Carpal Tunnel Syndrome Part 4. How do we treat it?

“The door is open but the ride ain’t free”

“Thunder Road” by Bruce Springsteen

 

Okay, we’ve gotten to the point where your doctor tells you that you have carpal tunnel syndrome.  The big question becomes, “What do I do about it?”  There have been a lot of misconceptions about the treatment of carpal tunnel syndrome, both surgical and non-surgical, so I’d like to try and give you the most recent and up to date information from the perspective of a hand surgeon.

In 2008 the American Academy of Orthopedic Surgeons (AAOS) published clinical guidelines for the diagnosis and treatment of carpal tunnel syndrome.  The AAOS is the main medical organization for orthopedic surgeons and is heavily involved in continuing education for orthopedic surgeons.  As part of their effort to develop guidelines for the treatment of common conditions a group of surgeons studied the available evidence and made treatment recommendations for carpal tunnel syndrome.  They basically found that there are only a couple of things that work for carpal tunnel syndrome.  Specifically, splinting, steroid injections into the carpal tunnel and surgery were shown to be the most effective treatments.  Oral steroids and ultrasound have some evidence that they work, but everything else from acupuncture to magnets to diets and vitamins could not be recommended one way or the other.

This is the approach I’ve taken in my practice.  As long as you don’t have severe carpal tunnel with muscle loss and/or loss of feeling, then it is reasonable to try a period of splinting.  I usually recommend trying 4-6 weeks of wearing a wrist splint at night and seeing what happens.  Carpal tunnel injections seem to work pretty well as a temporary measure but they don’t usually provide a long term cure.  If you’re having a lot of problems with carpal tunnel syndrome and don’t want to have surgery then an injection makes a lot of sense.  If the injections don’t work or quit working, then surgery is always an option.

I think carpal tunnel surgery probably has a much worse reputation than it warrants.  Most published studies show success rates with improvement or complete resolution of symptoms over 90% of the time, and this seems to be my personal experience as well.  Everyone wants to know if the have to have the surgery, and my usual recommendation is to at least try braces or splinting before considering surgery.  If you have severe carpal tunnel syndrome either by exam or on nerve conduction studies, then it’s probably smart to go ahead and have the surgery done sooner than later.  Otherwise you probably need to make your decision based on how much this is bothering you and whether it’s worth going through a surgery to get better.  Each patient is different.

The surgery involves dividing a ligament (the transverse carpal ligament for those that are interested) that forms the carpal tunnel.  This is called a release, so the surgery is called a carpal tunnel release.  The key element of the surgery is to completely divide the ligament.  There are a number of ways to do this and the two most common are the open and the endoscopic carpal tunnel release.  In the open technique an incision if made and the ligament is cut while looking directly at the ligament.  In the endoscopic release smaller incisions are made which allow the placement of a special instrument which cuts the ligament by looking at the ligament through a small camera.  A recent survey of hand surgeons showed that 75% do some form of open treatment while 25% prefer the endoscopic technique.  Most of the articles in the medical literature show little difference between the two techniques.  Proponents of the endoscopic technique claim that their patients have a quicker return of function while those that use the open techniques think their technique is safer.   I have used what is called a “limited” open release for many years.  I have seen catastrophic complications (the nerve was cut in half) with the endoscopic technique and heard of other physicians seeing this complication, so I’ve never been drawn to the technique.  If I, personally, was ever to have carpal tunnel surgery I would choose a surgeon who used the open technique.  If you choose a surgeon who does endoscopic releases I would recommend choosing something extensive experience with the technique.

The surgery itself is very straightforward.  I use local anesthesia, many times with no medication or sedation, but a lot of patients choose to be sedated so they won’t feel the injection in their hand.  It usually takes me about 10 minutes to cut down to the ligament, release the ligament and close the skin.  I use absorbable skin sutures so there’s no need to have sutures removed.  I usually schedule a single therapy visit after surgery to encourage use of the hand.  For the first 5-7 days the hand is weak and sore enough to impact activities, but usually improves week by week after that so that most folks are back to their normal activities in 4-6 weeks.  Most patients have scar tenderness and weakness, but these usually resolve with time.

I hope this series of articles has been helpful if you’re seeking information on carpal tunnel syndrome.  I’ll be continuing to blog on other topics about hand surgery, and if you have any thoughts or suggestions please send me an email at richard.smith@orthotennessee.com.

 

Carpal Tunnel Syndrome Part 3. How do you diagnose Carpal Tunnel Syndrome?

“This ain’t no party, this ain’t no disco, this ain’t no fooling around”

from “Life in Wartime” by The Talking Heads

So your hand is going numb and waking you up every night.  It goes numb while you’re working on your hair, driving a car, or reading a book.  You’re pretty sure you’ve got carpal tunnel syndrome.  As a hand surgeon, what do I look for to help make the diagnosis and guide you to make a treatment decision?

Most patients initially talk about these kind of symptoms with their primary care physician.  The primary care physician can usually treat straight forward cases of carpal tunnel syndrome, but if the symptoms are confusing or severe, then they may decide to refer you a specialist.  This is where I come in.

When I see a patient that may have carpal tunnel syndrome I have several goals.  First, I try to find out if the problem really is carpal tunnel syndrome.  There are several types of hand problems that people can have along with carpal tunnel syndrome, and it’s my job to try and figure what is causing the problem that brought you in to see me.   I can usually figure this out by listening to the symptoms you have and performing a pretty simple physical exam. There are three tests that are commonly done to evaluate carpal tunnel syndrome.  The first is to tap along the course of the nerve.  If this causes a shock to go though your fingers the test is positive.  This is known as “Tinel’s” test.  A second test is to push on the nerve at the level of the wrist and see if this reproduces numbness and tingling in the hand.  This test goes by several names but most people call it by the highly original name of  the “median nerve compression test.”  A third test involves bending your wrist down and waiting 15-30 seconds to see if this causes numbness and tingling in your hand.  This is called “Phalen’s” test, named after Dr. George Phalen who was one of the  main physicians responsible for figuring out what carpal tunnel syndrome was. None of these three tests will diagnose carpal tunnel syndrome for certain, but when you combine them with the history then you can get a pretty good idea if the patient has carpal tunnel syndrome or not.

The most common problems that people have along with carpal tunnel syndrome are arthritis and a condition called “trigger fingers”.  Trigger fingers occur when the tendons in your hand get thick and they stick when they pass through a sheath in your hand.  Arthritis occurs in several areas, but the joint where your thumb attaches to your hand is the most common painful area.  I can usually get a pretty good idea which problem is causing the problems that you came to have evaluated.

Next I try and figure out how bad the carpal tunnel syndrome is. I can often figure that out from your symptoms and the exam, but this may require extra testing.  The most common test we use is called a nerve conduction study.  This is a test where a neurologist or other qualified physician tests the nerves in your hand to try and tell if the nerves are damaged and if they are damaged, how severely the nerve is damaged.  This usually requires a referral to another physician to get the test done and then a return visit to go over the test, so it’s really nice when the patients primary care physician has these tests done before I see the patient.   The nerve test can provide a lot of information.  They can give you an idea how severe the carpal tunnel syndrome is and also whether or not there are any other areas of nerve damage.  A number of patients will have compression of their ulnar nerve (the funny bone) in addition to carpal tunnel syndrome and this can change or influence your treatment decision.  However not all patients need nerve conduction studies.  Sometimes the process is so advanced and the nerve damage is so severe that the diagnosis and treatment options are obvious.

Nerve conduction studies aren’t perfect since probably 10% or so of people with carpal tunnel syndrome have normal nerve conduction studies.  The test still remains our best objective data test to evaluate carpal tunnel syndrome.

Once all the data is in, then comes the hard part, which is to decide what to do about the problem.  And that will be the focus of my next post.

 

 

 

 

 

Carpal Tunnel Syndrome Part 2. How do I get it?

“Just the facts, Ma’m”

Sergeant Joe Friday from the 1960’s TV series “Dragnet”

Carpal tunnel syndrome is very common, and it seems like the diagnosis of the problem is increasing each year.  Naturally this begs the question as to whether or not something can be done to prevent the problem.  A lot of study has gone into this issue, but it turns out that a lot of what we thought we knew about the causes of carpal tunnel syndrome hasn’t stood up to statistical analysis.

In the 80’s and 90’s there were a large number of articles associating carpal tunnel syndrome with certain activities including repetitive motion of the hands, computer keyboard use and exposure to excessive vibration. This certainly spawned a cottage industry of workplace modification. The most well known example of this was probably the ergonomic keyboard. There was quite a bit of debate among hand surgeons about these claims, many of whom doubted the quality and the validity of the medical studies that seemed to show a correlation between specific activities and carpal tunnel syndrome. On the other hand there were several very prominent hand surgeons who vigorously defended the correlations shown in the published studies.  In fact I remember one year at the annual national meeting of hand surgeons we were treated to a lively Point/Counterpoint style debate between two prominent hand surgeons about whether or not work activities caused carpal tunnel syndrome.

Most of that changed in 2007, when a very well designed study was published in the Journal of Hand Surgery, the main source of up to date medical information in our field.  A group from the Massachusetts General Hospital in Boston led by Dr. David Ring, a well respected surgeon, reviewed 117 previously published articles and subjected the articles to a well defined statistical analysis to see if the data in the articles supported their conclusions.  They found that the cause of carpal tunnel syndrome was largely genetic (you’re born with a predisposition to develop it), structural (it’s the way your body is built) and biological (certain health problems can cause it).  They found that factors such as repetitive hand use and other occupational factors played a minor and more debatable role.  This data tended to confirm what many hand surgeons, myself included, thought was actually the case.  Most hand surgeons are now reluctant to link work activities with carpal tunnel syndrome.  However I can assure you that the idea that keyboard and repetitive hand use causes carpal tunnel syndrome is imbedded in the minds of most people and they are quite surprised when I inform them of the findings of this study.

There are certain health conditions which are associated with carpal tunnel syndrome.  The two most common are diabetes and hypothyroidism (low thyroid function).  I often see both these conditions together in patients with carpal tunnel syndrome.  People with chronic kidney disease and high blood pressure are also susceptible to carpal tunnel syndrome.  People with rheumatoid arthritis are another group who tend to get carpal tunnel syndrome as well. I will occasionally see someone with carpal tunnel syndrome after a fracture or dislocation of the wrist, sometimes right after the injury but other times showing up weeks or months later.

So can you prevent carpal tunnel syndrome?  Probably not.  But if you are predisposed to developing the problem and find your hand going numb after certain activities then it makes sense to try and moderate or change the activity.  If your hand goes numb while using a keyboard, then by all means try out an ergonomic keyboard.  If you have diabetes or hypothyroidism it helps to keep those conditions under control with the help of your primary care physician.  By taking common sense precautions you may not be able to prevent the problem, but you can certainly moderate the effects and prevent worse problems down the road.

In my next post I’ll discuss the thought processes I use to diagnose carpal tunnel syndrome.  Hopefully this will help you understand what I do and what I’m looking for when I’m in the exam room with the patient.

Carpal Tunnel Syndrome Part 1. What is it?

“Let’s start at the very beginning a very good place to start”

Do-Re-Mi from “The Sound of Music” by Richard Rodgers and Oscar Hammerstein II

If we’re going to talk Hand Surgery there’s no better place to begin than with Carpal Tunnel Syndrome.  Carpal Tunnel Syndrome (or CTS for short) is far and away the most common reason that patients see a hand surgeon.  CTS is well known among the lay public and almost everyone has heard about it in one way or another.  It certainly seems that I am seeing more and more patients with CTS every year.  There is also a large amount of misinformation about CTS out there as well, so what I would like to do is cover as many aspects as I can in four separate posts.  First we’ll look at exactly what CTS is and isn’t.  In Part 2 we’ll talk about how you get it, and the most recent medical data will probably surprise you.  In part 3 we’ll  talk about how to diagnose CTS.  In Part 4 I’ll discuss the treatment of carpal tunnel syndrome and tell you what I thinks works and what doesn’t.

Simply put, carpal tunnel syndrome is a compression of one of the nerves that goes to your hand at the level of the wrist.  Carpal is a Latin word that means wrist, so it simply means wrist tunnel.  The tunnel is located in the palm of your hand and starts at the point where your wrist bends.  There is tight ligament that connects the wrist bones and forms a tunnel.  The nerve that gives you feeling in the thumb, index and middle fingers (and also usually half of the ring finger as well) goes through this tunnel.  This is called the median nerve.  Packed into the tunnel as well are structures called tendons.  These come from the muscles in your forearm and attach to your fingers allowing you to bend your fingers.  The tendons have a lot of movement (or excursion) so they are covered in a soft tissue called synovium which allows the tendons to glide and move without restriction.

So what then, is carpal tunnel syndrome?  Basically there is too much pressure in the tunnel which winds up cutting off the blood flow to the median nerve.  The cause of the increased pressure isn’t exactly clear, and I’ll talk about that more in Part 2.  Suffice to say for now your nerves are very sensitive creatures and they don’t like it all to have their blood supply decreased or cut off.

The most common reaction of the nerve is to cause numbness and tingling in the hand.  This is usually, but not always, in the area the nerve goes to, specifically the thumb, index and middle fingers and half of the ring finger.  The most common time this occurs is at night and patients tell me they awaken from a deep sleep with their hands numb and tingling.  They usually have to shake their hands (probably to get the blood flowing into the nerve) to get their hands to quit tingling so they can get back to sleep.  People also relate that their hands go to sleep while they’re driving a car, working on their hair, reading a book ,working with heavy tools as well as any number of other activities.  Some patients have pain, but if the patient has pain without numbness I’m very nervous about making the diagnosis of carpal tunnel syndrome.  Patients do have pain with the numbness, and it can occur from the hand all the way up to the shoulder.  Interestingly a lot of patients main problem is their pain and it’s not until I ask them about the numbness do they put things together.

In summary, the main thing I’m listening for to see if a patient has carpal tunnel syndrome is whether or not their hand wakes them up from sleep by being numb.  This doesn’t happen in every case but it is so common it’s the main thing I look for.

In Part 2 I would like to talk about factors that cause carpal tunnel syndrome and give you an update on what the thinking is now among hand surgeons in the USA.

A Bridge between patients and surgeons

I’ve been a practicing hand surgeon for over 25 years.  During that time I’ve performed over 15,000 surgeries and treated many more thousands of patients without surgery in the form of injections, therapy or many times just with reassurance and providing information.  As I move forward in my career it has become clear that I sense a disconnect between the thoughts and expectations of the surgeon and the thoughts and expectations of the patient.

My goal with this blog is to try and bridge that gap.  I will try as best I can to explain my thought process during the evaluation and treatment of patients.  The topics I plan to discuss will include the common conditions that I treat as a hand surgeon.  My goal is to provide not only up to date information on topics, but also to let you inside my mind so you can get a glimpse of what I’m thinking when I come to a decision.

From your perspective I would like to know what your thoughts, concerns and worries are.  I plan to ask my own patients to help me provide some topics to cover, and I encourage you to get in touch with me via email at richard.smith@orthotennessee.com.  Hopefully this will be a site that can be mutually beneficial and help me to provide better care.

First, a little background information on me.  I was born in Chattanooga, Tennessee , went to college at the University of Tennessee, Knoxville and medical school at the University of Tennessee in Memphis.   I did an orthopedic surgery residency at the University of Florida program in Jacksonville, Florida and I did a one year hand fellowship at Baylor in Houston.  I currently work at the University of Tennessee medical center in Knoxville.  I’m a clinical professor in the department of surgery, but I’m engaged in private practice and don’t work with residents.  I practice hand surgery, which for me includes common and complex problems of the hand, wrist and elbow.

On the personal side I’ve been married to my wife Ruth since 1986.  Ruth is a physical therapist.  We have two daughters, Casey and Barbara.  Casey is a third year medical student and Barbara has been accepted to medical school for the fall of 2016.  I have plenty of hobbies outside of medicine.  I love to play and write music.  I play golf, sometimes competitively, and I run quite a bit, having run a marathon and over 25 half marathons.

The ideas I present will be my own.  I’ll try and back up all my opinions with the latest medical information possible.  I don’t have any relationships with any commercial entities, so you don’t have to worry about any outside influence on my opinions.  When I recommend a treatment or procedure, rest assured that it would be what I would want done to myself or to my family.

I plan to post at least once a week, maybe more depending on how much time I have and when topics of interest pop up.  I hope this turns out to be something fun and informative for all of us.  I’m looking forward to seeing where this leads.  Thanks for reading.