1152020 1 Carpal Tunnel Syndrome Carpal Tunnel Syndrome

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11/5/2020 1

11/5/2020 1

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome 11/5/2020 3

Carpal Tunnel Syndrome 11/5/2020 3

Case • A 40 years old right handed female presented with complaints of “pins

Case • A 40 years old right handed female presented with complaints of “pins and needles” in her right hand with wrist pain • Her symptoms started about 1 year ago • Radiates up into forearm and elbow • Worse with driving and knitting and in the evening • She wakes up at night and has to shake her hands to relieve her symptoms • Wakes up with tingling over tips of fingers • Finger’s swollen when symptoms at their worse • PMHx: DM 11/5/2020 4

Plan • Definition • Epidemiology • Etiology • Diagnosis • Differential Diagnosis • Treatment

Plan • Definition • Epidemiology • Etiology • Diagnosis • Differential Diagnosis • Treatment 11/5/2020 5

Definition • The most common peripheral compressive neuropathy • Results from compression of the

Definition • The most common peripheral compressive neuropathy • Results from compression of the median nerve in the area of the volar wrist in the Carpal tunnel 11/5/2020 6

Carpal Tunnel Anatomy: TCL is attached to the pisiform + hamate on one side

Carpal Tunnel Anatomy: TCL is attached to the pisiform + hamate on one side and the scaphoid + trapezium on the other. Depth of 10 to 13 mm 11/5/2020 7

Cross Section at Wrist 11/5/2020 8

Cross Section at Wrist 11/5/2020 8

Epidemiology of CTS • Incidence of 100 to 140 per 100, 000 • Female:

Epidemiology of CTS • Incidence of 100 to 140 per 100, 000 • Female: Male 3: 1 • 4 th-5 th decade (82% > 40 yo) • ~50% have bilateral CTS • ~400, 000 -500, 000 CTR per year (USA) 11/5/2020 9

Etiology 1. Idiopathic 2. Anatomic 3. Systemic 4. occupation 11/5/2020 10

Etiology 1. Idiopathic 2. Anatomic 3. Systemic 4. occupation 11/5/2020 10

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Etiology 1. Idiopathic (80%) hypertrophy of TCL 2. Diabetes (prevalence 14%-30% with neuropathy) 3.

Etiology 1. Idiopathic (80%) hypertrophy of TCL 2. Diabetes (prevalence 14%-30% with neuropathy) 3. 4. 5. 6. 7. 8. Obesity Hypothyroidism Pregnancy (usually 3 rd trimester) RA -- Inflammatory arthritis Old Colles # or lunate dislocation Chronic dialysis - Renal disease 11/5/2020 12

What causes it? There are two basic categories of causes Work Related Causes Repetitive

What causes it? There are two basic categories of causes Work Related Causes Repetitive Task Profession Grabbing & tugging cloth Tailor, sewer Handling objects on conveyor belt Assembly-line worker Hand weeding Gardener Using spray gun Painter Knitting Homemaker Turning keys Locksmith ﺍﻻﻗﻔﺎﻝ Typing Clerical worker Using scanner at checkout counter Cashier Scrubbing Janitor ﺍﻟﺒﻮﺍﺏ 11/5/2020 Stringed instruments Musician ﺻﺎﻧﻊ 13

Non-Work Related Causes Arthritis Diabetes Thyroid gland imbalance Gout Broken or dislocated bones of

Non-Work Related Causes Arthritis Diabetes Thyroid gland imbalance Gout Broken or dislocated bones of the wrist Hormonal changes associated with menopause Oral use of contraceptives Pregnancy Wrist cysts Gynecological surgery * Most cases have no known cause 11/5/2020 14

Pathophysiology q Median nerve: • Originates from lateral and medial cords of brachial plexus

Pathophysiology q Median nerve: • Originates from lateral and medial cords of brachial plexus • Contributions from C 6, C 7, C 8 & T 1 (± C 5) • Disturbed axoplasmic flow • Endoneural edema • Impaired neural circulation 11/5/2020 15

Pathophysiology • Normal subjects – carpal tunnel pressure = 2. 5 mm. Hg (neutral)

Pathophysiology • Normal subjects – carpal tunnel pressure = 2. 5 mm. Hg (neutral) • CTS subjects – carpal tunnel pressure = 32 mm Hg (neutral) – 94 -110 mm. Hg with wrist flexion/extension • A decrease in epineural blood flow and edematous changes occur when the pressure reaches 20 to 30 mm Hg 11/5/2020 16

Clinical Picture • Tingling+ Numbness+ Paresthesia + Pain at median n. distribution in hand,

Clinical Picture • Tingling+ Numbness+ Paresthesia + Pain at median n. distribution in hand, often worse at night • Sensory changes : nocturnal paresthesia (cardinal Sx) • Muscle atrophy Thenar eminence- late sign • Motor changes thumb movements/strength 11/5/2020 weak grip, fatigue with repetitive activity 17

 • Relieved by shaking, hanging or massaging your hands • Dropping objects, inability

• Relieved by shaking, hanging or massaging your hands • Dropping objects, inability to keep or count change with the affected hand • Cold intolerance , dryness, and unusual textures in the radial digits= disruption of the sympathetic fibers carried by the median nerve. 11/5/2020 18

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Atrophy 11/5/2020 20

Atrophy 11/5/2020 20

Carpal Tunnel Tests 1. Neurologic exam – Median nerve sensation and motor 2. Phalen’s

Carpal Tunnel Tests 1. Neurologic exam – Median nerve sensation and motor 2. Phalen’s Test: both wrists maximally flexed for 1 minute 3. Tinel’s Test ¥ 4. Tourniquet test 5. Closed fist sign 11/5/2020 21

Durkan’s test • Durkan’s test or the pressure provocation test • • Pressure to

Durkan’s test • Durkan’s test or the pressure provocation test • • Pressure to the palm over the nerve for up to 30 seconds to elicit symptoms. • The pressure is either applied by hand or a pressure gauge held at 150 mm. Hg. 11/5/2020 22

CTS: Exam 11/5/2020 medicine. ucsd. edu/clinicalmed/Joints 4. html 23

CTS: Exam 11/5/2020 medicine. ucsd. edu/clinicalmed/Joints 4. html 23

Investigations CTS is a clinical diagnosis • Imaging : to exclude structural causes •

Investigations CTS is a clinical diagnosis • Imaging : to exclude structural causes • EMG / nerve conduction studies • TSH, fasting glucose 11/5/2020 24

Electrodiagnostic tests • NOT the gold standard • ED tests can help: – identify

Electrodiagnostic tests • NOT the gold standard • ED tests can help: – identify peripheral neuropathy – locate other sites of compression – establish severity – (-) ED test, (+) classic sx = ? If CTS – (+) ED test, (-) symptoms CTS 11/5/2020 25

Differential Diagnosis • C 6, C 7 radiculopathy • Proximal median nerve entrapment at

Differential Diagnosis • C 6, C 7 radiculopathy • Proximal median nerve entrapment at the elbow • Traumatic injury at the level of the wrist • Double crush syndrome • Tenosynovitis • Diabetic neuropathy • Kienbock's disease 11/5/2020 26

Management q Conservative: 1. Do nothing, avoid aggrevating activities: • 1/3 resolve in 6

Management q Conservative: 1. Do nothing, avoid aggrevating activities: • 1/3 resolve in 6 months (more likely if younger and Phalen’s test negative) 2. Splints: • 24 hr splinting no better than night splinting 3. Anti-inflammatory drugs • • 11/5/2020 No evidence they are helpful Stop after 1 month, unlikely to provide further benefit 27

ORAL MEDICATIONS • Diuretics D ON OT • Nonsteroidal anti-inflammatory drugs WO RK !

ORAL MEDICATIONS • Diuretics D ON OT • Nonsteroidal anti-inflammatory drugs WO RK ! (NSAIDs) !! • pyridoxine (vitamin B 6) • Orally administered corticosteroids – Prednisolone – 20 mg per day for two weeks – followed by 10 mg per day for two weeks 11/5/2020 28

Splints 11/5/2020 29

Splints 11/5/2020 29

WRIST SPLINTS 11/5/2020 30

WRIST SPLINTS 11/5/2020 30

q Injection: Local corticosteroid injection – 80% relief short-term, ~10 -20% @ 1. 5

q Injection: Local corticosteroid injection – 80% relief short-term, ~10 -20% @ 1. 5 years – (+) response predictive of success with surgery – dexamethasone safest 11/5/2020 31

Injection for CTS • • • Syringe: 5 ml Needle: 25 gauge, 1. 5

Injection for CTS • • • Syringe: 5 ml Needle: 25 gauge, 1. 5 inch Position: palm up, slight wrist extension Where: carpal tunnel Landmark: between PL and ulnar artery Angle: 30 degrees, aim to 4 th finger Depth: 1 -2 cm What: 40 mg methylprednisolone (1 cc) Follow-up: 2 -4 weeks 11/5/2020 32

Injection for CTS • RISKS! – Standard injection risks • bleeding, bruising, infection, allergy

Injection for CTS • RISKS! – Standard injection risks • bleeding, bruising, infection, allergy – Trauma to: • median nerve • ulnar artery – Tendon weakening/rupture – Skin pigmentation changes 11/5/2020 33

q. Surgery • Indicated when: 1. 2. 3. 4. Failed conservative treatment Thenar atrophy

q. Surgery • Indicated when: 1. 2. 3. 4. Failed conservative treatment Thenar atrophy Acute CTS → trauma or infection Chronic CTS > 1 year with moderate to severe symptoms 11/5/2020 34

OPEN 11/5/2020 ARTHROSCOPIC 35

OPEN 11/5/2020 ARTHROSCOPIC 35

SURGERY 11/5/2020 36

SURGERY 11/5/2020 36

Facts about the ECTR procedure 11/5/2020 Small incision Single suture Fast rehabilitation Better cosmetic

Facts about the ECTR procedure 11/5/2020 Small incision Single suture Fast rehabilitation Better cosmetic result 37

PREGNANCY • Alterations in fluid balance may predispose some pregnant women to develop CTS:

PREGNANCY • Alterations in fluid balance may predispose some pregnant women to develop CTS: 20% to 45%. • Symptoms are typically bilateral and first noted during the third trimester. • Conservative measures are appropriate, because symptoms resolve after delivery in most women with pregnancy-related CTS. 11/5/2020 38

What Can I Expect After the Surgery? • Tenderness at incision site until healing

What Can I Expect After the Surgery? • Tenderness at incision site until healing complete • Symptom relief immediately or shortly afterwards • Numbness may remain for a period of time in older individuals or more severe cases 11/5/2020 39

Complications of surgery • Injury to the palmar cutaneous or recurrent motor branch of

Complications of surgery • Injury to the palmar cutaneous or recurrent motor branch of the median nerve • Hypertrophic scarring • • • laceration of the superficial palmar arch tendon adhesion Postoperative infection Hematoma arterial injury stiffness 11/5/2020 40

Exercises Post Surgery • Physical activities can be resumed only after a few weeks

Exercises Post Surgery • Physical activities can be resumed only after a few weeks & for some a few months • Exercises will be given in order to build muscle strength, joint flexibility of hand wrist 11/5/2020 41

Summary • most common compressive neuropathy of the upper extremity • C ⁄P :

Summary • most common compressive neuropathy of the upper extremity • C ⁄P : pain, weakness, and paresthesia in the hand digits • Etiology : multifactorial; anatomic, systemic, and occupational • Diagnosis : Hx and Ex and is confirmed by ED • Treatment: observation and splinting , cortisone injection & surgical intervention 11/5/2020 42

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DDx of Wrist Pain • Trauma – Fracture, Sprain, Dislocation, etc • Nontraumatic –

DDx of Wrist Pain • Trauma – Fracture, Sprain, Dislocation, etc • Nontraumatic – Radiocarpal arthritis (OA, RA, Crystal-induced, septic) – Dorsal Ganglion – Carpal Tunnel – Referred Pain from Thumb (de Quervain’s, Carpometacarpal osteoarthritis) 11/5/2020 44

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Chronic CTS • Classification 1. Early • mild sx (night, activity) • < 1

Chronic CTS • Classification 1. Early • mild sx (night, activity) • < 1 year duration • no gross morphologic changes in nerve 2. Intermediate • numbness, paresthesias (min. thenar atrophy) • chronic changes in median nerve (edema) reversible with decompression 3 -Advanced – marked sensory changes – thenar motor weakness – chronic pathologic changes in median nerve • endonerual edema, intraneural fibrosis, partial demyelination, axonal degeneration • some changes irreversible 11/5/2020 46

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Electrodiagnostic tests • Abnormal = across the wrist: – distal motor latency > 4.

Electrodiagnostic tests • Abnormal = across the wrist: – distal motor latency > 4. 5 ms – sensory latency > 3. 5 ms • However: – 8 -22% of patients with (-) electrodiagnostics and (+) clinical signs improve with CTR 11/5/2020 48