By John E. Blank, MD

I see many patients in my office suffering from Carpal Tunnel Syndrome which causes pain in the wrist and hand. It is caused by increased pressure in the wrist and more specifically in a space known as the carpal tunnel.   In the U.S., approximately 1 out of 20 people will suffer from this painful condition.  Women tend to suffer from this condition more than men.  The incidence also increases with age.

The carpal tunnel is formed by a floor and two walls of bone and a roof made of a ligament which connects the bones together.  The median nerve and nine tendons travel through this small space.  Increased pressure upon the median nerve can affect its sensory and motor function. This can result in pain, numbness and tingling (also referred to as paresthesia) especially in the distribution of the median nerve which most notably includes the thumb, index, long fingers and part of the ring finger. Patients can experience these paresthesias at a variety of times during the day, especially with repetitive and strenuous tasks. They can occur while driving, reading and gripping objects.  Some patients will even wake up at night with symptoms. Patients often have to shake and massage the hand in a lower or dependent position to effectively increase blood flow to the region. Later stages often include constant numbness, a sand paper type feel to the finger tips and muscle weakness including thumb atrophy.

Early diagnosis is helpful to avoid the potential for later chronic irreversible changes.  I will initially review the patient’s medical history to help determine if the patient has risk factors for this condition:
• Illnesses such as hypothyroidism, rheumatoid arthritis, and diabetes
• Pregnancy (usually in latter stages due to excessive fluid retention)
• Obesity
• Activities or repetitive motions that may exacerbate the condition

I will perform a physical examination to identify the location of pain and also identify sensitivity of the median nerve through compression or percussion tapping or testing of the nerve at the wrist crease.  I find diminished sensation and thumb/hand weakness with more advanced cases.  I may order electrodiagnostic testing to confirm the diagnosis.   Those with the condition will show a delay in response in the sensory and or motor function of the nerve as it travels through the carpal tunnel under pressure.

When possible, I will first try more conservative treatments to relieve the symptoms:
• Avoidance of activities that aggravate the symptoms.  Daytime avoidance of some wrist positions such as deep flexion and repetitive work for prolonged periods of time may reduce the paresthesias.
• Wrist and hand strengthening exercises to help improve wrist position and grip strength.
• Night time use of wrist splits to keep the wrist and hand in a more neutral position.
• Non-steroidal anti-inflammatory drugs taken orally to help reduce swelling in the carpal tunnel.
• Corticosteroid injections directly into the carpal tunnel for more long lasting relief. Injection therapy can provide relief commonly for 6-12 weeks but may need to be repeated.

Ultimately, if a patient has a significantly positive electrodiagnostic study and conservative treatments fail to relieve the symptoms, I will recommend surgery.   There are a variety of surgical techniques but they all have the same goal:  pressure release within the carpal tunnel through ligament transaction. For some patients, I can perform an endoscopic carpal tunnel release which involves a limited incision utilizing small instruments and a TV monitor.  Other patients may require a standard open palm carpal tunnel release.

The surgery is an out-patient procedure.  Dressings may be removed 3-4 days after surgery and replaced with a waterproof band-aide.  Stitches will be removed 7-10 days after surgery during the post operative visit. I recommend my patients to move their fingers as soon as they can after surgery for early range of motion recovery and to help with any swelling in the joints.  On average, patients go back to work light duty 5-7 days after surgery depending on their occupation.

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