Carpal Tunnel

Carpal tunnel syndrome is pressure on the median nerve -- the nerve in the wrist that supplies feeling and movement to parts of the hand. It can lead to numbness, tingling, weakness, or muscle damage in the hand and fingers. Carpal tunnel syndrome is common in people who perform repetitive motions of the hand and wrist.

Signs & Symptoms

The following may be symptoms of carpal tunnel:

  • Numbness or tingling in the thumb and next two or three fingers of one or both hands
  • Numbness or tingling of the palm of the hand
  • Pain extending to the elbow
  • Pain in wrist or hand in one or both hands
  • Problems with fine finger movements (coordination) in one or both hands
  • Wasting away of the muscle under the thumb (in advanced or long-term cases)
  • Weak grip or difficulty carrying bags (a common complaint)
  • Weakness in one or both hands

Prevention

Avoid or reduce the number of repetitive wrist movements whenever possible. Use tools and equipment that are properly designed to reduce the risk of wrist injury. 

Ergonomic aids, such as split keyboards, keyboard trays, typing pads, and wrist braces, may be used to improve wrist posture during typing. Take frequent breaks when typing and always stop if there is tingling or pain. 

Exams & Tests

During a physical examination, the doctor may find:

  • Numbness in the palm, thumb, index finger, middle finger, and thumb side of the ring finger
  • Weak hand grip
  • Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand (this is called Tinel's sign)
  • Bending the wrist forward all the way for 60 seconds will usually result in numbness, tingling, or weakness (this is called Phalen's test)

Tests may include:

  • Electromyography
  • Nerve conduction velocity
  • Wrist x-rays should be done to rule out other problems (such as wrist arthritis)

Causes

The median nerve provides feeling and movement to the "thumb side" of the hand (the palm, thumb, index finger, middle finger, and thumb side of the ring finger). 

The area in your wrist where the nerve enters the hand is called the carpal tunnel. This tunnel is normally narrow, so any swelling can pinch the nerve and cause pain, numbness, tingling or weakness. This is called carpal tunnel syndrome. 

Carpal tunnel syndrome is common in people who perform repetitive motions of the hand and wrist. Typing on a computer keyboard is probably the most common cause of carpal tunnel. Other causes include:

  • Sewing
  • Driving
  • Assembly line work
  • Painting
  • Writing
  • Use of tools (especially hand tools or tools that vibrate)
  • Sports such as racquetball or handball
  • Playing some musical instruments

The condition occurs most often in people 30 to 60 years old, and is more common in women than men. 

Biopsy

Definition
Carpal tunnel biopsy is a test in which a small piece of tissue is removed from the carpal tunnel (part of the wrist). 
 

How the Test is Performed 
The skin of your wrist is scrubbed and injected with medicine that numbs the area. Through a small cut, a sample of tissue is removed from the carpal tunnel. This is done by direct removal of tissue or by needle aspiration. Sometimes this procedure is performed at the time of carpal tunnel release. 

How the Test Will Feel 
You may feel some stinging or burning when the numbing medicine is injected. You may also feel some pressure or tugging during the procedure. Afterward, the area may be tender or sore for a few days. 

Why the Test is Performed 
This test may be done if you have symptoms of carpal tunnel syndrome and your health care provider suspects that you may have amyloidosis. 

Normal Results 
No abnormal tissues are found. 

What Abnormal Results Mean 
Amyloidosis involving the carpal tunnel. 

Risks 
Bleeding 
Damage to the nerve in this area 
Infection (a slight risk any time the skin is broken)

Considerations 
If the biopsy indicates abnormalities of the carpal tunnel, your health care provider may suggest the carpal tunnel release procedure. Your provider may also recommend more surgery to fix or improve the abnormality. 

Carpal Tunnel Release

Definition 
Carpal tunnel release is surgery to treat carpal tunnel syndrome. Carpal tunnel syndrome is pain and weakness in the hand that is caused by pressure on the median nerve in the wrist. 

Description 
The median nerve and the tendons that flex (or curl) your fingers go through a passage called the carpal tunnel in your wrist. This tunnel is narrow, so any swelling can pinch the nerve and cause pain. A thick ligament (tissue) just under your skin makes up the top of this tunnel. First, you will receive anesthesia (numbing medicine) so that you will not feel pain during surgery. You will be awake but also receive medicines to make you relax. In carpal tunnel release, the surgeon will cut through this ligament to make more space for the nerve and tendons. 

First your surgeon will make a small incision (cut) in the palm of your hand near your wrist. Then your surgeon will cut the carpal transverse ligament to ease the pressure on the median nerve. Sometimes, tissue around the nerve is removed as well. Your surgeon will then close the skin and tissue underneath with sutures (stitches). Sometimes surgeons do this procedure using a tiny camera that is attached to a monitor. The surgeon inserts the camera into your wrist through a very small incision and looks at the monitor to see inside your wrist. This is called endoscopic surgery. The instrument used is called an endoscope. 

Why the Procedure Is Performed 
Patients with symptoms of carpal tunnel syndrome usually try non-surgical treatments first. These are:

  • Anti-inflammatory medicines
  • Occupational therapy
  • Workplace changes to improve your seating and how you use equipment at work
  • Wrist splints
  • Shots of corticosteroid medicine into the carpal tunnel

If none of these treatments help, some surgeons will test the electrical activity of the median nerve with an EMG. If the test shows that the problem is carpal tunnel syndrome, carpal tunnel release surgery may be recommended. 

If the muscles in the hand and wrist are getting smaller because the nerve is being pinched, surgery will usually be done right away. 

Risks 
Risks of carpal tunnel release are:

  • Allergic reactions to medicines
  • Bleeding
  • Infection
  • Injury to the median nerve or nerves that branch off of it
  • Rarely, injury to another nerve or blood vessel (artery or vein)
  • Scar sensitivity

Before the Procedure 
Always tell your doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription. 
 

  • You may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen, (Advil, Motrin), naproxen (Naprosyn, Aleve), and other drugs. 
  • Ask your doctor which drugs you should still take on the day of your surgery. 
  • If you smoke, try to stop. Ask your doctor or nurse for help. Smoking can slow healing. 
  • Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery. 
  • You will usually be asked not to drink or eat anything for 6 to 12 hours before the procedure. 
  • Your doctor or nurse will tell you when to arrive at the doctor’s office.

After the Procedure 
This surgery is done on an outpatient basis. You will not need to stay in the hospital. 

After the surgery, your wrist will probably be in a splint or heavy bandage for about a week. After the splint or bandage is removed, you will begin motion exercises or a physical therapy program. 

Outlook (Prognosis) 
Carpal tunnel release decreases pain, nerve tingling, and numbness better, and restores muscle strength. Still, most people are helped by this surgery. 

The length of your recovery will depend on how long you had symptoms before surgery and how badly damaged your median nerve is. If you had symptoms for a long time, you may not be completely free of symptoms after you recover.

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