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Carpal Tunnel Syndrome

Median nerve compression at the wrist resulting in Carpal tunnel syndrome is the most common peripheral nerve entrapment neuropathy. Patients will report tingling and numbness in the thumb index and middle fingers, difficulty manipulating small objects, aching around the wrist and a tendency to drop things. Night time symptoms of tingling disturb sleep and frequently numbness persists on waking. The loss of fine motor control is due to loss of sensory feedback as well as median-innervated intrinsic muscle weakness and the loss of thumb opposition. Clinical examination will confirm the diagnosis and neurophysiological tests may be used to confirm the diagnosis, provide a severity of grading or help in diagnosis in challenging or atypical presentation.

Open surgical decompression of the Carpal tunnel remains the gold standard although mini-open and endoscopic Carpal tunnel decompression have become popular in an attempt to reduce scar sensitivity following surgery and shorten return to work. Limited exposure techniques convey a higher risk of iatrogenic nerve injury. I use a traditional open approach in my practice.

Readers will also find the following associated techniques of interest:

Extended approach Carpal Tunnel decompression

Revision carpal tunnel decompression and application of Polyganics Vivosorb membrane

Combined median and ulnar nerve decompressions

Median nerve neurolysis, resection and reconstruction using Axogen AVANCE processed nerve allograft

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- Discussion:
- median nerve compression syndrome at the wrist;
- most common form of nerve entrapment;
- first described by Paget;
- references: The First Description of Carpal Tunnel Syndrome. James Paget FRS
- pathophysiology:
- nerve compression may result in ischemia, focal demyelination, decrease in axonal caliber, and finally axonal loss;
- ref: A Histological and Immunohistochemical Study of the Subsynovial Connective Tissue in Idiopathic Carpal Tunnel Syndrome.
- anatomy of carpal tunnel
- differential dx
- electrodiagnosis

- Initial Work Up:
- history:
- presence of pain in the wrist and/or fingers and presence of paresthesias in fingers;
- night pain may be especially predictive;
- physical exam
- differential dx
- EMG studies
- carpal tunnel injection / median nerve block
- references:
- The surgical treatment of the carpal-tunnel syndrome correlated with preoperative nerve-conduction studies.
- Carpal tunnel syndrome. An evaluation of the provocative diagnostic tests.

- Radiographic Studies:
- cross table lateral (for cervical spondylosis)
- carpal tunnel view
- MRI: (indicated w/ atypical CTS, ie. ? tumor, ? anomalous muscle).

- references:
The use of routine wrist radiography in the evaluation of patients with carpal tunnel syndrome.

- Non Operative Treatment:
- carpal tunnel injection / median nerve block

- Surgical Treatment:

- anatomy of carpal tunnel
- preoperative considerations:
- goals of surgery:
- eliminate compression by the tenosynovium;
- tenosynovectomy is performed if tissue is bulky, displaces flexor tendons;
- restore the gliding capacity of the nerve
- remove constriction by external epineurium, & liberate fascicles from internal adhesions; (latter two goals are controversial);
- eliminate pain:
- females who do not perform manual labor may not experience as much relief as male patients who do perform manual labor;
- factors influencing surgical results:
- The influence of age on outcome after operation for the carpal tunnel syndrome. A prospective study.
- Pre-operative factors and treatment outcome following carpal tunnel release.
- Results of treatment of severe carpal tunnel syndrome.
- Clinical Outcomes of Surgical Release Among Diabetic Patients With Carpal Tunnel Syndrome: Prospective Follow-Up With Matched Controls 
                  - Topographical Assessment of Symptom Resolution Following Open Carpal Tunnel Release 

- Surgical Treatment Options:

Carpal tunnel results from compression of the median nerve on the volar aspect of the wrist. Decompression is a successful operation when performed for the appropriate indication, when the nerve is completely released and when there is no impairment of nerve glide in the post-operative period.

Persistent carpal tunnel symptoms are associated with incomplete decompression and recurrent symptoms after an interval of 3 months or more are usually associated with a degree of scar formation causing further compression or resulting from nerve tether. The rate of failed primary carpal tunnel decompression is approximately 1:20. This figure includes those with significant persistent symptoms or new symptoms after surgery, incorrect diagnosis, contributing concomitant cervical radiculopathy and  a failure to manage the patient’s expectations when there is severe nerve dysfunction. The rate of recurrent carpal tunnel syndrome requiring revision decompression within 10 years of the primary procedure is an additional 1:20. Recurrence rates are higher in diabetic patients due to nerve susceptibility to compression and a tendency to develop thickened chronic tenosynovium around the flexor tendons within the carpal canal. Recurrence is also common in women with low body mass index, possibly due to the decreased subcutaneous adipose tissue that otherwise fills the void left after flexor retinaculum (FR) release. The post operative healing in such cases includes rapid reforming of the FR which results in the recurrent compression. Patients with Hereditary Neuropathy with sensitivity to Pressure Palsies (HNPP), a genetic condition, are prone to multiple peripheral nerve compressions and recurrent compression after release. Patients with complications from primary surgery including infection may have impaired nerve glide and develop persistent or recurrent symptoms after primary release.

One of the causes of failed carpal tunnel decompression (CTD) is scarring of the median nerve paraneurium that impairs physiological nerve glide. Revision CTD may require the use of an adjunct barrier to prevent scar formation resulting in recurrent nerve tether. There are a number of biological and synthetic alternatives. The Vivosorb is a bioresorbable polymer layer that can be sutured loosely around a scarred nerve to prevent scar tether in the surgical bed, maintain nerve gliding and prevent recurrence of compression.

Readers will also find the following associated techniques of interest:

Extended approach Carpal Tunnel decompression

Carpal tunnel decompression

Combined median and ulnar nerve decompressions

Median nerve neurolysis, resection and reconstruction using Axogen AVANCE processed nerve allograft

Read more »

This overview is brought to you by Orthoracle - the online e-learning Orthopeadic Surgery Atlas

Take the Tour

View this procedure on OrthOracle.com


- open surgical release
- enodscopic carpal tunnel release
- post op care and complications
- references:
- Endoscopic versus open carpal tunnel release: a randomized trial.
- A systematic review of reviews comparing the effectiveness of endoscopic and open carpal tunnel decompression.
- Outcomes of Open Carpal Tunnel Release at a Minimum of Ten Years

 

- References for Carpal Tunnel Syndrome

commercial devices for CTS
AM Surgical Endoscopic
CTRS - Carpal Tunnel Release System
Biomet Carpal Tunnel Release System

Ortho-Active Splint
Promed Braces

Medi-Dx 7000
Spectrum Dx Services
neurometrix nerve conduction studies
neumedinc nerve conduction studies

ASSI surgical instruments
Lone Star Retractors

Pain Relievers - carpal tunnel products