Carpal Tunnel Syndrome

The condition is characterised by pain in the hand with numbness and tingling in the palmar aspect of the thumb, index, and middle finger. In severe cases there can be wastage of the thenar eminence due to chronic compression with associated thumb weakness. Pain is typically worse at night, and waking up with a numb, painful hand is very common.

It can often affect both hands; in such cases, patients often complain of loss of general dexterity as they struggle to feel things properly with their fingers, making it difficult to do up buttons on shirts or recognise small objects such as coins.Source: Carpal Tunnel Syndrome – StatPearls – NCBI Bookshelf (opens in a new tab)

The diagnosis of carpal tunnel syndrome will be made from a combination of your clinical history, examination findings, and occasionally Nerve Conduction Studies (NCS).

Patients will present to the clinic with the aforementioned symptoms. Clinical tests used to help confirm the diagnosis are the Phalen’s and Tinel’s tests, which involve prolonged wrist flexion/extension and repeated percussions over the top of the carpal tunnel to provoke symptoms, respectively.Source: Sensitivity and Specificity of Phalen’s Test and Tinel’s Test in Patients with Carpal Tunnel Syndrome | Diyala Journal of Medicine (opens in a new tab)

NCS is considered the gold standard diagnostic test for carpal tunnel syndrome; however, this is not always required. Ultrasound can clearly see the median nerve and any associated nerve swelling or lesions that may be a site of compression. MRI can do the same but is not dynamic. X-rays are not usually indicated in diagnosing carpal tunnel syndrome.Sources: Electrodiagnostic Evaluation of Carpal Tunnel Syndrome – StatPearls – NCBI Bookshelf (opens in a new tab); Diagnostic accuracy of ultrasonography in diagnosis of Carpal Tunnel Syndrome – PubMed (opens in a new tab)

Treatment options are divided into conservative and surgical.

Conservative options

• Activity modification, ergonomic modifications, +/- analgesia/short course of NSAIDs. These simple interventions can be helpful initially, allowing things to calm down. A wrist splint can also be used, especially at night, which might be helpful for certain patients with mild to moderate symptoms; however, the efficacy of it remains unclear.Source: Splinting for carpal tunnel syndrome – PubMed (opens in a new tab)
• A local anaesthetic and steroid injection into the carpal tunnel, usually done under ultrasound guidance, can provide symptomatic relief for 6 months, sometimes longer, in patients with mild to moderate symptoms.Source: Local corticosteroid injection versus placebo for carpal tunnel syndrome – PubMed (opens in a new tab)
• A hydrodissection procedure can also be done under ultrasound guidance, which involves the use of saline to strip away any tight surrounding tissue from the median nerve with the aim of making more space and relieving any localised compression. This is usually combined with a steroid and local anaesthetic. It has been shown to be effective at relieving the symptoms in the short to medium term, but its additional benefit over local anaesthetic and steroid in isolation is still not fully understood.Source: Hydrodissection With or Without Corticosteroid Versus Corticosteroid-Only Injection for Carpal Tunnel Syndrome: Double-Blind Randomised Controlled Trial – PubMed (opens in a new tab)

Surgical options

If conservative options mentioned previously do not provide adequate relief or if there is a recurrence in symptoms, then surgery is usually definitive.

• Surgical treatment involves the release of the carpal tunnel (carpal tunnel decompression) and is the most common hand operation performed. This procedure involves roughly a 4 cm incision in the palm cutting through the transverse carpal ligament, which forms the roof of the carpal tunnel. This subsequently makes more space for the nerve to pass into the hand, relieving any localised compression. Carpal Tunnel release is a successful and safe procedure offering significant symptomatic relief.Source: Efficacy of Surgical Management Among Patients With Carpal Tunnel Syndrome Not Responding to Medical Management – PubMed (opens in a new tab)

Other surgical options, such as endoscopic and ultrasound-guided percutaneous release, can also be offered. They have been shown to be as effective as ‘open’ surgery but with shorter post-procedure recovery times.Source: Ultrasound-guided percutaneous carpal tunnel release: A systematic review – PubMed (opens in a new tab)