eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Carpal Tunnel Syndrome
Updated: Oct 21, 2009
Introduction
Carpal tunnel syndrome (CTS) is the most commonly diagnosed and treated entrapment neuropathy. The syndrome is characterized by pain, paresthesia, and weakness in the median nerve distribution of the hand. Surgical and nonsurgical treatments exist that can produce excellent outcomes for patients.
Cross sections of the carpal canal at the levels of the proximal and distal carpal rows are depicted. The transverse carpal ligament bridges the carpal tunnel and is under tension.
Surgical incision for an open carpal tunnel release is depicted. The incision can be extended proximally across the wrist flexion crease for a more extended exposure.
Surgical incisions for an endoscopic (1- and 2-incision) carpal tunnel release are depicted. Precise location of the incisions is critical and depends on individual anatomy.
American Academy of Orthopaedic Surgeons guidelines
The AAOS has developed the following clinical guidelines for the treatment of carpal tunnel syndrome (level of evidence provided in parentheses)1 :
Recommendation 1
A course of nonoperative treatment is an option in patients diagnosed with carpal tunnel syndrome (CTS). Early surgery is an option when there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. (Grade C, level V)
Recommendation 2
We suggest another nonoperative treatment or surgery when the current treatment fails to resolve the symptoms within 2-7 weeks. (Grade B, level I and II)
Recommendation 3
We do not have sufficient evidence to provide specific treatment recommendations for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace. (Inconclusive, No evidence found)
Recommendation 4a
Local steroid injection or splinting is suggested when treating patients with carpal tunnel syndrome, before considering surgery. (Grade B, level I and II)
Recommendation 4b
Oral steroids or ultrasound are options when treating patients with carpal tunnel syndrome. (Grade C, level II)
Recommendation 4c
We recommend carpal tunnel release as treatment for carpal tunnel syndrome. (Grade A, level I)
Recommendation 4d
Heat therapy is not among the options that should be used to treat patients with carpal tunnel syndrome. (Grade C, level II)
Recommendation 4e
The following treatments carry no recommendation for or against their use: activity modifications, acupuncture, cognitive behavioral therapy, cold laser, diuretics, exercise, electric stimulation, fitness, Graston instrument, iontophoresis, laser, stretching, massage therapy, magnet therapy, manipulation, medications (including anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs [NSAIDs]), nutritional supplements, phonophoresis, smoking cessation, systemic steroid injection, therapeutic touch, vitamin B6 (pyridoxine), weight reduction, yoga. (Inconclusive, level II and V)
Recommendation 5
We recommend surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum regardless of the specific surgical technique. (Grade A, level I and II)
Recommendation 6
We suggest that surgeons do not routinely use the following procedures when performing carpal tunnel release: skin nerve preservation (Grade B, level I); epineurotomy (Grade C, level II)
The following procedures carry no recommendation for or against use: flexor retinaculum lengthening, internal neurolysis, tenosynovectomy, ulnar bursa preservation. (Inconclusive, level II and V)
Recommendation 7
The physician has the option of prescribing preoperative antibiotics for carpal tunnel surgery. (Grade C, level III)
Recommendation 8
We suggest that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. (Grade B, level II)
We make no recommendation for or against the use of postoperative rehabilitation. (Inconclusive, level II)
Recommendation 9
We suggest physicians use one or more of the following instruments when assessing patients’ responses to CTS treatment for research:
- Boston Carpal Tunnel Questionnaire (disease-specific)
- DASH—Disabilities of the Arm, Shoulder, and Hand (region-specific; upper limb)
- MHQ—Michigan Hand Outcomes Questionnaire (region-specific; hand/wrist)
- Patient Evaluation Measure (region-specific; hand)
- SF-12 or SF-36 Short Form Health Survey (generic; physical health component for global health impact) (Grade B, level I, II, and III)
Recent studies
Jarvik et al compared surgical (57 patients) versus multi-modality, nonsurgical treatment (hand therapy and ultrasound; 59 patients) for carpal tunnel syndrome without denervation. Analyses showed a significant 12-month adjusted advantage for surgery in function and symptoms; there were no clinically important adverse events and no surgical complications. According to the authors, symptoms in both groups improved, but surgical treatment led to better outcome than nonsurgical treatment.2
In a Mayo Clinic study by Gelfman et al, temporal trends in CTS were assessed for incidence, surgical treatment, and lost time at work. Using Olsmsted County residents as the study population, 10,069 residents were found to have been diagnosed with CTS from 1981-2005 (491 per 100,000 person years for women; 258 per 100,000 person years for men; 376 per 100,000 person-years combined). Adjusted annual rates increased from 258 per 100,000 in 1981-1985 to 424 in 2000-2005. The average annual incidence of carpal tunnel release surgery was 109 per 100,000, and that for work-related CTS was 11 per 100,000. According to the authors, the increase seen in this population corresponds to a national epidemic of CTS cases resulting in lost work days that began in the mid-1980s and lasted through the mid-1990s, but the cause for the increase is not yet clear.3
Pomerance et al compared direct costs and results for patients with electrodiagnostically proven CTS treated with surgery versus nonsurgical care. In the study, 120 patients were divided into 2 groups: group 1 received nonsurgical therapy, and group 2 received surgical treatment. Follow-up averaged 13 ± 5 months for group 1 and 12 ± 2 months for group 2, with 32 patients in group 1 electing to have surgery during the follow-up period. Cost of care averaged $3,335 ± $2,097 in the nonsurgery group and $3,068 ± $983 in the surgery group. The authors concluded that surgery should be considered as the initial form of treatment when patients are diagnosed with CTS confirmed by nerve conduction studies because surgery provides symptom resolution with a favorable cost analysis.4
Wolf et al studied the diagnosis of CTS in the United States military population from 1998-2006 and found the incidence to be 3.98 per 1,000 person-years, which compared with incidences of 1.5 to 3.5 per 1,000 person-years in other regional or working-group populations studied. In the military study, females had a significantly higher incidence of CTS than males, with an adjusted incidence rate ratio of 3.29. CTS incidence was found to increase with age, with the age group 40 years or older having a significantly higher incidence. Additionally, military rank was found to be an independent risk factor for CTS, with rates higher in senior officer and enlisted groups, suggesting that occupational requirements have an effect on CTS within the military.5
For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center and Arthritis Center. Also, see eMedicine's patient education article Carpal Tunnel Syndrome.
History of the Procedure
In 1854, Sir James Paget first reported median nerve compression at the wrist following a distal radius fracture.6 In 1880, James Putnam presented the first series of patients with pain and paresthesia in the median nerve distribution of the hand.7 In 1913, Pierre Marie and Charles Foix described the pathology of median nerve compression underneath the transverse carpal ligament (TCL).8 In 1933, Sir James Learmonth reported the first TCL release to treat median nerve compression at the wrist.9 Since these early reports, much work has described the signs and symptoms of CTS, as well as its treatments.
Frequency
Carpal tunnel syndrome (CTS) is common in the general population.10 It has previously been reported with acute onset following trauma to the wrist; it has also been detailed as a gradual progression of symptoms typically occurring in women who are in the late middle-aged years of life. A new population at risk has been reported to be industrial workers whose hands and wrists are subjected to repetitive motion and trauma.11,12
Controversy exists regarding the clinical and electrophysiologic findings necessary to diagnose CTS. Despite this controversy, several surveys have been conducted to determine the prevalence of CTS in the general population. In the Netherlands, the prevalence of undetected CTS was 5.8% in women and 0.6% in men.10 In Sweden, the overall prevalence of CTS in the population was 2.7%. These prevalence rates were based on clinical and electrophysiologic criteria and probably represent minimum prevalence rate estimates.
Etiology
The etiology of carpal tunnel syndrome (CTS) is multifactorial, with local and systemic factors contributing to varying degrees. Symptoms of CTS are a result of median nerve compression at the wrist, with ischemia and impaired axonal transport of the median nerve across the wrist.13 Compression results from elevated pressures within the carpal canal.
Elevated pressures can develop within the carpal canal even though the canal is not a separate, closed compartment within the upper extremity. Direct pressure or a space-occupying lesion within the carpal canal can increase pressure on the median nerve and produce CTS. Fracture callus, osteophytes, anomalous muscle bodies, tumors, hypertrophic synovium, and infection, as well as gout and other inflammatory conditions, can produce increased pressure within the carpal canal. Extremes of wrist flexion and extension also elevate pressure within the carpal canal.
Compression of a nerve affects intraneural blood flow.14,15,16 Pressures as low as 20-30 mm Hg retard venular blood flow in a nerve. Axonal transport is impaired at 30 mm Hg. Neurophysiologic changes manifested as sensory and motor dysfunction are present at 40 mm Hg. Further increases in pressure produce increasing sensory and motor block. At 60-80 mm Hg, complete cessation of intraneural blood flow is observed. In one study, the carpal canal pressures in patients with CTS averaged 32 mm Hg, compared with only about 2 mm Hg in control subjects.14
The double crush syndrome, in which there is pressure on the median nerve at a second site (remote from the wrist), can further lower the median nerve's pressure threshold for producing symptoms of CTS. If a nerve is compressed at multiple sites, traction within the nerve with joint motion may be produced. In addition to pressure, traction or stretch has been demonstrated to produce alterations in intraneural circulation. Elongation of only 8% can impair venular flow, and all intraneural microcirculation can cease at 15% nerve elongation.
Many systemic conditions are strongly associated with CTS. These conditions may directly or indirectly affect microcirculation, pressure thresholds for nerve conduction, nerve cell body synthesis, and axon transport or interstitial fluid pressures. Perturbations in the endocrine system, as observed in individuals with diabetes and hypothyroidism and in women who are pregnant, are linked to CTS. Conditions affecting metabolism (eg, alcoholism, renal failure with hemodialysis, mucopolysaccharidoses) also are associated with CTS.
The international debate regarding the relationship between CTS and the performance of repetitive motion and work is ongoing.11,12 The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. Occupational risk factors — repetitive tasks, force, posture, and vibration — have been cited. However, the American Society for Surgery of the Hand has issued a statement that the current literature does not support a causal relationship between specific work activities and the development of diseases such as CTS.
Psychosocial and socioeconomic issues are increasingly being studied. In a study of risk factors for CTS in women, the greatest risk factor was found to be a previous history of another musculoskeletal complaint.17 Perceptions of health and tolerance to pain also may influence the development of CTS.
Pathophysiology
The pathophysiology of carpal tunnel syndrome (CTS) is typically demyelination. In more severe cases, secondary axonal loss may be present. The most consistent findings in biopsy specimens of tenosynovium from patients undergoing surgery for idiopathic CTS have been vascular sclerosis and edema.18 Localized amyloid deposition in the tenosynovium also has been reported in persons with idiopathic CTS. Inflammation, specifically tenosynovitis, is not part of the pathophysiologic process in chronic, idiopathic CTS.
Presentation
Acute carpal tunnel syndrome (CTS) can develop following a major trauma to the upper extremity (typically a distal radius fracture), a carpal dislocation, or a crush injury. Swelling, pain, and paresthesia in the median nerve distribution of the hand (palmar and radial) are observed.
In the more common idiopathic or chronic CTS, symptoms are more gradual in onset.19 Pain and paresthesia in the median nerve distribution of the hand are common. Symptoms are often worse at night and can wake a patient from sleep. As the condition worsens, daytime paresthesia becomes common and is often aggravated by daily activities, such as driving, combing the hair, and holding a book or phone. Weakness can be present. With long-standing or severe cases of CTS, thenar atrophy is frequently observed.
Because of the motor and sensory disturbances, manual dexterity is diminished, and difficulty with such daily activities as buttoning clothes and holding small objects is often encountered. Pain and paresthesia can also occur proximally in the forearm, elbow, shoulder, and neck in up to one third of patients. Pain and paresthesia in the hand are not always isolated to median nerve distribution but can involve the ulnar aspect or the entire hand.
Indications
Acute carpal tunnel syndrome (CTS) can be thought of as a compartment syndrome of the carpal canal, and decompression should be performed as soon as possible, assuming that reduction of associated fractures or dislocations or removal of tight splints does not relieve the symptoms. Other medical and surgical factors may impact the opportunity to operate emergently, but relieving pressure on the median is a priority in order to reduce the risk of permanent nerve injury. Acute CTS can be diagnosed through history and physical examination alone. Electrophysiologic studies are not required. Sometimes, carpal canal pressure measurements are made to help support the diagnosis of acute CTS, with pressures greater than 30 mm Hg being consistent with the diagnosis.
Chronic CTS presents over time and is treated in an operative and nonoperative fashion. Patients with milder symptoms and shorter nerve conduction delays on electrodiagnostic studies respond most favorably to nonoperative treatments. Patients with more severe symptoms — duration longer than 1 year, weakness, atrophy, radial-sided hand numbness, 2-point discrimination greater than 6 mm, and longer nerve conduction delays — often do not benefit from nonoperative care. Failure or findings that are predictive of nonoperative treatment failure are indications for surgical treatment of CTS.
Relevant Anatomy
The carpal canal is a fibro-osseous tunnel at the wrist through which 9 flexor tendons and the median nerve pass.20 The carpal bones define the dorsal aspect of the carpal canal and are shaped in a concave arch. The palmar aspect of the carpal canal is defined by the TCL, which bridges the 2 sides of the carpal arch. Intrinsic and extrinsic ligaments of the wrist and hand further stabilize the carpal bones. The carpal canal is narrowest at the level of the hook of the hamate, where the canal averages 20 mm in width.
The TCL attaches to the scaphoid tuberosity and trapezial crest on the radial side of the wrist, as well as to the pisiform and hook of the hamate on the ulnar side of the wrist (see Image 1). The TCL is 1.5 mm thick and 21.7 mm in length on average. Proximally, the TCL is a continuation of the antebrachial fascia in the forearm, and distally, the TCL attaches to the fibers of the midpalmar fascia. The TCL is under tension and helps to maintain the carpal arch. It serves as a retinacular pulley for the flexor tendons. Cutting the TCL increases the volume of the carpal canal. Cutting the TCL has also been postulated to alter the kinematics of the carpus, risk bowstringing of the flexor tendons, and decrease grip strength.
Cross sections of the carpal canal at the levels of the proximal and distal carpal rows are depicted. The transverse carpal ligament bridges the carpal tunnel and is under tension.
A combination of the lateral (C6-7) and medial (C8-T1) cords of the brachial plexus forms the median nerve. At the wrist and into the palm, the median nerve divides into terminal motor and sensory branches, with some anatomic variability. The variability is caused in part by the branching point of the recurrent motor branch. An extraligamentous pattern, with a branching point distal to the TCL, is the most common. The recurrent motor branch can also divide from the median nerve underneath the TCL in a subligamentous fashion; it can then either wrap around the distal end of the TCL or pass directly through the TCL to innervate the thenar muscles. Other less common patterns, such as a branch point proximal to the TCL, exist as well. These variations can have major surgical implications.
The ulnar nerve is the other major motor and sensory nerve of the hand. The ulnar nerve does not pass through the carpal canal but instead goes through the Guyon canal, which is located adjacent to the carpal canal, at the wrist. Division of the TCL will change the morphology of the Guyon canal from triangular to ovoid.
Contraindications
No specific contraindications exist for surgical treatment of carpal tunnel syndrome (CTS). Medical conditions should be stabilized prior to surgery. Pregnancy should be allowed to proceed to term, because CTS often resolves after the pregnancy. Unrealistic expectations can influence surgical outcomes, and risk factors for poor outcomes should be sought pre-operatively. Individuals with severe CTS should be cautioned that their numbness may persist, at least to some degree, despite a complete surgical release. Patients receiving worker's compensation have a lower return-to-work rate. A greater preference for improved strength pre-operatively also has been associated with lower satisfaction.21
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 Overview: Carpal Tunnel Syndrome |
| Workup: Carpal Tunnel Syndrome |
| Treatment: Carpal Tunnel Syndrome |
| Follow-up: Carpal Tunnel Syndrome |
| Multimedia: Carpal Tunnel Syndrome |
| References |
| Further Reading |
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References
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Further Reading
Related eMedicine topics
Carpal Tunnel Syndrome (Emergency Medicine)
Steroid Injection, Carpal Tunnel (Clinical Procedures)
Carpal Tunnel Syndrome (Physical Medicine and Rehabilitation)
Carpal Tunnel Syndrome (Radiology)
Carpal Bone Injuries
Clinical guidelines
American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of carpal tunnel syndrome.
American Academy of Orthopaedic Surgeons - Medical Specialty Society. 2008 Sep. 76 pages. NGC:006751
American Academy of Orthopaedic Surgeons clinical guideline on diagnosis of carpal tunnel syndrome.
American Academy of Orthopaedic Surgeons - Medical Specialty Society. 2007 May 19. 72 pages. NGC:005664
Forearm, wrist and hand complaints.
American College of Occupational and Environmental Medicine - Medical Specialty Society. 1997 (revised 2004). 34 pages. NGC:004754
Clinical trials
Post-Operative Mobilization for Carpal Tunnel Syndrome
Effect of Lumbrical Stretching on Carpal Tunnel Syndrome
Early Motion Following Carpal Tunnel Release
Keywords
carpal tunnel syndrome, carpel tunnel syndrome, carpal tunnel surgery, carpal, carpal tunnel, repetitive stress injury, cumulative trauma disorder, median nerve entrapment, median neuropathy, mononeuropathy, nerve compression syndrome, CTS, median nerve compression at the wrist, double crush syndrome, carpal canal, median nerve
