lending a hand with carpal tunnel care, tvsc 2003

Lending a Hand Lending a Hand With the Carpal With the Carpal Tunnel SyndromeTunnel Syndrome

Robert Lieberson, M.D., F.A.C.S.Robert Lieberson, M.D., F.A.C.S.Northern California Neurosurgery Medical Group, Inc.Northern California Neurosurgery Medical Group, Inc.

Specializing in Spine and Peripheral NerveSpecializing in Spine and Peripheral Nerve

Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.

OverviewOverviewHistoryHistoryAnatomyAnatomyPhysiologyPhysiologySymptomsSymptomsDifferential diagnosisDifferential diagnosisPhysical examinationPhysical examinationSpecial studiesSpecial studiesTreatmentTreatmentOutcomesOutcomes



HistoryHistory

Carpal tunnel syndrome first described by Carpal tunnel syndrome first described by Paget in 1854Paget in 1854First carpal tunnel release in 1924 by First carpal tunnel release in 1924 by Galloway and Mackinnon or in 1933 by Galloway and Mackinnon or in 1933 by LearmonthLearmonthWorld war IIWorld war II

Her majesty’s guide to the peripheral nervous Her majesty’s guide to the peripheral nervous systemsystem

U.S. And British studies describing recovery U.S. And British studies describing recovery from peripheral nerve injuriesfrom peripheral nerve injuries



HistoryHistory

Increase in frequency of CTS since Increase in frequency of CTS since the 1980’sthe 1980’s

50 to 150 cases per 100,000 population50 to 150 cases per 100,000 population Cause of the increase not clearCause of the increase not clear

ComputersComputers Reimbursement issuesReimbursement issues



PhysiologyPhysiology

Repetitive traumaRepetitive traumaTraumaTrauma

Old fractureOld fracture New fractureNew fracture DislocationDislocation Hyper-flexion or Hyper-flexion or

hyper-extension hyper-extension injuryinjury

PregnancyPregnancyDiabetesDiabetes

Renal failureRenal failure

GoutGoutMass lesionsMass lesions

Ganglion cystsGanglion cysts LipomasLipomas TumorsTumors HematomaHematoma OsteophytesOsteophytes

Generalized edemaGeneralized edema HypothyroidismHypothyroidism AcromegallyAcromegally Multiple myelomaMultiple myeloma MucolipidosesMucolipidoses MucopolysaccharidosesMucopolysaccharidoses

Hereditary predisposition to Hereditary predisposition to pressure palsiespressure palsies

Familial carpal tunnel syndromeFamilial carpal tunnel syndrome



Anatomy: MacroAnatomy: MacroThe median nerve The median nerve is and extension of is and extension of the C6 nerve rootthe C6 nerve root

It can be It can be compressed at compressed at several locationsseveral locations

Compression at Compression at the carpal tunnel is the carpal tunnel is most commonmost common

C6 also commonC6 also common



Anatomy: MacroAnatomy: MacroThe median nerve is The median nerve is immediately beneath the flexor immediately beneath the flexor retinaculum, superficial to the retinaculum, superficial to the tendons and above the carpal tendons and above the carpal bonesbones



Anatomy: MicroAnatomy: Micro

Axons are wrapped by Axons are wrapped by Schwann cellsSchwann cellsEndoneurium includes the Endoneurium includes the wrapped nerves, wrapped nerves, connective tissue and connective tissue and extracellular fluidextracellular fluidPerineurium is a sheath Perineurium is a sheath the bundles fibers together the bundles fibers together into fasiclesinto fasiclesEpineurium ensheaths Epineurium ensheaths fasicles to form nervesfasicles to form nerves



Anatomy: AbnormalAnatomy: Abnormal

The The abnormal abnormal carpal carpal tunnel is tunnel is too small too small for the for the median median nervenerve



Anatomy: AbnormalAnatomy: Abnormal

DemyelinationDemyelination is loss of the is loss of the coverings of coverings of the nerve fiberthe nerve fiber

Axonal lossAxonal loss is is damage to the damage to the fiber itselffiber itself



SymptomsSymptoms

Frequently bilateralFrequently bilateralImproved by “shaking out” the Improved by “shaking out” the hands (the “flick test”)hands (the “flick test”)Worse at night, worse with Worse at night, worse with positioningpositioningParasthesias/numbness, Parasthesias/numbness, median nerve distributionmedian nerve distributionHand pain, sometimes to the Hand pain, sometimes to the shouldershoulder““Dropping things” common Dropping things” common (possibly due to numbness)(possibly due to numbness)



Differential DiagnosisDifferential Diagnosis

Cervical radiculopathyCervical radiculopathy (C6)(C6)

Physiologic “soreness”Physiologic “soreness”

Tendonitis, focal or diffuseTendonitis, focal or diffuse

““Overuse” injuryOveruse” injury

Other focal peripheral neuropathyOther focal peripheral neuropathy

Thoracic outlet syndromeThoracic outlet syndrome



Physical Examination: Physical Examination: “Rule In’s”“Rule In’s”

Motor, sensory and reflex examinationMotor, sensory and reflex examination Specific numbnessSpecific numbness Weakness in APBWeakness in APB No reflex changeNo reflex change

Tinel’sTinel’s sign and sign and Phalen’sPhalen’s sign sign Moderately sensitive (20% to 70%)Moderately sensitive (20% to 70%) Moderately specific (70%-83%)Moderately specific (70%-83%)



Physical Examination: Physical Examination: “Rule Out’s”“Rule Out’s”

Motor, sensory and reflex examinationMotor, sensory and reflex examination

Spurlings testSpurlings test

Cervical muscle spasmCervical muscle spasm

Adson’s testAdson’s test

Finkelstein’s signFinkelstein’s sign



Physical Examination: Physical Examination: “The Double Crush”“The Double Crush”

The combination of a C6 radiculopathy The combination of a C6 radiculopathy and a carpal tunnel syndromeand a carpal tunnel syndrome

Both are commonBoth are common

Both may result from similar stressesBoth may result from similar stresses

Symptoms and signs overlapSymptoms and signs overlap

EMG/NCV useful to delineateEMG/NCV useful to delineate



Special Studies: EMG/NCVSpecial Studies: EMG/NCV

Electromyography (EMG) Electromyography (EMG) and nerve conduction and nerve conduction studies (NCV’s)studies (NCV’s)

Accurate localization of the Accurate localization of the lesion (focal peripheral lesion (focal peripheral neuropathy, not neuropathy, not radiculopathy, etc.)radiculopathy, etc.)

Determine the severityDetermine the severity Exclude non-neurologic Exclude non-neurologic

causescauses

Sensitivity of 60% to 82%, Sensitivity of 60% to 82%, specificity of 95% to 100%specificity of 95% to 100%



Special Studies: EMG/NCVSpecial Studies: EMG/NCV

Variety of specific accepted protocolsVariety of specific accepted protocols

Generally compare the median nerve Generally compare the median nerve velocities with the ulnar or radial velocities with the ulnar or radial velocitiesvelocities

A difference in velocities is significantA difference in velocities is significant

If all nerves show delayed conduction, If all nerves show delayed conduction, consider a generalized neuropathyconsider a generalized neuropathy



Special Studies: Special Studies: MRI ScanningMRI Scanning

First used in the mid-1980’sFirst used in the mid-1980’sCan clearly show the carpal Can clearly show the carpal tunnel syndrometunnel syndromeT2-weighted imagesT2-weighted images

Swelling of the median nerve Swelling of the median nerve proximal to the carpal tunnelproximal to the carpal tunnel

Flattening of the nerve in the Flattening of the nerve in the tunneltunnel

Bowing of the flexor retinaculumBowing of the flexor retinaculum Thickening of the tendon sheathsThickening of the tendon sheaths

Sensitivity 27% to 87%Sensitivity 27% to 87%



Special Studies: Non-Special Studies: Non-standardstandard

Calibrated sensory testing (von Frye Calibrated sensory testing (von Frye hairs, et al.)hairs, et al.)

Two-point discriminationTwo-point discrimination

Many other “unusual tests” such as Many other “unusual tests” such as functional testing, SSEP’s and surface functional testing, SSEP’s and surface EMG’s of dubious valueEMG’s of dubious value



TreatmentTreatment

MildMild Blood-nerve barrier Blood-nerve barrier

breakdown, symptoms breakdown, symptoms but no signs, sensory but but no signs, sensory but notnot motor slowing by NCV motor slowing by NCV

ModerateModerate Demyelination, symptoms Demyelination, symptoms

and signs, sensory and and signs, sensory and motor slowingmotor slowing

SevereSevere Axonal loss, symptoms Axonal loss, symptoms

and signs, sensory and signs, sensory conduction blockconduction block

MildMild Workplace ergonomics, Workplace ergonomics,

task rotationtask rotation Occupational therapyOccupational therapy Nocturnal splintingNocturnal splinting

ModerateModerate Anti-inflammatory Anti-inflammatory

medicationsmedications Corticosteroid injectionsCorticosteroid injections Twenty-four hour splintingTwenty-four hour splinting

SevereSevere Surgery (open or Surgery (open or

endoscopic)endoscopic)



Treatment: Treatment: Open SurgeryOpen Surgery

Better exposureBetter exposure



Treatment: Endoscopic Treatment: Endoscopic SurgerySurgery

Decreased scar Decreased scar formationformationNo palmar incisionNo palmar incisionLess painLess painEarlier return to workEarlier return to workPossibly more risk of Possibly more risk of nerve injury or nerve injury or incomplete releaseincomplete releaseNo more or less costlyNo more or less costly



Treatment: Endoscopic Treatment: Endoscopic SurgerySurgery

Higher risk of injury Higher risk of injury to the recurrent to the recurrent branchbranch



Treatment: ControversialTreatment: Controversial

More aggressive surgeryMore aggressive surgery Lysis of the epineurium is indicated only Lysis of the epineurium is indicated only

for thinned, internally scarred nervesfor thinned, internally scarred nerves

ChiropracticChiropractic There is no demonstrated efficacy for There is no demonstrated efficacy for

adjustmentadjustment External laser therapy of no valueExternal laser therapy of no value Massage, ultrasound, heat, etc. Provide Massage, ultrasound, heat, etc. Provide

temporary comfort at besttemporary comfort at best



Treatment: Postoperative Treatment: Postoperative CareCare

Bulky dressingBulky dressing Delayed suture removalDelayed suture removal Physical therapyPhysical therapy Return to work in four to six weeksReturn to work in four to six weeks

The most common complication is The most common complication is recurrencerecurrence

7% to 20% depending on series7% to 20% depending on series Inadequate releaseInadequate release Recurrent scarRecurrent scar Wrong diagnosisWrong diagnosis



OutcomesOutcomes

Biopsychosocial model does applyBiopsychosocial model does apply ““Workers’ comp” patients are differentWorkers’ comp” patients are different

In non-compensible injuries there is In non-compensible injuries there is rarely any residual disabilityrarely any residual disability

Significant time off work uncommonSignificant time off work uncommon

No repetitive or forceful activities No repetitive or forceful activities translates into approximately a 30% translates into approximately a 30% standard in Californiastandard in California

Approximately $ 20,000 (current rates)Approximately $ 20,000 (current rates) Often off work a year or moreOften off work a year or more



The EndThe End

lending a hand with carpal tunnel care, tvsc 2003

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