Carpal Tunnel Syndrome…and Wrist-Hand Pain

 

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Authors:
Dr. Jimmy Enrique Gil Jr
MS 4 Universidad Autónoma de Guadalajara

Dr. Felix Roque


What is Carpal Tunnel Syndrome?

9More than 3 million people per year in the United States alone suffer from the symptoms and signs of Carpal Tunnel Syndrome (CTS).  So what is this common syndrome that affects so many people each year?

A small nerve called the median nerve passes through the wrist and into the hand and is responsible for much of the feelings and sensation in the thumb and first three fingers of the hand.  This nerve passes through a compartment known as the carpal tunnel and when it becomes compressed as it passes through the wrist patients feel many of the common symptoms associated with CTS such as numbness and tingling.  The type and intensity of the symptoms vary depending on the severity of the compression as well as the strength of the relevant structures of the hand.

Nerves are responsible for two aspects of the way we function—sensory and motor skills—in other words, how we feel the environment around us, and how we are capable of responding to it.  When this carpal tunnel area becomes compressed the median nerve running through it begins to suffer and loses some of its normal functions.  Sensory fibers are often affected first before motor fibers.  This explains the reason why numbness is one of the first symptoms people with CTS experience.



Who is affected by CTS?

in the United States, CTS affects about 50 of every 1000 subjects in the general population.  Females are affected 3:1 compared to males and the peak age demographic for those with CTS are between 45-60 years old.  Many patients exhibit symptoms in their dominant hand due to the simple nature of using it more than their non-dominant hand but it is not uncommon for CTS to be present in both wrists.  In these cases, however, the dominant hand is usually affected first and with symptoms being found most severe there as well. While the syndrome is not fatal, failure to address it can lead to complications including the irreversible damage of the median nerve and potentially severe loss of function in the affected hand. 

 

DID YOU KNOW?
Before the invention of modern day EMG (electromyogram) diagnostic testing in the 1940s, CTS was though to be result of damage to nerves in the neck area known as the brachial plexus?

 

 What Should I Expect When I Visit My Doctor For CTS Symptoms?

A variety of people develop CTS; different genetic, medical, social and environmental factors affect individual risk of forming CTS.  There is no one causative factor in the development of the syndrom; most likely it involves an interaction of many that ultimately leads to the formation of the symptoms. 


When your doctor evaluates you for CTS, he may ask you about some of the following:

-the kind of work you do for a living
-daily routines
-exercise habits
-hypothyroidism
-rheumatoid arthritis
-diabetes
-pregnancy

4The clinical history your physician takes is often more revealing in the diagnosis of CTS than a physical exam.  The numbness and tingling already described is not only the most common complaint, but also an easy tell in symptomatology of the syndrome. 

Patients of CTS will tell their physicians that their hands fall asleep or that they experience sudden weakness in the hand without noticing.  The feelings will not be constant in the early stages but certain activities will cause the affects hand(s) to fall asleep.  Also due to fingers that are controlled by the median nerve, the pinky finger is almost exclusively unaffected in CTS.  The thumb and first three fingers of the hand will be the part of the hand experiencing the classic tingling.  If the pinky finger is the main source of any numbness and pain, this should be indicative of another problem going on.

Pain often accompanies the numbness in the hand and often radiates through the palm and wrist and sometimes even into the first part of the forearm.  Any pain or discomfort in the elbows, upper arm, shoulders or neck will most likely be associated to a different issue.

Aside from the clinical history, the electromyogram (EMG) is one test that is very common to help with the diagnosis of CTS.  The EMG is a way to graph the electrical potential of skeletal muscle cells much in the same way an EKG does with the heart.  In this way, doctors and other medical staff can analyze any abnormalities or loss of function in specific muscles and nerves due to existing circumstances.

What To Expect:

The skin over the areas tested will be cleaned. A small needle electrode that is attached to a recording machine will be inserted into a particular muscle to be tested.  The electrical activity in that muscle is recorded while the muscle is at rest. Then the technologist or doctor will ask you to tighten the muscle slowly and steadily so he or she can record the differences between the rest and contracted states.  The electrode may be moved a number of times to record the activity in different areas of the muscle or in different muscles.  The activity in the muscle will look like wavy and spikey lines on the EMG and will also have a particular sound that can be heard during the exam.  When the test is done the electrodes will be removed, and the area cleaned.  The test will usually then be repeated on the opposite limb’s muscle or nerve.  Whenever nerve conduction tests or EMGs are performed, usually both the left and right sides will be tested in order to provide a comparison.

Nerve conduction studies may also be done prior to the EMG to further determine nerve function.  In this test, several flat metal disc electrodes will be attached to the skin with tape or a paste. A shock-emitting electrode will be placed directly over the nerve, and a recording electrode placed over the muscles controlled by that nerve. Several quick electrical pulses will be sent to the nerve, and the time it takes for the muscle to contract in response to the electrical pulse is recorded. The speed of the response is called the conduction velocity.

So Now That CTS Has Been Established What’s Next?

There are several ways to treat CTS but often the first line of treatment is some form of occupational therapy combined with medication.  Wrist splints provide a low cost, low risk way to keep the wrist joint neutral or even slightly extended and can be used initially to alleviate some of the symptoms.  They may keep the CTS from progressing, and give structures in the immediate area time to heal while avoiding additional stress to the median nerve.  The splints are often recommended for use while sleeping because we often bend our wrists and this can cause the discomfort many patients complain of during the night.  

 

DR ROQUE

 

DID YOU KNOW?
Women are three times as likely than men to develop CTS.  This may be because female wrists are smaller and shaped slightly differently than male wrists, but hormonal differences are probably the most important reason for this variation.

 

Non-steroidal anti-inflammatory drugs (NSAIDs) and or diuretics are also often used before moving to more invasive procedures such as steroid injections.  These can help with local swelling and help reduce the tenderness in the area.  These are still more short-term solutions, which need to be re-evaluated over time to avoid excessive use of medications that could produce any long-term side effects. 

8Steroid injections, however, can produce a longer lasting effect in the area and is a good option if more conservative treatments fail.  They have been compared in many studies to other non-invasive procedures as well as injections to the area without any medication (placebos).  Results have shown that treatment with steroid injections has helped CTS patients in about half of the cases.  In those who had been diagnosed with CTS and went untreated with injections, about 28 of 100 people showed improvement in two to four weeks.  In patients with CTS who DID get treated, about 73 of 100 patients improved after two to four weeks following steroids. 

A topic of debate in the effectiveness of injections is they way they are administered—until relatively recently, injections have been given using landmark guidance and the individual skill of the physician.  A new alternative to traditionally administered steroids is using image-guided injections.  Studies have shown a statistically significant improvement in pain and function at six weeks.  When using image guidance, medicine is more likely to get where it needs to be and thus providing a much higher percentage of intended results in the patients.

At the pain relief center, Dr. Roque and his team offer the latest image-guided technology in order to be precise and deliver medications with effectiveness, and as a result, achieve the best possible solution to alleviate the pain and discomfort associated with CTS; this is accompanied by providing a satisfying and rewarding experience for you.



What About Surgery?

 

ctsIn cases where splints, NSAIDs and even steroid injections do not have any effect on the CTS, surgery can be a good option to discuss with your doctor.   Success rates are highly variable but in certain cases release of the transverse ligament and carpal tunnel release may or may not provide long-lasting relief from all of the CTS associated symptoms.

If you or someone close to you suffers from wrist or hand pain associated with Carpal Tunnel Syndrome, and that negatively interferes with the physical emotional, socio-labor and family sphere, consult us in our pain clinic to offer you the most advanced medical treatments such as image-guided injection technology for the relief and pain management of your wrist or hand pain; that you can recover the optimal physical and functional abilities quickly, allowing you reintegrate with all enjoyable experiences and your socio-occupational life.

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Dr. Roque has a vast and extensive experience in the mentioned field; In addition, the Center for Pain Management, located at 543 45th St. Union City NJ - Telephone 201-766-6469 - is fully equipped with innovative cutting-edge equipment and technology required to practice this type of procedures safely and effectively.

 

Authors:

Dr. Jimmy E. Gil Jr
MS 4 Universidad Autónoma de Guadalajara

Dr. Felix Roque 

carpal


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