Topic Review :

Carpal Tunnel
Syndrome

Outlines
Definition and Epidemiology
Review Anatomy
Pathophysiology
Etiology
Clinical Manifestation
Diagnosis
Treatment

Definition
/

The American Academy of Orthopaedic

Surgeons (AAOS) definition :
a symptomatic compression
neuropathy of the median nerve at the
level of the wrist

Epidemiology
More common in females than in males
Peak age range 40 - 60 years
5060% of the cases are bilateral
1 in every 5 subjects who complains of
symptoms such as pain, numbness and a
tingling sensation in the hands

Carpal Tunnel Syndrome: A Review of the

Recent Literature
Open Orthop J. 2012; 6: 6976.

Review Anatomy
Carpal Tunnel
fibro-osseous canal : passageway from the
forearm to the anterior hand

Review Anatomy : Border

Review Anatomy :
Contents

Review Anatomy : Median

n.
Digital nerves :
- Sensory of lateral palm
& lateral three and half
digits
- Lateral two lumbrical
muscles
Recurrent branch of
Median n. :
- Thenar muscles :
opponens pollicis
abductor pollicis
brevis

Pathophysiology
Multiple Mechanisms
Increased tunnel pressure
Demyelination of the nerve in compression
site
impaired endoneural capillary system
alteration of blood-nerve barrier
development of endoneural edema
Neuropathic pain

Etiologies
Idiopathic carpal tunnel syndrome
correlated with hypertrophy of the synovial
membrane of the flexor tendons
Predisposing Factor

Sex
Age
Size of the carpal tunnel
Repetitive manual activities
Obesity
Smoking

Note : Workplace Factors (eg. Computer use)

Controversial

Etiologies (2)
Secondary carpal tunnel syndrome
Container

Content

Shape or position of
the carpal bones : Fx,
Dislocation
Shape of the distal
extremity of the
radius : fx DER
Joint : infectious
arthritis, Posttraumatic arthritis
(Osteophytes)
Acromegaly

Tenosynovitis :
Inflammatory
Metabolic : DM,
gout,
chondrocalcinosis
Edema
Hypothyroid

Pregnancy (esp. 3rd

tm)

Obesity
Intratunnel Tumor :
lipoma, synovial cyst,
neural tumor
Hematoma :

Clinical Presentations
Sensory

Motor

Stage 1

Frequent Night awakening due

to pain , sensation of swollen,
numb, tingling in Median n.
distribution
Hand Shaking (Flick sign) relieve
symptoms
Sensation of hand stiffness in
morning

Stage 2

Symptom present during the day Motor deficit :

mostly when remaining in same
object fall from
position or repeated movement
hands due to
of hand and wrist
unable to feel
the fingers

Clinical Presentations (2)

Sensory
Stage 3

Motor

Sensory symptoms may diminish Thenar Atrophy

Aching in the thenar eminence
Weakness of
abductor pollicis
brevis and
opponens
pollicis

Clinical Presentations (3)

In 159 hands of patients with
electrodiagnostically confirmed CTS
symptoms were most commonly reported in
both the median and ulnar digits more
frequently than the median digits alone.
21% of patients had forearm paraesthesias
and pain
13.8% reported elbow pain
7.5% reported arm pain
6.3% reported shoulder pain
0.6% reported neck pain

Clinical Presentations (4)

Autonomic
hands being cold/hot all the time , Sweating
sensitivity to changes in temperature
(particularly cold) and a difference in skin
color

Diagnosis
History Taking
Physical Examination
Investigation

Diagnosis : History Taking

Symptom onset & duration
Characteristics

Time : day? Night? All day?

Quality : Tingling, burning, aching
Intermittent? Persistent?
Exacerbating factor
Alleviating Factor

Location? Radiation?
Previous treatment
Lifestyle and activities? , Functional limitation?

Diagnosis : Physical
Examination
Motor :
Abductor policis longus
Thenar atrophy

Sensory
tested in all regions of the hand, forearm,
and upper arm
two-point discrimination, Semmes-Weinstein
monofilament

Diagnosis : Physical
Examination (2)
Provocative Test : Adjunctive
Phalens Test
Wrist Flex Increase Intra-tunnel pressure
Positive = pain or paresthesia in the distribution of median n.

Tinels Test
Temporary increase pressure
Positive = paresthesia in the fingers innervated by the median nerve:
the thumb, index, middle finger and the radial side of the ring finger

Manual Carpal Compression test

Apply pressure over the transverse carpal ligament
Positive = Paresthesia within 30 seconds

Unreliable when used alone in the diagnosis of CTS

Physical Examination :
Provocative Test
Phalens test
Tinels test
Manual Carpal
Compression
test

Sensitivity
68%
50%
64%

Specificity
73%
77%
83%

Diagnosis : Investigation
Options
Electrodiagnostic testing :
Nerve conduction studies (NCS)
Needle Electromyography (EMG)

Imaging
Ultrasound : patients with CTS have
significantly increased cross-sectional area of
the median nerve
MRI : May be beneficial in patients with
suspected intralesion mass

Diagnosis : Investigation
(2)
Nerve Conduction Study
Myelin sheath Delayed Conduction velocity
Axon loss Reduce Action potential
amplitude

Indication
Confirming Diagnosis if Clinical unclear
Guide appropriate selection of patient for
Carpal tunnel release and Inform prognosis

Accuracy
sensitivity : 80- 92%
specificity : 80-99%

Diagnosis : Investigation

Differential Diagnosis
Distinguished
characteristics
Cervical radiculopathy
(esp. C6 or C7)
+ CTS = Double Crush
syndrome

Cervical spondylotic
Myelopathy /
Cervical Spondylotic
radiculopathy

Neck pain
Radiation of pain from neck
Shoulder arm
Weakness of proximal arm
muscle
Sensory loss outside the
region
NCS : unaffected sensory
nerve AP
Neck pain
Usually bilateral
Involve lower limbs

Differential Diagnosis
Distinguished
characteristics
Brachial Plexopathy

weakness, sensory loss, or

diminished reflexes outside
the distribution of the median
nerve

Proximal Median neuropathy

(Esp. Pronator teres lvl)

sensory loss over the thenar

eminence,
weakness of thumb flexion,
wrist flexion, and arm
pronation

Treatment
Non-Surgical Treatment
Surgical Treatment

Treatment : Non-Surgical
Recommendati Lifestyle
on

Instrument

Medication

Suggest
(Grade B, Level I
and II)

Nocturnal Wrist
Splint

Local Steroid
injection

Option
(Grade C, Level
II)

Ultrasound
therapy

Oral steroid

-Cold therapy
-Acupuncture
-Electric
stimulation
-Iontophoresis
-Phonophoresis

-NSAIDs
-Diuretics
-Vitamin B6
-Antidepressants
-Anticonvulsants
-Systemic
Steroid injection

No
Recommendatio
n for or against
the use
(Inconclusive,
Level II and V)

-Activity
modification
-Exercise : nerve
gliding exercise
-Massage
-Stretching
-Smoking
cessation
-Weight
reduction
-Yoga

Nerve Gliding Exercise for CTS

Treatment : Non-Surgical
(2)
Nocturnal Wrist Splint (cockup splint)
Wrist splints
Good choice for initial therapy, Esp in those
with mild moderate symptoms

Treatment : Non-Surgical
(3)
Local Glucocorticoid Injection
Appear effective in reducing subjective
symptoms of CTS for 1-3 months
Suggest once every 6 months per wrist
Recurrent symptoms after 2 injections,
suggest another nonsurgical treatments or
surgical evaluation.
Side effect : limits reduces collagen and
proetoglycan synthesis reduce tendon strength

Treatment : Surgical
Indication
Patient Preference
Severe median nerve injury, characterized by
Significant axonal degeneration on nerve
conduction studies or
Denervation on needle electromyography

Moderate to Severe Clinical Symptoms

Failure of Non-surgical therapy
Predictors associated with the failure

Treatment : Surgical
Carpal Tunnel Release by Complete Division of
Flexor Retinaculum (Grade A, Level I)
Open vs Endoscopic

Outcome
Nocturnal pain, tingling, and numbness improved
within six weeks.
grip and pinch strength initially worsened, returned to
preoperative levels at about 3 months, and improved
significantly by 2 years.
90 % : relief of either nighttime or daytime pain
Persistent or Recurrent symptoms : mostly due to
incomplete incision