Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome (CTS) is a condition where pressure on the median nerve as it passes through a narrow tunnel, into the hand, results in pain, tingling and numbness in the fingers.

wrist pain

What is the cause of Carpal Tunnel Syndrome?

The carpal tunnel is a short tunnel on the palm side of the wrist formed by the carpal bones of the wrist and a thick ligament known as the flexor retinaculum. The carpal tunnel contains 9 flexor tendons (which roll the fingers and thumb into a fist) and the median nerve as they pass into the hand. The median nerve supplies sensation to the thumb, index, middle and half of the ring finger, as well as the muscles that form the bulk at the base of the thumb. Swelling within the carpal tunnel or pressure on the tunnel from the outside, can reduce the volume of the carpal tunnel and compress or irritate the median nerve, resulting in CTS symptoms. CTS can occur in association with common medical conditions such as diabetes, thyroid disorders and rheumatoid arthritis. Symptoms can also develop in pregnancy and these generally clear after delivery of the baby. However, in most cases of CTS there is no single identifiable cause.

What are the symptoms?

Common symptoms of Carpal Tunnel Syndrome include:

  1. Tingling sensations (“pins and needles”), pain and numbness in thumb, index, middle and ring fingers. These are typically worse at night, or first thing in the morning. Symptoms are aggravated by holding the hand in an elevated position, such as when driving, reading or speaking on a telephone. In the early stages the symptoms are intermittent and sensation will return to normal.
  2. As the condition progresses the symptoms become constant and weakness in the hand develops, resulting in the feeling of clumsiness, difficulty with fine tasks and dropping of objects.
  3. In more advanced stages, wasting of the muscle bulk at the base of the thumb can be seen and this mound flattens.
  4. The diagnosis is normally made on clinical assessment but sometimes special tests on the nerve known as nerve conduction studies are required. These are not required in every case.

What treatment is available?

Treatments for Carpal Tunnel Syndrome may include some of the following:

  1. Mild carpal tunnel symptoms will sometimes resolve spontaneously, especially if the hand is rested from heavy activity.
  2. Splints are often proposed to be worn especially at night. The purpose of this sort of splint is to keep the wrist straight, since bending the wrist in any direction tends to increase the pressure on the nerve and pinch the nerve.
  3. NSAIDS (non-steroidal anti-inflammatory drugs). These work by reducing any inflammation of the lining of the tendons in the tunnel and thereby gaining a bit of space.
  4. Carpal tunnel syndrome associated with pregnancy may settle after the birth of the baby. These symptoms sometimes persist through the period of breast-feeding.
  5. Steroid injection: In cases where the symptoms are mild or have been present for a relatively short period of time, a steroid injection directly into the carpal tunnel can lead to resolution of symptoms. Steroids cause shrinkage of tissues in contact and in this way, steroids into the carpal tunnel thin the tendon lining and gain some free space. The injection can be performed in the clinic during the consultation. This does not work instantly, but can lead to the resolution of symptoms over a period of a few weeks. The symptoms may return and the injection can be repeated.

If these treatments have not worked, or the symptoms are more severe, and especially if they have become continuous, carpal tunnel decompression surgery is recommended. There are generally two methods of surgery:

  • Open surgery. This is performed under local anaesthetic through a short incision at the palm/wrist. Through this incision, the tight ligament (flexor retinaculum) is cut and this releases all pressure on the nerve.The wound is stitched and the hand is then elevated above the level of the heart for a period advised by your surgeon, It is important to move the fingers through the full range during this period. The stitches are removed and the hand can be used normally
  • Endoscopic (keyhole) surgery. The flexor retinaculum can be cut through one, or two, very small incisions in the skin. An illuminated scope is inserted and the ligament can be cut through this. This is a specialised technique which many surgeons perform while others consider the extra risk is not justified by the gain.

Your surgeon can advise you on the choices and explain his/her preference.Both methods usually result in a resolution of symptoms. The tingling settles first, followed by the loss of feeling. In advanced cases the symptoms make take a long time to resolve or may not resolve completely. Patients with diabetes are particularly prone to incomplete return of feeling and use.

It generally takes about three months to regain full strength and a fully comfortable scar, but the hand can be used normally after two weeks, although surgeons’ policies vary.

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