CARPAL TUNNEL SYNDROME Name: Age: Sex: Race: R/N: HLL 45 yrs Female Chinese 02/1016

Sarawak General Hospital Case Report 45 year ol Chinese ho!se"i#e $resen%e "i%h %he chie# com$lain% o# $rogressi&e $ain an n!m'ness o&er %he le#% "ris% #or more %han 5 years( She clearly s%a%es %ha% her le#% han has %he %en ency %o ro$ o')ec%s an also has se&ere noc%!rnal $aras%hesia( Her $ain in %he le#% han mos% o#%en is%!r's her slee$( She has no *no"n me ical illness( +n examina%ion no%e $a%ien% %o ha&e ,inel sign an -halen %es% $osi%i&e( ,he -halen %es% $osi%i&e "as elici%e "i%hen 15 secon s( ,here "as no signi#ican% %henar m!scle "as%ing '!% mil "ea*ness "as no%e ( Her a' !c%or $ollicis 're&is m!scle $o"er "as gra e 4( ,"o $oin% iscrimina%ion %es% o&er her in ex an mi le #inger sho"e more

%han 10mm( Care#!l examina%ion o# %he cer&ical s$ine an L sho!l er re&eale no a'normali%ies( Semmes .eins%ein /ono#ilamen% %es% sho"e an $ro%ec%i&e sensa%ion o# %he L %h!m'0 in ex an mi iminishe ligh% %o!ch

le #inger(

She "as iagnose %o ha&e L car$al %!nnel syn rome( -a%ien% "as ini%ially s!')ec%e conser&a%i&e managemen% 'y !sing a s$lin% an %a'le% ne!ro'ion( A#%er 1 mon%hs $a%ien% "as re&ie"e an she com$laine o# $ain "i%h no im$ro&emen% in her sym$%oms( She "as s!')ec%e #or an o$en car$al %!nnel release on 22/2/01 !n er general anaes%hesia( ,he me ian ner&e "as #o!n %o 'e #la%%ene !e

a hesion o# s!rro!n ing %iss!es( ,he car$al %rans&erse ligamen% "as i&i e !n er irec% &ision an ne!rolysis "as one( Nex% ligh% ressing a$$lie 0 #ollo"e 'y s$lin%ing o# %he L han ( A#%er 1"ee*s $os% o$era%i&e $a%ien% claime %o ha&e re !ce nigh% $ain an Semmes .eins%ein /ono#ilamen% sho"e minimal im$ro&emen%( A% 6 "ee*s $a%ien% claime %o 'e sym$%om #ree an %he Semmes .eins%ein /ono#ilamen% "as normal(

DISSCUSSION Car$al %!nnel syn rome is increasingly recogni3e as one mani#es%a%ion o# o&er!se syn rome res!l%ing in com$ression o# me ian ner&e a% %he "ris%( 4n 1550 6ames -!%nam0 a 7os%on ne!rologis% $!'lishe a re$or% on a $re&io!sly !n8 escri'e con i%ion o# $ain an $araes%hesia in %he me ian ner&e is%ri'!%ion o# %he han a%%ri'!%ing i% ae%iology %o &asomo%or in origin( 9A ,h!rs%on0 2000: H!n% s%resse %ha% %he n!m'ness an $araes%hesia accor ing %o %heir is%ri'!%ion is more a%%ri'!%e %o %he com$ression o# %he %henar 'ranch o# %he me ian ner&e as i% $asses 'enea%h %he %rans&erse car$al ligamen% as a res!l% o# occ!$a%ional o&er!se 9A ,h!rs%on0 2000: 4n 1;11 /arie an Foix re$or%e %ha% %he %henar a%ro$hy "as !e %o %he me ian ner&e com$ression an 'y early %ransac%ion o# %he %rans&erse car$al ligamen% %he $rogression o# %he isease can 'e arres%e ( Ho"e&er Learmon%h $re#orme %he #irs% s!rgical release o# %he %rans&erse car$al ligamen% in 1;11( 4n or er %o !n ers%an %he %rea%men% o# %his $ro'lem0 "e "ill isc!ss %he ana%omy0 e%iology0 $a%ho$hysiology0 iagnosis an %rea%men% o$%ion o# car$al %!nnel syn rome(

ANATOMY Car$al %!nnel is a #i'ro8osseo!s %!nnel $resen% a% %he "ris%( Flexor re%inac!l!m #orms %he roo# o# %his %!nnel( /e ially a%%ache %o hoo* o# hama%e an $isi#orm( La%erally a%%ache %o %ra$e3i!m an sca$hoi %!'ercle( ,he #loor #orme 'y car$al 'ones( ,en s%r!c%!res $ass %hro %his %!nnel( 1: #lexor $ollicis long!s 2: #o!r s!$er#icial #lexor igi%or!m %o %he #inger 1: #o!r ee$ #lexor igi%or!m %o %he #ingers 4: me ian ner&e All s%r!c%!res are s!rro!n e 'y %hic* syno&ial lining o# ra ial an !lna '!rsae( 92: ,he rec!rren% mo%or 'ranch o# me ian ner&e has %hree common &arian%s< ex%raligamen%o!s 946=:0 s!'ligamen%o!s 911=:0 %ransligamen%o!s 921=:(,he la%%er %"o are a% ris* #or in)!ry !ring car$al %!nnel release(,he comm!nica%ing me ian an !lnar ner&e is $resen% in 50= %o ;0= o# cases an may lie in close $roximi%y %o %he is%al e ge o# %he %rans&erse car$al ligamen%( ,he in)!ries can res!l% in a $os%o$era%i&e $aras%hesia %o %he long an ring #inger(,he $almar c!%aneo!s 'ranch origina%es #rom %he me ian ner&e in %he #orearm0 a$$roxima%ely 5cm $roximal %o %he "ris% crease an con%in!es is%ally 'e%"een %he #lexor car$i ra ialis an $almaris long!s %en ons(

4% 'ecomes s!$er#icial a% %he "ris% an is &!lnera'le %o 'o%h %rans&erse an o'li>!e "ris% incisions( PATHOPHYSIOLOGY AND ETIOLOGY Any con i%ion %ha% lea s %o %he s"elling o# %he syno&ial %iss!e or increase in %he &ol!me o# s%r!c%!res insi e %he car$al %!nnel "ill ca!se com$ression o# %he me ian ner&e( Fac%ors ca!sing car$al %!nnel syn rome 1 Anato!" a: ecrease in %he si3e o# %he car$al %!nnel 'ony a'normali%ies o# %he car$al 'ones acromegaly #lexion an ex%ension o# %he "ris%

': increase in con%en%s o# %he canal #orearm an "ris% #rac%!res 9e(g( Colles an sca$hoi #rac%!res: isloca%ion an s!'laxa%ion o# %he car$al 'ones 9e(g( Sca$hoi ro%a%ory s!'laxa%ion0 l!na%e &olar isloca%ion: $os% %ra!ma%ic ar%hri%is 9e(g( +s%eo$hy%es: m!sc!lo%en ino!s &arian%s a'erran% m!scles 9e(g( l!m'ricals 0 $almaris long!s: local %!mo!rs 9e(g( Ne!roma0 li$oma0 m!l%i$le myeloma: $ersis%en% me ial ar%ery 9%hrom'ose / $a%en%: hy$er%hro$hic syno&i!m hema%oma 9e(g( hemo$hilia0 an%icoag!lan% %hera$y0 %ra!ma:

# P$"siolo%" a ne&ropat$i' 'on(itions ia'e%es melli%!s alcoholism o!'le cr!sh syn rome ' alteration in *l&i( )alan'e $regnancy meno$a!se eclam$sia hy$o%hyroi ism renal #ail!re long %erm ialysis rayna! isease ( ) in*la!!ator" 'on(itions non s$eci#ic syno&i%is go!% rhe!ma%oi ar%hri%is e+ternal *or'es &i'ra%ion irec% $ress!re

-age% isease Sclero erma o'esi%y amyloi osis

Ro)&iro) e% al 91;;2: re$or%e %ha% he $ress!re o# %he car$al %!nnel in $a%ien%s "i%h an i io$a%hic car$al %!nnel syn rome0 "as signi#ican%ly higher %han normal an %he mean $ress!re "as highes% in ;0 egrees o# "ris% orsi#lexion an lo"es% in %he ne!%ral $osi%ion( S3a'o 91;52: re$or%e similar #in ings '!% sho"e %ha% a#%er re$ea%e ex%en ing an #lexing %he "ris%0 reco&ery %o res%ing $ress!re %oo* longer %han in $a%ien%s "i%ho!% car$al %!nnel syn rome( Changes in %he ner&e #ollo"ing com$ression are com$lex an m!l%i#ac%orial incl! ing ner&e ischemia an changes in axo$lasmic %rans$or%( As $arano al s"elling occ!rs0 in%erno al myelin %hins lea ing %o segmen%al emyelina%ion( -rolong an re$ea%e amage %o %he myelin al%ers %he axon is%al %o %he $oin% o#

com$ression( 4# com$ression $ersis% all mo ali%ies ? mo%or0 sensory an a!%onomic can 'e a##ec%e ( @5A

CLINICAL MANIS,ESTATION AND DIAGNOSIS Commones% sym$%oms are sensory in na%!re "i%h %he $a%ien% re$or%ing %he han Bgoing %o slee$C( N!m'ness mos%ly con#ine %o %he me ian ner&e is%ri'!%ion "i%h in ex an mi le #inger in&ol&e ( 9ini%ially in%ermi%%en% '!% may 'ecome $ersis%en% an

aggra&a%e "i%h "ris% #lexion: Sym$a%he%ic is%!r'ances s!ch as excessi&e s"ea%ing an mil e ema( As car$al %!nnel syn rome "orsens noc%!rnal $ain an %ingling sensa%ion may "a*e %he $a%ien%( Sha*ing or r!''ing %he han relie&es %he $ain %em$orarily( /o%or in&ol&emen% may $resen% as cl!msiness !e %o "ea*ness in%rinsic %henar m!sc!la%!re s!$$lie 'y me ian ner&e( -a%ien% e&elo$s %en ency %o ro$ %hings an i##ic!l%y in !nscre"ing 'o%%le ca$s( 7ase o $a%%ern o# in&ol&emen% car$al %!nnel syn rome can 'e i&i e in%o %hree s%ages< early0 $rogressi&e an la%e( 4n early %he sym$%oms only arise "hen $ro&o*e ( 4n $rogressi&e %he sensory sym$%oms are al"ays %here "i%h mil mo%or sym$%oms( 4n la%e 'o%h sensory an mo%or in&ol&emen% are >!i%e a &ance an %henar "as%ing is !s!ally no%e (

DIAGNOSTIC TEST a: a' !c%or $ollicis 're&is $o"er %es% ? com$are %he s%reng%h on %he normal an a##ec%e si e( ': %"o $oin% iscrimina%ion "hich is ma$$e o!% on %he #inger ?%i$s c: %inselCs %es% : $halenCs %es% e: re&erse $halenCs %es% Songcharoen e% al 91;55: e&al!a%e %he !se#!lness o# %he a'o&e %es% "here %innelCs "as ;5= s$eci#ic0 -halenCs "as 26(1= s$eci#ic "here else re&erse $halenCs "as less s$eci#ic( IN-ESTIGATION a: Ner&e con !c%ion s%! ies can 'e !se %o con#irm %he iagnosis an may'e !se#!l in eci ing "he%her s!rgery is nee e ( 4% m!s% 'e *e$% in min %ha% #alse nega%i&e res!l%s co!l occ!r( Dr!n 'erg 91;51: re$or%e 5= o# sym$%oma%ic $a%ien%s "i%h normal elec%rical s%! ies( ': Ra iogra$hs ? car$al %!nnel syn rome #ollo"ing %ra!ma%ic e&en%s or associa%e "i%h os%eoar%hri%is a normal A- x8ray "ill 'e nee e %o r!le o!% any 'ony $a%hology(

DI,,ERENTIAL DIAGNOSIS 1: cer&ical ra ic!lo$a%hy 2: %horacic o!%le% com$ression 1: an%erior in%erosseo!s ner&e en%ra$men% 4: o!'le cr!sh syn rome

5: $olymyalgia rhe!ma%ica TREATMENT A Conser.ati.e %his mo e o# %rea%men% is !s!ally o##ere %o early s%ages o# car$al %!nnel syn rome( 4% com$romises o# nigh% s$lin%s0 NSA4E0 change in aily ac%i&i%ies/occ!$a%ion ca!sing %he sym$%oms0 $hysio%hera$y0 s%eroi al in)ec%ions( 9Del'erman RH0 1;;2 S$lin%ing8 a regimen o# ay an nigh% s$lin%ing is 'elie&e %o re !ce me ian ner&e irri%a%ion !e %o excessi&e ex%ension( i# sym$%oms im$ro&e 'y 1 mon%hs %hen only con%in!e nigh% s$lin%ing( i# no im$ro&emen% no%e %hen a NSA4E/ s%eroi al in)ec%ions #or 1 mon%hs(

Ees$i%e %he a'o&e %rea%men% i# se&eri%y s%ill increases %o o$% #or s!rgical release( -hysio%hera$y an occ!$a%ional %hera$y %ha% is aime %o e&al!a%e s%a%ic an $os%!res %ha% increases %he o&er!se o# cer%ain gro!$ o m!scles( ynamic

-ain0 e ema an "ea*ness can 'e %rea%e "i%h #l!i %hera$y an ,FNS 9%ransc!%aneo!s elec%rical ner&e s%im!la%ion: -yri oxine a minis%ere in e#iciency s%a%es ca!sing car$al %!nnel syn rome S%eroi 9hy rocor%isone: in)ec%ion in%o car$al %!nnel %o re !ce s"elling !e %o #lexor ,enosyno&i%is has $!'lishe re$or%s %o s!gges% !$ %o 50= im$ro&emen% ini%ially in $a%ien%s "i%h early car$al %!nnel syn rome an only a'o!% 10= o# %hese $a%ien%s ha&e $ermanen% relie#( 9Del'erman RH0 1;;2: / S&r%er" 4n ica%ion: 8 #aile conser&a%i&e managemen% in $a%ien%s "i%h early car$al %!nnel syn rome( :8$a%ien%s "ho $resen% "i%h $rogressi&e an la%e car$al %!nnel syn rome :8ac!%e $resen%a%ion o# car$al %!nnel syn rome( -rinci$al o# %he s!rgery "o!l 'e %o ecom$ress %he me ian ner&e 'y releasing %he %rans&erse car$al ligamen%( ,echni>!es a: o$en car$al %!nnel release ': o!'le incision o# B.ilsonC c: minimal incision o# B7romleyC ? en osco$ic %echni>!e 4n o$en car$al %!nnel release generally a longi%! inal c!r&e incision is ma e o&er %he $alm region $arallel %o %he %henar crease( ,he incision can 'e in a #orm o# a la3y GSH %h!s a&oi crossing %he #lexor crease a% righ% angle %o a&oi $ain#!l scar $os% o$era%i&ely

+n reaching %he %rans&erse car$al ligamen%0 $lace a 'l!n% issec%or 'enea%h %he #ascia an %hen incise %he "hole 'rea%h o# %he ligamen% 9a&oi in)!ry %o %he s!$er#icial $almar ar%erial arch a'o!% 585mm is%al %o %he %rans&erse car$al ligamen%( 4# syno&i%is is $resen% %hen %enosyno&ec%omy may 'e in ica%e ( A#%er %he s!rgery com$ression ressing an &olar s$lin%ing m!s% 'e carrie o!%( 4n %he $as% #e" years0 en osco$ic %echni>!es ha&e 'een !se more "i ely %o ecrease %he inci ence o# $os% o$era%i&e $ain an $ain#!l scar #rom an o$en o$era%i&e $roce !re A(.anta%es o* en(os'opi' s&r%er" are 8less $almar scarring 8less !lnar $illar $ain 8ra$i re%!rn %o "or* an com$le%e re%!rn o# han s%reng%h( Disa(.anta%es o* en(os'opi' s&r%er" 8%echnically eman ing $roce !re 8limi%e &is!al #iel 8increase chances %o in)!re me ian ner&e #lexor %en ons an s!$er#icial $almar ar%ery arch 8ina'ili%y %o con%rol 'lee ing 8limi%a%ion ca!se 'y mechanical #ail!res(

Contrain(i'ation o* en(os'opi' release are 8$a%ien%s "ho re>!ire ne!rolysis0 %enosyno&ec%omy or ecom$ression o# g!yonCs canal( 8$resence o# s$ace occ!$ying lesions an m!scle0 %en on or &essel a'normali%ies( 8$a%ien%s "i%h locali3e in#ec%ion( 8$a%ien%s "ho ha&e !n ergone $re&io!s s!rgeries an c!rren%ly re>!ires re&ision s!rgery 8$resence o# ana%omical &arian%s o# me ian ner&e( +r%ho$e ic s!rgeons are "or*ing %o im$ro&e en osco$ic car$al %!nnel release 'y mo i#ying %echni>!es or ins%r!men%a%ion( Cho" 91;;1: has re#ine his %"o $or%als a$$roach 'y re$lacing an ex%ra'!rsal a$$roach #or %he original %rans'!rsal %echni>!e0 "i%h #e"er $os% o$era%i&e com$lica%ions( Recen%ly0 /ir3a e% al 1;;6 in%ro !ce a is%al 9$almar: !ni$or%al en osco$ic car$al %!nnel release (/ir3a an Iing 'elie# %ha% a is%al 9$almar: !ni$or%al en osco$ic car$al %!nnel release has i% 'ene#i%s since i% is a single incision in %he $alm "hich excl! es %he nee #or a secon incision in %he "ris% an a&oi s in)!ry %o %he $almar c!%aneo!s 'ranch o# %he me ian ner&e( Ho"e&er all en osco$ic "ris% s!rgery has a large learning c!r&e an nee s %o 'e $er#orme 'y ex$erience han s(

RE,ERENCES 1( A( ,h!rs%on: Ae%iology o# %he so calle Bi io$a%hicC car$al %!nnel syn rome( C!rren% +r%ho$ae ics N+J 2000( 2( Car$al ,!nnel an !lnar ,!nnel Syn romes an S%enosing ,enosyno&i%is: Cam$'ell +$era%i&e +r%ho$ae ic Jol!me 4< 1615 1( Del'erman RH0 Aronson E0 .eisman /H< Car$al ,!nnel Syn rome0 res!l% o# a $ros$ec%i&e %rial o# s%eroi in)ec%ion an s$lin%ing( 6 Han S!rg 1;;2< 12A:100181005( 4( Dr!n 'erg A7: Car$al %!nnel ecom$ression in s$i%e o# a normal elec%romyogra$hy( 6 Han S!rg 1;51< 145814;( 5( /ir3a /A0 Iing F,0 Ne"er %echni>!es o# car$al %!nnel release( +r%ho Clin( Nor%h Am( 1;;6< 22:1558121( 6( Ro)&iro) S0 Siricha%i&a$ee N0 Io"s!"on .0 .ong"i"a%%ananon 60 ,amnan %hong N0 6eera&i$ool&am -: -ress!res in %he car$al %!nnel( A com$arison o#$a%ien%s "i%h car$al %!nnel syn rome an normal s!')ec%s( 6 7one an 6oin% S!rg 1;;0< 227 5168515( 2( S3a'o R/0 Del'erman RH0 .illiamson RJ0 e% al: Ji'ra%ory sensory %es%ing in ac!%e $eri$heral ner&e com$ression( 6 Han S!rg 1;54< ;A 104810;( 5( ,o$ics in !$$er ex%remi%y care $!'lishe )oin%ly 'y %he Chris%ine /( Ileiner% 4ns%i%!%e #or Han an /icros!rgery an Lo!is&ille Han S!rgery(