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Carpal Tunnel Syndrome: A Review
2010-11-15 11:11:53 Christopher Faubel, MD

By Chris Faubel, MD

Source: MedicineNet.com

Background
Carpal tunnel syndrome is a peripheral entrapment mononeuropathy of the median nerve as it courses through the carpal tunnel. Local compressive entrapment causes demyelination leading to nerve block (neuropraxia). If the compression persists, local nerve blood flow decreases (vasa nervorum) leading to a cascade of events eventually causing axon damage (axonotmesis). The pain is thought to result from inflammatory mediators (TNF) causing abnormal Na+ influx into these damaged nociceptive fibers.

Epidemiology
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. A Swedish general population survey in 1999 [1] showed 14.4% of responders reported numbness and/or tingling in the median nerve distribution, although only 1 in 5 (20%) symptomatic subjects were found to have clinically AND

electrodiagnostically confirmed CTS. The overall prevalence was said to be 2.7% of CTS confirmed by clinical exam and nerve conduction studies A US survey conducted in 1988 [2] showed an estimated 1.88% of the general population had self-reported carpal tunnel syndrome, with females and whites having the highest prevalence Certain occupations have been shown to have a much higher prevalence of CTS than the general population Female supermarket checkers: prevalence = 62.5% (self-reported symptoms only) [3] Mail service, health care, construction, and assembly and fabrication. [4] Risk factors (most strongly associated with CTS) [4] Repetitive bending/twisting of the hands/wrists at work (OR = 5.2) [OR = odds ratio] Race (OR = 4.2; WHITES higher than nonwhites) Gender (OR = 2.2; FEMALES higher than males) Use of vibrating hand tools (OR = 1.8) Age (OR = 1.03; risk increasing per year) Wrist ratio (A-P:med-lat) If the anterior to posterior distance is 70% of the medial to lateral distance, there is a significant association with idiopathic CTS. [30] High body mass index (BMI) obesity [38] Keyboard Use and CTS Some studies have shown no association between computer use and carpal tunnel syndrome. [31] [32] Another study found that workers who identified themselves as intensive keyboard users had less CTS than the control group. [34] A big problem with this study was that the control group had a significantly greater number of manual laborers with jobs that required repetitive twisting/bending of the wrists (the number one risk factor above). The question of whether intense keyboard use (i.e., >4 or >6 hours per day) is associated with an increased or decreased risk of CTS is still unanswered. [33] Bilateral CTS [29] 87% of patients with CTS, have electrodiagnostic (EDX) abnormalities bilaterally. 50% of asymptomatic hands have EDX findings of CTS. Most cases of unilateral CTS developed symptoms in the contralateral hand over time. Duration of symptoms, not severity of symptoms, positively correlated with developing bilateral CTS. Pregnancy Carpal tunnel syndrome is common during pregnancy. Wearing a night-time wrist splint helps reduce the pain for a week, but then it stays the same until delivery. [35]

Pain cuts in half during the first week after delivery, then half again the next week. [35] Pain reduction strongly correlated with weight loss after delivery. Symptoms frequently persist after delivery More than 50% of the patients after 1 year and in about 30% after 3 years [36] Corticosteroid injections provide significant relief [37] 4 mg of dexamethasone acetate was used in the third trimester. A month after delivery, both the injected and non-injected hands had symptom improvement.

Clinical Features
CTS can be thought of as occurring in three stages First stage Nocturnal sensations of hand swelling, numbness/tingling (in the median nerve distribution), and pain that frequently is felt all the way up to the ipsilateral shoulder. Patients may report that shaking their hands helps. Hand stiffness in the morning Second stage Same symptoms, but now during the day; mostly when the patients wrist remains in the same position too long, or with repetitive wrist movements. Dropping objects patients may start reporting that they drop objects because of hand weakness. Third stage Noticeable thenar muscle atrophy. Note: sensory complaint are now much less, or even completely absent. Paresthesia distribution in the hand [39] 70.4% of patients with CTS present with whole hand distribution of paresthesias 29.6% present with paresthesias strictly in the median nerve distribution Patients suffering from severe CTS were more likely to have median nerve distribution symptoms. Severity of symptoms vs NCS findings No statistically significant relationship between the severity of symptoms a patient has, and the severity of electrodiagnostic findings. [40]

Diagnosis
Important history (to get from the patient) Symptom onset (night vs day) Provocative factors (certain positions; repeated movements) Occupation (wrists movements; vibratory tools)

Pain localization (median distribution; ascending to shoulder; descending from shoulder) Alleviating maneuvers (shaking out hands; position changes) Predisposing factors (diabetes, obesity, acromegaly, pregnancy, polyarthritis) Sports/activites (baseball; body-building) Physical examination Katz hand diagram (click here for image) A patient is given a sheet of paper with outlined palmar and dorsal hands, and is asked to fill in the areas where they experience symptoms (pain; numbness; tingling). The physician then looks at the filled out diagram and classifies it as classic, probable, and unlikely. It was originally thought to correlate well with whether the patient will have electrodiagnostically-confirmed CTS. [5] A recent study in 2010 [6] had two hand surgeons evaluate 75 diagrams (filled out by patients with CTS and other pathologies) at two occasions 4-weeks apart. Inter-rater agreement was poor and intra-rater agreement was fair, making this test unreliable and inconsistent. Tinels test (at the wrist) Tapping over the median nerve directly over the carpal tunnel, or just proximal Sensitivity = 67%, Specificity = 68% [8] Very little diagnostic value in CTS More likely to be positive in the later stages of nerve compression [7] Phalens test Static wrist flexion for 60 seconds (or until symptoms) Sensitivity = 85%, Specificity = 89% [8] Positive mostly in moderate to severe CTS [41] Hypalgesia in the median nerve distribution Sensitivity = 51%; specificity = 85% [9] Electrodiagnostics **For a more detailed electrodiagnostic review of carpal tunnel syndrome, click here. Nerve conduction studies (median sensory and motor) setup description and photos here Median sensory and motor NCS: Sensitivity = 85%; Specificity = 95% If the median sensory is abnormal, test the ulnar sensory to make sure this isnt a polyneuropathy If the median sensory is normal, perform the combined sensory index (CSI) numb thumb, split ring, P8 (details here) Needle electromyography (EMG) Used to evaluate for axonal degeneration of the motor fibers in the

median nerve (will see positive sharp waves and fibrillations) Also used in the rest of the ipsilateral upper extremity to rule out other possible diagnoses. Not performed unless the patient has signs/symptoms that could be from another pathology. Grading the severity of electrodiagnostically-confirmed CTS Negative CTS = Normal findings on all tests Borderline mild CTS = Abnormal findings only on comparative or CSI tests (side-to-side comparison with ulnar sensory, or CSI tests) Mild CTS = Slow median sensory with normal distal motor latency Moderate CTS = Slow median sensory AND distal motor latency Severe CTS = Absent sensory and increased motor latency Profoundly severe CTS = Absent sensory and motor response MRI resonance imaging Median nerve signal intensity, transverse carpal ligament bowing, and other measurements of the carpal tunnel has a very high sensitivity [10] Also useful if a space-occupying lesion is the suspected cause of the CTS Ultrasound (image of carpal tunnel here excellent!) A study in 2009 showed that sonographic measurement of the median nerve cross-sectional area (CSA) at the tunnel inlet is a good alternative to NCS as the initial diagnostic test for CTS, but it cannot grade the severity of CTS as well as NCS. [11]

Natural History of CTS

1/3 of hands mid and moderate cases improve [27] In another study of 132 patients that received no treatment at all, 47.6% recovered, 28.8% remained stable, 23.4% worsened [28] two-year followup Nerve conduction study results mostly either stayed the same or improved Remission rates are highest in young females, and pregnant women.

Treatment (Non-Surgical)
Always start with a conservative approach unless motor deficits and severe sensory or electrodiagnostic abnormalities are present. Corticosteroid injections (carpal tunnel injection image and technique) More effective than placebo (saline) injections in the short-term, but not at a 12-month follow-up [12] Note: they only used 10-mg of kenalog, not the 40mg typically used in clinical practice, so the results may have been even better.

Another study found that steroid injections and wrist splinting are effective for relief of mild-moderate carpal tunnel syndrome symptoms but have a long-term effect in only 10 percent of patients (those with symptom duration less than 3 months and no thenar atrophy). [15] This study gave patients three injections of betamethasone throughout the year, not just a single injection. Many other studies have demonstrated clinical efficacy for months, but not an entire year. Keep in mind that corticosteroid injections can be repeated when symptoms return. Dosing matter! A study in 2006 looked at the efficacy of different doses of DepoMedrol. [16] In the 20, 40 and 60 mg treatment groups, 56%, 53% and 73% of the patients respectively were free of important symptoms at six months follow-up. Also, fewer patients in the 60-mg group went on to get surgery within a 12-months. Oral Corticosteroids Multiple studies have shown that oral steroids are less effective than injected steroids (into the carpal tunnel) Better than placebo with dose of 20-mg prednisolone daily for 2 weeks, followed by 10-mg daily for 2 weeks [17] Corticosteroid Iontophoresis Six sessions of 0.4% dexamethasone was not effective in the treatment of mild to moderate CTS [13] Wrist splints (image of neutral wrist splint) Use a neutral wrist splint, instead of a cock-up (extension) splint [20] Advised to tell patients to use only at night, because daytime use interferes with normal activities and the patient is therefore more likely to discontinue use all together Nighttime-only use of a neutral wrist splint was shown to be significantly more effective than doing nothing in patients with mild, recent onset CTS [14] NSAIDs No better than placebo [17] Diuretics No studies have shown any clinical benefit Yoga In one trial involving 51 people yoga significantly reduced pain after eight weeks compared with wrist splinting. [18] [19] Carpal mobilization In one trial involving 21 people carpal bone mobilisation significantly improved symptoms after three weeks compared to no treatment. [18] Pyroxidine (B6) In two trials involving 50 people, vitamin B6 did NOT significantly improve overall symptoms. [18] Ergonomic keyboards

Two trials involving 105 people compared ergonomic keyboards versus control and demonstrated equivocal results for pain and function. [18] Ultrasound Short to medium term benefits due to ultrasound treatment in patients with mild to moderate idiopathic carpal tunnel syndrome [21] 20 sessions of ultrasound (active) treatment (1 MHz, 1.0 W/cm2, pulsed mode 1:4, 15 minutes per session). Daily for two weeks, then twice a week for 5 weeks. Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did NOT demonstrate symptom benefit when compared to placebo or control. [18]

Treatment (Surgical)
Indications Patients who fail conservative methods, or have severe sensory deficits, or muscle atrophy. The major difference with the medical approach is that surgical transverse carpal ligament release (CTR) has very good long-term results, with very low recurrence rates. [25] Efficacy A 2007 review of 209 studies showed: [26] 75% complete resolution of symptoms, or only mild residual symptoms 17% mild improvement or no change 8% worsening of symptoms Best results are seen in patients with moderate NCS readings [42] Open vs Endoscopic release [22] (image of endoscopic carpal tunnel release) Patient satisfaction was equal (84-89%) Open method had longer return to work (median, 28 days, compared with 14 days ) Equal benefits (between the two techniques) Surgical vs splinting A significant proportion of people treated with splinting-only will require surgery [23] Diabetics Patients with diabetes have the same beneficial outcome after carpal tunnel release as nondiabetic patients. [24] Pregnant women should postpone surgery because symptoms frequently resolve completely soon after delivery. REFERENCES: 1 Atrosh et al. Prevalence of carpal tunnel syndrome in a general population.

JAMA. 1999 Jul 14;282(2):153-8. 2 Tanaka et al. The US prevalence of self-reported carpal tunnel syndrome: 1988 National Health Interview Survey data. Am J Public Health. 1994 Nov;84(11):18468. 3 Margolis W, Kraus JF. The prevalence of carpal tunnel syndrome symptoms in female supermarket checkers. J Occup Med. 1987 Dec;29(12):953-6 4 Tanaka et al. Prevalence and work-relatedness of self-reported carpal tunnel syndrome among U.S. workers: analysis of the Occupational Health Supplement data of 1988 National Health Interview Survey. Am J Ind Med. 1995 Apr;27(4):45170. 5 Katz JN, Stirrat C, Larson MG, et al. A self-administered hand symptom diagram in the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol. 1990;17:1495-1498. 6 Amirfeyz et al. Katz and stirrat hand diagram revisited. Hand Surg. 2010;15(2):71-3 7 Novak et al. Provocative sensory testing in carpal tunnel syndrome. The Journal of Hand Surgery. Volume 17, Issue 2, April 1992, Pages 204-208 8 Bruske et al. The usefulness of the Phalen test and the Hoffmann-Tinel sign in the diagnosis of carpal tunnel syndrome. Acta Orthopaedica Belgica 2002, N 2 (Vol. 68/2) p.141 9 DArcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA. 2000 Jun 21;283(23):3110-7. 10 Britz et al. Carpal tunnel syndrome: correlation of magnetic resonance imaging, clinical, electrodiagnostic, and intraoperative findings. Neurosurgery. 1995 Dec;37(6):1097-103 11 Moran et al. Sonographic measurement of cross-sectional area of the median nerve in the diagnosis of carpal tunnel syndrome: correlation with nerve conduction studies. J Clin Ultrasound. 2009 Mar-Apr;37(3):125-31 12 Peters-Veluthamaninga et al. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC Fam Pract. 2010 Jul 29;11:54 13 Amirjani et al. Corticosteroid iontophoresis to treat carpal tunnel syndrome: a double-blind randomized controlled trial. Muscle Nerve. 2009 May;39(5):627-33 14 -Premoselli et al. Neutral wrist splinting in carpal tunnel syndrome: a 3- and 6months clinical and neurophysiologic follow-up evaluation of night-only splint therapy. Eura Medicophys. 2006 Jun;42(2):121-6

15 Graham et al. A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome. Plast Reconstr Surg. 2004 Feb;113(2):550-6 16 Dammers et al. Injection with methylprednisolone in patients with the carpal tunnel syndrome: a randomised double blind trial testing three different doses. J Neurol. 2006 May;253(5):574-7 17 Chang et al. Oral drug of choice in carpal tunnel syndrome. Neurology. 1998 Aug;51(2):390-3 18 OConnor et al. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(1):CD003219 19 Garfinkel et al. Yoga-based intervention for carpal tunnel syndrome: a randomized trial. JAMA. 1998 Nov 11;280(18):1601-3 20 Burke et al. Splinting for carpal tunnel syndrome: in search of the optimal angle. Arch Phys Med Rehabil. 1994 Nov;75(11):1241-4 21 Ebenbichler et al. Ultrasound treatment for treating the carpal tunnel syndrome: randomised sham controlled trial. BMJ. 1998 Mar 7;316(7133):731-5 22 Brown et al. Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods. J Bone Joint Surg Am. 1993 Sep;75(9):1265-75 23 Verdugo et al. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(3):CD001552 24 Thomsen et al. Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-up with matched controls. J Hand Surg Am. 2009 Sep;34(7):1177-87 25 Keiner et al. Long-term follow-up of dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome: an analysis of 94 cases. Neurosurgery. 2009 Jan;64(1):131-7 26 Bland. Treatment of carpal tunnel syndrome. Muscle Nerve. 2007 Aug;36(2):167-71 27 Padua et al. Natural history of carpal tunnel syndrome according to the neurophysiological classification. Ital J Neurol Sci. 1998 Dec;19(6):357-61 28 Ortiz-Corredor et al. Natural evolution of carpal tunnel syndrome in untreated patients. Clin Neurophysiol. 2008 Jun;119(6):1373-8 29 Padua et al. Incidence of bilateral symptoms in carpal tunnel syndrome. J Hand Surg Br. 1998 Oct;23(5):603-6 30 Lim et al. The role of wrist anthropometric measurement in idiopathic carpal

tunnel syndrome. J Hand Surg Eur Vol. 2008 Oct;33(5):645-7 31 Stevens et al. The frequency of carpal tunnel syndrome in computer users at a medical facility. Neurology. 2001 Jun 12;56(11):1568-70. 32 Andersen et al. Computer use and carpal tunnel syndrome: a 1-year follow-up study. JAMA. 2003 Jun 11;289(22):2963-9 33 Rempel et al. Intensive keyboard use and carpal tunnel syndrome: Comment on the article by Atroshi et al. Arthritis Rheum. 2008 Jun;58(6):1882-3 34 Atroshi et al. Carpal tunnel syndrome and keyboard use at work: a populationbased study. Arthritis Rheum. 2007 Nov;56(11):3620-5 35 Finsen et al. Carpal tunnel syndrome during pregnancy. Scand J of Plas and Reconst Surg and Hand Surg 2006, Vol. 40, No. 1 , Pages 41-45 36 Padua et al. Systematic review of pregnancy-related carpal tunnel syndrome. Muscle Nerve. 2010 Nov;42(5):697-702 37 Niempoog et al. Local injection of dexamethasone for the treatment of carpal tunnel syndrome in pregnancy. J Med Assoc Thai. 2007 Dec;90(12):2669-76 38 Sharifi-Mollayousefi et al. Assessment of body mass index and hand anthropometric measurements as independent risk factors for carpal tunnel syndrome. Folia Morphol (Warsz). 2008 Feb;67(1):36-42 39 Caliandro et al. Distribution of paresthesias in Carpal Tunnel Syndrome reflects the degree of nerve damage at wrist. Clin Neurophysiol. 2006 Jan;117(1):228-31 40 Chan et al. The relationship between electrodiagnostic findings and patient symptoms and function in carpal tunnel syndrome. Arch Phys Med Rehabil. 2007 Jan;88(1):19-24 41 Sawaya et al. When is the Phalens test of diagnostic value: an electrophysiologic analysis? J Clin Neurophysiol. 2009 Apr;26(2):132-3 42 Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001 Jul;24(7):935-40

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