel are formed by small wrist bones called carpal bones.
The carpal tunnel protects the median nerve and flexor tendons that bend the fingers and thumb. The roof of the tunnel is a strong band of connective tissue called the transverse carpal ligament. The nine tendons that bend the fingers and thumb also travel through the carpal tunnel.

Description
Carpal tunnel syndrome occurs when the tunnel becomes narrowed or when tissues surrounding the flexor tendons swell, putting pressure on the median nerve. This abnormal pressure on the nerve can result in pain, numbness, tingling, and weakness in the hand. 
Carpal tunnel syndrome is caused by pressure on the median nerve as it travels through the carpal tunnel.

Causes

A number of factors have been associated with carpal tunnel syndrome. Although they may not directly cause carpal tunnel syndrome, they may increase the risk of irritation or damage to the median nerve. Studies show that women and older people are more likely to develop the condition.Risk factors include:

• Heredity (smaller carpal tunnels can run in families)
• Anatomic factors (fracture or dislocation)
• Inflammatory conditions(Rheumatoid arthritis)
• Obesity *Hormonal changes (diabetes, pregnancy, menopause, thyroid disorders)
• Medical conditions (kidney failure and lymphedema)
• Workplace factors (Working with vibrating tools)
• A mass (tumor) in the carpal tunnel
• Amyloid deposits (an abnormal protein)

Carpal tunnel syndrome is also more common in women than in men.

Symptoms

Symptoms of carpal tunnel syndrome may include:

• Numbness, tingling, burning, and pain—primarily in the thumb and index, middle, and ring fingers
• Weakness and clumsiness in the hand—this may make it difficult to perform fine movements such as buttoning your clothes
• Dropping things—due to weakness, numbness, or a loss of proprioception (awareness of where your hand is in space)

During the day, symptoms often occur when holding something for a prolonged period of time with the wrist bent forward or backward, such as when using a phone, driving, or reading a book but night-time symptoms are very common. Many patients find that moving or shaking their hands helps relieve their symptoms.

Physical Examination

First, the doctor will discuss about the symptoms, medical history and examine the patient. Next is to perform some tests which may include:

• Tinel’s sign: The physician taps over the median nerve at the wrist to see if it produces a tingling sensation in the fingers.
• Wrist flexion test (or Phalen test): The patient rests his or her elbows on a table and allows the wrist to fall forward freely. Individuals with carpal tunnel syndrome will experience numbness and tingling in the fingers within 60 seconds. The more quickly symptoms appear, the more severe the carpal tunnel syndrome is.
• Electromyography (EMG) and nerve conduction studies: These studies determine how well the median nerve itself is working and how well it controls muscle movement.

Treatment

Although it is a gradual process, for most people carpal tunnel syndrome will worsen over time without some form of treatment. For this reason, it is important to be evaluated and diagnosed by the doctor early on. In the early stages, it may be possible to slow or stop the progression of the disease.

Carpal tunnel syndrome can be treated in two ways:
Non-surgically or with surgery. There are pros and cons to both approaches. Typically, non-surgical treatments are used for less severe cases and allow the patient to continue with daily activities without interruption. Surgical treatments can help in more severe cases and have very positive outcomes.

Nonsurgical Treatment
If diagnosed and treated early, the symptoms of carpal tunnel syndrome can often be relieved without surgery. If the diagnosis is uncertain or if the symptoms are mild, the doctor will recommend nonsurgical treatment first.
Bracing or splinting: Wearing a brace or splint at night will keep you from bending your wrist while you sleep and reduces pressure on the nerve in the carpal tunnel.This reduces pressure on the median nerve by keeping your wrist straight.
Nonsteroidal anti-inflammatory drugs (NSAIDs): Medications such as ibuprofen and naproxen can help relieve pain and inflammation.
Activity changes: Symptoms often occur when your hand and wrist are in the same position for too long—particularly when your wrist is flexed or extended.
​Steroid injections: Corticosteroid, or cortisone, is a powerful anti-inflammatory agent that can be injected into the carpal tunnel. Although these injections often relieve painful symptoms,their effect is sometimes only temporary. A steroid injection into the carpal tunnel may relieve symptoms for a period of time.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms after a period of time, the doctor may recommend surgery. The decision whether to have surgery is based on the severity of the patient’s symptoms. There are two different surgical techniques for carpal tunnel syndrome (endoscopic or open release), but the goal of both is to relieve pressure on the median nerve by cutting the ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve. The transverse carpal ligament is cut during carpal tunnel release surgery. When the ligament heals, there is more room for the nerve and tendons. The surgery can be done under general anesthesia or regional anesthesia. In open surgery, the doctor makes a small incision in the palm of your hand and views the inside of the hand and wrist through this incision. During the procedure, the doctor will divide the transverse carpal ligament. This increases the size of the tunnel and decreases pressure on the median nerve. In endoscopic surgery, the doctor makes one or two smaller skin incisions and uses a miniature camera to see inside the hand and wrist. A special knife is used to divide the transverse carpal ligament, similar to the open carpal tunnel release procedure.

Complications

Although complications are possible with any surgery the most common complications of carpal tunnel release surgery rarely include bleeding, infection, nerve aggravation or injury.

+How can carpal tunnel syndrome be prevented?

There are no proven strategies to prevent carpal tunnel syndrome, but the patient can minimize stress on the hands and wrists with these methods:

• Sleeping with your wrists held straight.
• Avoiding flexing (curling) and extending the wrists repeatedly.
• Decreasing repetitive/strong grasping with the wrist in a flexed position.
• Taking frequent rest breaks from repetitive activities.

Recovery

Surgery to repair carpal tunnel syndrome does not have a particularly long recovery. The hand can then be used for light activities in a few days. The patient can usually return to most activities in three weeks. Immediately following surgery, the patient will be encouraged to elevate your hand above your heart and move your fingers to reduce swelling and prevent stiffness. Grip and pinch strength usually return by about 2 to 3 months after surgery. Surgery for carpal tunnel syndrome has a very high success rate of over 90%. Many symptoms are relieved quickly after treatment, including tingling sensation in the hands and waking up at night. Numbness may take longer to be relieved, even up to six weeks.