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Carpal Tunnel Syndrome

 

Facts

  • 50% cases occur in 5th and 6th decades
  • Females > Males
  • Occupational related
  • Repetitive wrist motion
  • Resting “heel” of the hand
  • 5% - 10% remote Hx of trauma

Clinical Findings

The area most commonly affected are the thumb, index, middle and half of the ring finger of the affected hand. Symptoms can radiate back to the forearm, elbow, arm, shoulder and even neck on the affected side. Patients often wake up at night with "pain, pin & needles and numbness" and shake their hand to improve symptoms.

Sensory Motor Signs
Loss of feeling Muscle wasting Trophic Ulcers
Numbness Weakness Swelling(21%)
Tingling
Burning
Pain
Night Pain
Stiffness

 

Clinical Findings

  • Decreased sensation of median nerve distribution  over base of the thumb and base of palm
  • Motor weakness: thumb, index finger, pinching and grasping
  • Muscle wasting of the palm and back of the hand
ECTR 1

Patient with right carpal tunnel syndrome. Red arrow shows wasting of muscles at base of the thumb compared to normal side (blue arrow).

ECTR 2

Affected right hand shows muscle wasting over the back of the hand at base of thumb (red arrow).

ECTR 3

Patient with both hands affected and muscle wasting ( red arrows).

Treatment

Treatment begins with conservative and medical therapy. Splinting of the wrist, modification of work habits, anti-inflammatory meds, hand therapy and steroid injections. When conservative therapy fails to treat the problem, surgery is the next and last option. The goal of surgery is to cut the transverse carpal ligament and increase the size and capacity of the carpal tunnel, thereby relieving the pressure on the median nerve.

OPEN SURGERY

 

Many surgeons use "open"techniques to get to the ligament and cut it. This requires making an incision on the palm over the ligament and going through a number of highly innervated structures to reach and cut the ligament. The surgery is done as an outpatient and is relatively quick. patients are often left with splints and bandages for a week or two. Complete healing time can take 6-8 weeks. The photographs below show the different types on open incisions.

ECTR 6
ECTR 5
ECTR 4

ENDOSCOPIC SURGERY

Another, more elegant and less invasive way to treat carpal tunnel syndrome utilizes endoscopes and very small incisions to cut the ligament and relieve pressure on the median nerve. Dr. Jimenez has been using endoscopic techniques very successfully for over 20 years. Surgery usually takes less than 10 minutes to perform and is associated with very little pain and discomfort. The surgery is done on an outpatient basis and there are no stitches to remove. No splints or bandages are sued and the patient can use their hands immediately. Recovery  takes place in a week or two and many patients can return to work within  a week.

ECTR 13

One small incision (A) is made at the end of the forearm near the wrist and a second smaller incision (B) is made in the palm.

ECTR 11

Incision in the forearm.

ECTR 10

The instruments are placed inside the carpal tunnel and under the ligament, thereby negating the need cut the skin on the palm of the hand.

ECTR15

The endoscope is placed in the carpal tunnel thru the palm incision. The blade is placed in the forearm incision and the ligament is cut under direct visualization.

ECTR 8

View of the transverse carpal ligament (A) with the endoscope inside the carpal tunnel.

ECTR 9

The curved blade (A) is being used to cut the ligament (B), therefore releasing the tight carpal tunnel. A muscle (C) is seen above the ligament.

RESULTS

There are six different types of endoscopic procedures used to treat carpal tunnel syndrome. Below is a table showing the outcomes of these different techniques in terms of percentages..

METHOD                   SUCCESS  RATE                        COMPLICATION  RATE          FAILURE RATE                 

AGEE                                    96.2                                                            1.83                                    1.44

BROWN                                96.0                                                            4.41                                     1.78

CHOW                                   98.3                                                            1.87                                     1.44

MENON                                94                                                                 9.0                                      0.6        

OKUTSU                              99.6                                                              0.4                                      0.3   

WORSEG                             95                                                                 1.56                                    4.7        

TOTAL                                 96.5                                                               2.67                                    2.61

Dr Jimenez uses the Brown technique, whose results ,as presented by Brown in 1,236 cases are listed below.

  • BROWN TECHNIQUE                    (n = 1236)
  • SYMPTOM RELIEF                             98 %
  • FAILURE RATE                                     2 %
  • COMPLICATION RATE                      0.97 %
  • RECCURENCE RATE                          2 %
  • RSD (painful hand)                             0.49 %
  • AVERAGE RETURN TO WORK       14  d