Carpal Tunnel Syndrome (CTS)
Carpal Tunnel Syndrome is a condition consequent to the compression of a nerve (the median nerve) inside the carpal tunnel, a passageway between the wrist and the palmar hand.
This picture helps you to visualize where the carpal tunnel is located and the course of the median nerve.
Carpal Tunnel Syndrome is mostly affecting ladies (at a ratio of approximately 10:1) and is more frequent among manual workers. Although in the vast majority of cases, no clear cause can be related to the onset of the symptomatology, predisposing conditions (e.g. diabetes, rheumatic diseases, previous wrist fractures and dialysis treatment) can favor the occurrence of this entrapment syndrome (a medical term generally used to describe a condition arising from the compression of a nerve along its course).
Carpal Tunnel Syndrome is mostly bilateral: symptoms can often start on both hands at the same time, maybe with prevalence on one of them (most often the dominant hand).
The course of the syndrome is usually characterized by 3 phases.
The initial phase is associated with pain, numbness and tingling on the hand, typically radiating on the thumb, index and middle finger; yet, in many cases, the whole hand can be affected.
Pain can occasionally radiate along the whole upper arm up to the shoulder. Symptoms usually worsen at night, often completely disrupting the patient’s quality of sleep. At the beginning the entrapment syndrome can present a relapsing- remitting course: pain, numbness and tingling usually subside with the warm season and recur when fall arrives. Most of the ladies report they had similar symptoms when they were pregnant or breast-feeding and then they started to re- experience them during the menopause.
The second phase is characterized by continuous pain, numbness and tingling that present progressive intensity. In this stage the patient begins to experience difficulties in manual activity, often dropping objects from their hands.
During the third stage, the compression results in damage to the nerve, whose function becomes severely impaired: a progressive sensory loss on the thumb, index and middle fingers associated with hand strength decrease can develop. In the most severe cases, thenar muscles (the muscles at the base of the thumb) become thinner and weaker and there can be remarkable difficulties in using the thumb.
The following photo is showing you the result of ongoing compression on the median nerve with consequent thenar muscle atrophy (a word meaning loss of bulk in the muscle)
Carpal Tunnel Syndrome is diagnosed according to clinical evaluation (that means that according to your surgeon, the symptoms you are experiencing are characteristic for this condition) and ruling out the possibility of other pathologies.
An EMG and nerve conduction study are routinely utilized to confirm your doctor’s clinical suspicion.
If your surgeon suspects the association with other pathologies, further instrumental investigations (e.g. MRI study of the cervical spine or brachial plexus) can be required to complete the diagnostic assessment. The information provided by the investigations is evaluated by your surgeon before the diagnosis is confirmed.
Patients diagnosed with Carpal Tunnel Syndrome can be offered conservative treatment or surgery. It must be stated as preliminary remark that if muscle atrophy is present, indication for surgery is straightforward: there is no possibility to recover without surgical decompression. Moreover, if muscle denervation (that means that signs of nerve damage are detected given the progressive muscle waste) is occurring, surgery is necessary also to prevent further worsening.
Conservative treatment is therefore mainly finding its role in the initial phases of the symptomatology. Wearing splints, medications (such as vitamin supplements or furosemide), cortisone injections into the carpal tunnel, iontophoresis are among the methods advocated to conservatively treat carpal tunnel syndrome. They usually provide only temporary relief and may present side effects: for instance, in the long run cortisone injections into the carpal tunnel are proved to worsen the severity of the pathology due to the scarring consequent to the chemical effect of cortisone on the tissues.
Surgery aiming to perform decompression of the nerve is certainly the elective treatment option, given the causative mechanism of Carpal Tunnel Syndrome.
Carpal Tunnel Surgery
Indications for surgery
Your surgeon advocates surgery after evaluating your medical history, performing a neurological examination on you and reviewing your investigations.
Concerning EMG and Nerve Conduction Study, when performed for other conditions, note that this test may reveal a non-clinically manifest carpal tunnel syndrome (that means that the patients have no symptoms): in such cases, no treatment would be required, only follow up is necessary in case symptoms possibly develop later on.
Moreover Nerve Conduction Study is just a tool to confirm the pathology and not to assess its severity.
Type of surgery
The procedure is performed under local anesthesia: You will receive an injection on the wrist/palmar hand and through a small palmar incision (like it is shown in the picture below) the surgeon will cut the carpal ligament that has become thick and therefore responsible of the compression on the nerve.
After the procedure, you will have to wear a splint for about 7-10 days and then you can resume your daily activities except performing efforts (see “Recovery instructions after Carpal Tunnel Surgery”) with the operated hand.
Length of hospitalization
Carpal Tunnel surgery is a daycare procedure. That means that you will be admitted to the hospital in the morning, submitted to the procedure and then discharged after a short observation.