1152020 1 Carpal Tunnel Syndrome Carpal Tunnel Syndrome
















































- Slides: 48

11/5/2020 1

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome 11/5/2020 3

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 11/5/2020 5

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 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

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

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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 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 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 • 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) • 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, 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 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

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 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

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 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 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 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 ! (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

WRIST SPLINTS 11/5/2020 30

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 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 – 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 Acute CTS → trauma or infection Chronic CTS > 1 year with moderate to severe symptoms 11/5/2020 34

OPEN 11/5/2020 ARTHROSCOPIC 35

SURGERY 11/5/2020 36

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: 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 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 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 & 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 : 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 – 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 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. 5 ms – sensory latency > 3. 5 ms • However: – 8 -22% of patients with (-) electrodiagnostics and (+) clinical signs improve with CTR 11/5/2020 48