What is Carpal Tunnel Syndrome? A Brief Description.
Carpal Tunnel Syndrome (CTS) is one of the leading causes of hand and finger numbness and pain.
Carpal Tunnel Syndrome is most commonly caused by compression of the median nerve at the wrist secondary to tenosynovitis or inflammation of the flexor tendons as they travel together with the nerve through the carpal canal of the wrist.
Classic symptoms include the sensation of ‘pins and needles’, tingling or numbness at the fingertips, particularly at the thumb, index, and middle fingers. There may be associated tightness or pain at the wrist area. In severe cases, patients may have more pronounced numbness (decreased sensation) and pain, weakness of the hand, a feeling of ‘clumsiness’ handling small objects like buttons and dropping objects, changes in hand writing and wrist pain.
Symptoms are often worse during the night and after repetitive activities like typing, gripping tools, driving, reading the newspaper, holding the telephone receiver and using chopsticks. Night symptoms can disturb the patient’s sleep.
Other conditions associated with Carpal Tunnel Syndrome include a tumour in the carpal tunnel canal, diabetes mellitus, hypothyroidism, menopause, pregnancy, renal failure, Raynaud’s Disease, Repetitive Strain Injuries and Double Crush Syndrome. These conditions cause carpal tunnel syndrome by similarly increasing the pressure within the carpal tunnel at the wrist and compressing the median nerve.
An accurate medical history and clinical examination are usually sufficient to make the diagnosis. X-rays may be considered if a bone problem is thought to be a possible cause. Nerve conduction studies, either alone or with electromyography (EMG), may be necessary in severe cases or when there is suspicion that that more than one area of the nerve is being compressed.
Non-surgical treatment (sometimes called Conservative treatment) usually involves taking anti-inflammatory medication, nerve vitamins, splinting and physiotherapy.
When non-surgical treatments are unsuccessful, in cases of symptom recurrence, and in symptomatically severe cases, surgical treatment may be necessary. There are several surgical options available – the traditional open carpal tunnel release, and the (minimally invasive) endoscopic carpal tunnel release.
What Non-Surgical Treatments are useful for Carpal Tunnel Syndrome?
The current conservative treatments for carpal tunnel syndrome include splints, non-steroidal anti-inflammatory medications, activity modification, pyridoxine, and local injection of corticosteroids. In addition, yoga, chiropractics, ultrasound and laser treatment have also been advocated but evidence for their effectiveness is still lacking.
1. Wrist Splinting (or brace)
Splinting is the most popular method among the conservative treatments of Carpal Tunnel Syndrome. Splinting the wrist immobilises the wrist in a neutral position to maximise carpal tunnel volume and minimise pressure on the median nerve, and aims to avoid further damage from twisting or bending. It is especially important to wear this splint during sleep or with activities that aggravate symptoms. Rest the affected hand and wrist for at least two weeks.
2. Non-Steroidal Anti-inflammatory medications (NSAIDs)
NSAIDs relieve pain and inflammation of the tendons (tenosynovitis) that pass through the carpal tunnel at the wrist. This in turn helps to reduce the pressure within the carpal tunnel that compresses the median nerve, and alleviates symptoms.
NSAIDs are very useful as short-term therapy for 2 and 4 weeks and for controlling occasional flare-ups. Long-term results with NSAIDs have been poor and have potentially serious side effects such as gastric irritation and ulceration.
3. Vitamin B6 (Pyridoxine)
Vitamin B 6, given in conjunction with vitamins B 1 and B 12 , has a pain-killing effect that is due to inhibition of the body’s natural pain conduction system. Studies demonstrate that vitamin B 6 is effective in relieving the pain associated with CTS, and there is also evidence that B6 deficiency may cause CTS in some cases (Jurna I 1998; Holm G et al 2003). One study (Holm G et al 2003) recommended that 200 mg vitamin B 6 daily be included in treatments for CTS.
However, Vitamin B6 should be used with caution since high doses over the long term can cause damage to the central nervous system or neuropathy (damage to peripheral nerves).
4. Corticosteroid or Cortisone injections
When an initial course of non-surgical treatments (such as rest, splints, and anti-inflammatory medicines) is unsuccessful, injections of corticosteroids directly into the carpal tunnel may sometimes be recommended.
Corticosteroids are powerful anti-inflammatory medicines and may have side effects. Repeat or multiple injections with corticosteroids should be avoided, to avoid the complications associated with corticosteroid injections, including nerve damage and relapse.
5. Activity Modification
Avoiding activities that may worsen symptoms, especially those that require repetitive hand and wrist movements, and the use of vibrating tools. Take frequent breaks and perform stretches and warm-ups before activity. Ergonomic changes at work may also include adjusting your desk, chair, and keyboard so you are in the best possible position.
In the very early stages of the condition, or as a preventive measure, try these hand and wrist exercises that may reduce your symptoms. [read our post: exercises to prevent Carpal Tunnel Syndrome]
6. Control underlying conditions.
Controlling any underlying conditions, such as diabetes, rheumatoid arthritis, or hypothyroidism, which may contribute to some extent in making your carpal tunnel syndrome symptoms worse.
When do I need to see a doctor for my Carpal Tunnel Syndrome?
The relative safety of conservative treatment options offer obviously benefits in using them for the initial management of early Carpal Tunnel Syndrome. However, one should also consider that except in these early or mild cases, conservative therapy generally offers only temporary symptom relief.
Delay in formal medical assessment and definitive surgical treatments could result in progressive damage to the median nerve. The purpose of surgery is to relieve pressure on the nerve and prevent the condition from progressing, preventing permanent damage to the nerve that can sometimes lead to thumb muscle weakness and permanent numbness of the fingers.
If your symptoms persist beyond a few weeks or are increasing in severity; if your hand and finger numbness lasts for hours at a time or regularly interrupts your sleep; or if you have severe symptoms like weakness of grip, frequently dropping objects or inability to distinguish between different coin sizes etc., do see your local hand surgeon soon.
Do I need Conservative (non-surgical) or Surgical Treatment for Carpal Tunnel Syndrome
Treatment recommendations for carpal tunnel syndrome are based on several factors including symptom severity, duration of symptoms, evidence of nerve damage, presence of other medical conditions, and whether other non-surgical treatments have worked.
One useful research paper entitled Predictive factors in the non-surgical treatment of carpal tunnel syndrome, by Kaplan et al [published in Journal of Hand Surgery (Br.) 1990 Feb; 15(1): 106-8] proposed a way to identify patients that are likely to respond to the medical (non-surgical) management of carpal tunnel syndrome. 331 hands in 229 patients were evaluated in this study. Medical treatment included wrist splints and anti-inflammatory medication. These patients were followed-up for a period of an average of 15.4 months with a minimum of six months in some patients.
The average treatment success rate with this approach was 18.4%. However, when they stratified these patients into groups based on their symptoms and clinical tests, they manage to identify 5 factors that were important in predicting response to non-surgical treatment. These were:
Age over 50 years,
Duration of symptoms greater than 10 months,
Constant paraesthesiae (numbness),
Stenosing flexor tenosynovitis, and
A Phalen’s test that is positive in less than 30 seconds.
When none of these factors was present, two-thirds (67%) of these patients were cured by medical (non-surgical) therapy. When any one factor was present, only 40% improved. When any 2 factors were present, only 16% of these patients improved and when 3 factors were present, those 7% of those patients improved. When a patient had four or five of these factors present, none of them were cured by medical management alone!
Simply put – the older you are, the longer you’ve had your symptoms, the more severe those symptoms are, and if you have other tenosynovitis conditions in the hand (e.g. trigger finger), then the less likely you are to improve with non-surgical treatments alone. In these cases, early surgical treatment provides better results and a more complete and rapid recovery.
Surgery decompresses the carpal tunnel, relieves the pressure on the median nerve and prevents the condition from progressing. This prevents permanent damage to the nerve that can sometimes lead to thumb muscle weakness and permanent numbness of the fingers.
Dr. Jonathan Y. Lee, a leading Singapore Hand Surgery and Orthopedic upper limb Specialist, discusses Carpal Tunnel Syndrome, a common cause of pain and numbness of the hands and fingers.
