What Is Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common hand problem. People with this condition experience pain, numbness, and weakness in their hands. If left untreated, it can lead to worsening symptoms and nerve damage.
Carpal tunnel syndrome is a condition that causes numbness, tingling sensation, weakness and pain in the hand and forearm. This condition occurs when there is an increased pressure on one of the major nerves (median nerve) to the hand as it travels to the wrist.
Median nerve1 causes sensation in the thumb, index, middle, and ring fingers; small finger sensation is not caused by the median nerve.
Early symptoms can often be relieved with simple measures like lifestyle changes, wearing a wrist splint and hand exercise to keep the nerve mobile. If left untreated for too long, it can lead to permanent dysfunction of the hand and may need surgical procedures to restore the damage.

Overview

 The carpal tunnel¹ is a narrow space in the wrist that includes the tendon and the median nerve and is surrounded by bones. The median nerve helps in sensation in all fingers except the little finger; it passes through the forearm towards the hand.  Any compression or irritation to the median nerve causes symptoms like pain, numbness, tingling sensation, and weakness, and that is called carpal tunnel syndrome.

Causes of carpal tunnel syndrome

Carpal tunnel syndrome develops when there is pressure on the median nerve.

The carpal tunnel is a narrow space in the wrist where the median nerve runs from the forearm to the hand. It gives sensory and motor function to the thumb and fingers, except the little finger. Development of carpal tunnel syndrome happens when the carpal tunnel narrows, and the tissue surrounding the tendons compresses the median nerve and reduces the blood flow.

Most of the cases are caused by a combination of other factors.

Signs and symptoms of carpal tunnel syndrome

Symptoms appear very slowly, come, and go quickly and it can appear at any time. Some of the symptoms are:

• Numbness in the fingers – this causes the dropping of things, and this feeling can become constant over time if left untreated.
• Tingling sensation/pain – may travel from wrist to forearm and towards the shoulder. There will be an electric shock like sensation in these fingers and make it difficult for the person to sleep at night.
• Weakness and clumsiness of the hand makes it difficult to perform fine movements.
• Swelling in the fingers.  
• Dropping things - due to weakness and numbness while holding objects.
• Difficulty to do tasks that require delicate motions.
•  In chronic cases or untreated cases, the muscle at the base of the thumb may shrink (atrophy of muscle).
• Symptoms occur commonly during daytime as there is prolonged use of wrist like holding things, driving, reading book or newspaper, using computer keyboards.

 Management and treatment for carpal tunnel syndrome

Carpal tunnel syndrome deteriorates gradually but can worsen if left untreated. There are two different ways of treatment: surgical and non-surgical methods. Surgical way of treatment is usually advised for more severe conditions, and non-surgical treatment is advised for less severe conditions.

Non-surgical treatments.

• Wrist splinting or bracing: Wearing a splint or brace reduces pressure on the median nerve, it will keep the wrist from bending while sleeping and while during things that aggravate the symptom.
• Changing position: these symptoms appear when there is prolonged use of the wrist in the same position, changing or modifying the activities like making changes in the workstation or worksite can reduce the symptoms and help slow the progression of the condition.
• Non-steroidal anti-inflammatory drugs (NSAIDs): Medications such as ibuprofen and naproxen can reduce inflammation and pain.
• Steroid injection: The usage of corticosteroids or cortisone injections can reduce severe pain and inflammation; these are powerful anti-inflammatory agents.
• Exercises⁵: Stretching and strengthening exercise can reduce the symptoms. Nerve gliding exercises may help some pateint to move the median nerve freely in the carpal tunnel.

 Surgical treatment

Carpal tunnel release is the surgical procedure done for carpal tunnel syndrome. This is done in two ways: open surgery and endoscopic surgery. In both cases either local anaesthesia (pain numbing medication) or general anaesthesia (intravenous sedative) is given.

Procedure done during surgery is cutting the ligament that forms the roof of the tunnel, known as transverse carpal ligament. This provides an increase of the tunnel space and reduces the pressure on the median nerve, which allows the normal blood flow to the nerve and function of the nerve.

 Open carpal tunnel surgery: In this procedure, carpal tunnel release is performed by making a small incision in the hand through which the doctor views the inside of your wrist. The procedure is done by dividing the transverse carpal ligament and increasing the carpal tunnel space, and reducing the pressure on the median nerve. The ligament gradually grows back after the surgery, leaving more space in the carpal tunnel.

Endoscopic carpal tunnel surgery: In this procedure, the doctor makes one or two smaller incisions (portals) and inserts the endoscope to view the inside of the hand and wrist. A cutting instrument (special knife) is inserted to divide the transverse carpal ligament. The outcomes of both open surgery and endoscopic surgery are similar.

Recovery

Carpal tunnel surgery recovery depends on the severity of the nerve affected. It will be encouraged to move your fingers to reduce the swelling and stiffness after surgery. There will be some pain, swelling, and stiffness even after the procedure. Minor soreness in the palm will last for several months. In severe cases of carpal tunnel syndrome, normal strength may not completely return.

 Diagnosis of carpal tunnel syndrome

Physical examination.

• Tinel’s sign³: During this test the physician presses down or tap along the median nerve at the wrist to see if tingling sensation occurs.
• Wrist flexion test (Phalen test): In this test, the patient rests their elbow on a table and allows the wrist to move forward freely. The patient experiences numbness or tingling sensation, and more quickly, symptoms appear that show the severity of carpal tunnel syndrome.

Tests

• Nerve conduction studies(NCS): These tests analyse the signals travelling through the nerves of your hand and arm, helping to determine the severity of the nerve damage.
• Electromyogram (EMG): This measures the electrical activity in muscles and shows whether you have nerve or muscle damage.
• X-rays: These tests provide images of dense structures, such as bones. When your wrist moves restricted, it may also be due to other causes. An X-ray will be helpful to exclude causes like arthritis, ligament injury, or a fracture.
• Ultrasound: Ultrasound uses high-frequency sound waves to provide pictures of bone and soft tissue. Ultrasound examination can help in evaluating any compression on the median nerve.
• Magnetic resonance imaging (MRI) scans: MRI scans provide better images of the body's soft tissue than X-rays. Doctors may suggest taking MRI scans to help determine other causes of the symptoms or any abnormal tissue growth causing pressure on the median nerve.

 Risk factors

• Heredity: The carpal tunnel naturally will be smaller in some people due to anatomic differences and these traits can run in families
• Hormonal changes or metabolic changes: in conditions like pregnancy, menopause, old age and thyroid complaints
• Repetitive hand use: Frequent long-term use may aggravate the tendons in the wrist and cause swelling, which may cause pressure on the median nerve
• Hand or wrist fracture or dislocation
• Health conditions: Diabetes, rheumatoid arthritis, haemodialysis and tumour or mass in the carpal tunnel
• Alcoholism
•  Amyloid deposits - an abnormal protein deposition
•  Carpal tunnel syndrome is more commonly seen in women than men
•  Repeated sleeping on a bent wrist
•  Repeated use of vibrating hand tools

FAQs

          How can I prevent carpal tunnel syndrome?

Reduce repetitive hand movement, and take short breaks after repetitive hand work. Doing stretching and strengthening exercises in a day can help in reducing the stiffness of the hand. Monitoring and timely treating medical symptoms related to carpal tunnel syndrome.

           How common is carpal tunnel syndrome?

Carpal tunnel syndrome is a relatively common condition in middle-aged people, caused by pressure on the median nerve in the wrist, causing numbness and tingling sensation in the fingers. Most commonly seen in people who do activities or jobs which involve repetitive finger use.

        When should I see a doctor?

During the early onset of symptoms, it is recommended to consult a doctor, which can help in reducing symptoms and progression of the carpal tunnel syndrome.

Summary

Carpal tunnel syndrome (CTS) is a common condition occurring when the median nerve is compressed in the wrist (carpal tunnel).  The carpal tunnel is a narrow passageway which contains the median nerve, flexor tendons and carpal bones. When the carpal tunnel is narrowed, or the tissue (synovium) surrounding the flexor tendon swells up, causing pressure on the median nerve and decreasing the blood flow causes carpal tunnel syndrome. The median nerve helps in bending the thumb and fingers, except the little finger. The pressure on the median nerve causes numbness, tingling sensation, weakness and pain in the hand and forearm.

Most commonly seen in middle-aged persons and also with other risk factors. People with repetitive hand work, heredity, pregnancy and other health conditions (Diabetes, rheumatoid arthritis, hormonal imbalance) are prone to have carpal tunnel syndrome.

Tinel’s test is a physical examination performed to test for nerve damage, where the doctor taps along the median nerve to see whether it causes tingling sensation in the fingers. Looks for atrophy of muscle around the thumb finger, where in severe cases muscles shrink.

Nerve conduction studies help to know severity of the disease and Electromyogram tests help in finding the nerve or muscle damage. X-ray and MRI scans help in ruling out other causes of the symptoms such as arthritis, fracture or tumour.

In early symptoms, non-surgical treatment can be helpful. Wearing a splint or brace helps in keeping the wrist straight, which reduces the pressure on the nerve. Usage of Nonsteroidal anti-inflammatory drugs and steroid injections to relieve pain and inflammation.In severe cases, a surgical procedure is performed to relieve the pressure on the median nerve by cutting the transverse carpal ligament.

Recovery from carpal tunnel syndrome surgery depends on the severity of the disease, and I used to wear a splint for a few weeks to avoid moving the wrist. To prevent stiffness and swelling,  fingers will be asked to move.

To prevent carpal tunnel syndrome, reduce repetitive hand movement and take short breaks after repetitive hand work. Doing stretching and strengthening exercises daily can help reduce the stiffness of the hand. Monitor and timely treat medical symptoms related to carpal tunnel syndrome.