Pain, General | July 20, 2014 | Author: The Super Pharmacist
The carpal tunnel is an anatomical structure located at the end of the wrist. It is an 'arch' formed by the carpal bones leading from the wrist into the palm in the general direction of the thumb. The function of the carpal tunnel is to allow tendons and the medial nerve to pass into the hand, which provides motor ability and sensation to this structure. The median nerve controls sensation in the thumb, first two fingers, and also the proximal (i.e. closest to the palm) portion of the third finger. In addition, the medial nerve serves the muscles located at the base of the thumb. This controls its range of motion away from the fingers and palm.
Carpal tunnel syndrome is a condition in which the arch is compressed or otherwise becomes smaller. If this results in mechanical impingement to the medial nerve, it may result in pain and motor problems in the hand. It may also result in a loss of sensation in the fingers mentioned above.
Compression of the carpal tunnel may be associated with accumulation of the material normally present in the structure for the purposes of lubrication and protection, known as synovium. It may also be associated with swelling in other soft tissue. Other symptoms of carpal tunnel syndrome may include tingling and extreme numbness in the affected area. This condition is often chronic and can cause considerable reductions in the life quality of those affected.
Carpal tunnel syndrome is also often associated with repetitive strain, i.e. with occupations that involve a high volume of hand motions, such as typing or other manual labour. This association is often dismissed, but research has shown a consistent link with service industry, healthcare or office work and self-reports of carpal tunnel syndrome worldwide.
The incidence of carpal tunnel syndrome is also associated with a range of conditions that may increase the risk of carpal tunnel and/or medial nerve compression or soft tissue swelling in general.
These conditions include:
Diagnosis of carpal tunnel syndrome is initiated by patient reports to a doctor, who may then recommend procedures to verify the presence of the condition. These reports usually involve numbness intense enough to wake the patient from sleep, which is a classic first sign of carpal tunnel syndrome. The better-regarded diagnostic tests include:
There are many treatment strategies available for carpal tunnel syndrome, which mainly focus on reducing swelling or allowing the free movement of the medial nerve. These include:
This may involve the use of splints, which are specifically-designed devices worn on the wrist, similar in appearance to braces or casts.
In some cases, the splint is worn only at night to prevent wrist postures that contribute to carpal tunnel syndrome. Although treatment is more effective if applied full-time.
Splinting may be a more acceptable treatment for patients who do not wish to undergo surgery However, some research indicates that this treatment is only effective in the short term.
This is a pharmacological option that acts by inhibiting pain and inflammation when injected into the affected area. In the case of carpal tunnel syndrome, corticosteroid injection may also contribute to decompression in the carpal arch. An alternative to injected steroids are oral steroids, which have been found to be effective in the treatment of carpal tunnel syndrome. Steroid therapy carries some risks, including side-effects such as weight gain, mood swings and gastrointestinal damage.
Steroid therapy has been found to be most effective in short-term treatment of carpal tunnel syndrome.
Procaine is a local anaesthetic medication that may be administered in combination with corticosteroids, to provide additional pain relief. Recent research has indicated that procaine alone is equally effective, however. A trial of a heated patch releasing other local anaesthetics (tetracaine and lidocaine) in 15 patients resulted in significant pain reduction over 14 days.
Local anaesthetics may provide a viable alternative to steroid therapy for carpal tunnel syndrome.
The modern form of acupuncture is regarded as effective in treating a variety of pain conditions.
A trial of acupuncture in carpal tunnel patients found that this treatment produced significant improvements in symptoms, and was equal in effect to steroid (prednisolone) therapy.
This may be an undesirable option for many patients, but often results in long-term improvement in the symptoms of carpal tunnel syndrome. These procedures typically involve the bisection of the transverse carpal ligament, which lies roughly above the medial nerve (if the hand is placed palm upwards).
This alleviates compression on the nerve, resulting in a significant reduction of pain and/or numbness.
There are two basic types of carpal tunnel surgery:
These are regarded as equal in efficacy, although endoscopic surgery may be associated with quicker recovery times. There is also little difference between the two types in terms of complications or risks, which may include scarring, reduction in grip strength and 'pillar pain', a type of pain felt in the upper surface of the hand. Surgery is recommended for moderate to severe cases of carpal tunnel syndrome.
Ghasemi-Rad M, Nosair E, Vegh A, et al. A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment. World journal of radiology.2014;6(6):284-300.
Aroori S, Spence RA. Carpal tunnel syndrome. The Ulster medical journal.2008;77(1):6-17.
Iuliano SL, Laws ER, Jr. Recognizing the clinical manifestations of acromegaly: case studies. Journal of the American Association of Nurse Practitioners.2014;26(3):136-142.
Baker NA, Livengood HM. Symptom Severity and Conservative Treatment for Carpal Tunnel Syndrome in Association With Eventual Carpal Tunnel Release. The Journal of hand surgery.2014.
Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review of the recent literature. The open orthopaedics journal.2012;6:69-76.
Ten Cate DF, Glaser N, Luime JJ, et al. A comparison between ultrasonographic, surgical and histological assessment of tenosynovits in a cohort of idiopathic carpal tunnel syndrome patients. Clinical rheumatology.2014.
Werner RA. Evaluation of work-related carpal tunnel syndrome. Journal of occupational rehabilitation.2006;16(2):207-222.
Raman SR, Al-Halabi B, Hamdan E, Landry MD. Prevalence and risk factors associated with self-reported carpal tunnel syndrome (CTS) among office workers in Kuwait. BMC research notes.2012;5:289.
Tsovili E, Rachiotis G, Touche S. Prevalence of self-reported symptoms compatible with carpal tunnel syndrome (CTS) among employees at a neonatal intensive care unit: a cross-sectional study. La Medicina del lavoro.2012;103(2):106-111.
Bonfiglioli R, Mattioli S, Fiorentini C, Graziosi F, Curti S, Violante FS. Relationship between repetitive work and the prevalence of carpal tunnel syndrome in part-time and full-time female supermarket cashiers: a quasi-experimental study. International archives of occupational and environmental health.2007;80(3):248-253.
Gell N, Werner RA, Franzblau A, Ulin SS, Armstrong TJ. A longitudinal study of industrial and clerical workers: incidence of carpal tunnel syndrome and assessment of risk factors. Journal of occupational rehabilitation.2005;15(1):47-55.
Tseng CH, Liao CC, Kuo CM, Sung FC, Hsieh DP, Tsai CH. Medical and non-medical correlates of carpal tunnel syndrome in a Taiwan cohort of one million. European journal of neurology : the official journal of the European Federation of Neurological Societies.2012;19(1):91-97.
Gerritsen AA, Scholten RJ, Assendelft WJ, Kuiper H, de Vet HC, Bouter LM. Splinting or surgery for carpal tunnel syndrome? Design of a randomized controlled trial [ISRCTN18853827]. BMC neurology.2001;1:8.
Ono S, Clapham PJ, Chung KC. Optimal management of carpal tunnel syndrome. International journal of general medicine.2010;3:255-261.
Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Archives of physical medicine and rehabilitation.2000;81(4):424-429.
Povlsen B, Bashir M, Wong F. Long-term result and patient reported outcome of wrist splint treatment for Carpal Tunnel Syndrome. Journal of plastic surgery and hand surgery.2014;48(3):175-178.
Kamanli A, Bezgincan M, Kaya A. Comparison of local steroid injection into carpal tunnel via proximal and distal approach in patients with carpal tunnel syndrome. Bratislavske lekarske listy.2011;112(6):337-341.
de Pablo P, Katz JN. Pharmacotherapy of carpal tunnel syndrome. Expert opinion on pharmacotherapy.2003;4(6):903-909.
Jenkins PJ, Duckworth AD, Watts AC, McEachan JE. Corticosteroid injection for carpal tunnel syndrome: a 5-year survivorship analysis. Hand (New York, N.Y.).2012;7(2):151-156.
Chang MH, Ger LP, Hsieh PF, Huang SY. A randomised clinical trial of oral steroids in the treatment of carpal tunnel syndrome: a long term follow up. Journal of neurology, neurosurgery, and psychiatry.2002;73(6):710-714.
Karadas O, Omac OK, Tok F, Ozgul A, Odabasi Z. Effects of steroid with repetitive procaine HCl injection in the management of carpal tunnel syndrome: an ultrasonographic study. Journal of the neurological sciences.2012;316(1-2):76-78.
Karadas O, Tok F, Akarsu S, Tekin L, Balaban B. Triamcinolone acetonide vs procaine hydrochloride injection in the management of carpal tunnel syndrome: randomized placebo-controlled study. Journal of rehabilitation medicine.2012;44(7):601-604.
Nalamachu S, Nalamasu R, Jenkins J, Marriott T. An Open-Label Pilot Study Evaluating the Effectiveness of the Heated Lidocaine/Tetracaine Patch for the Treatment of Pain Associated with Carpal Tunnel Syndrome. Pain practice : the official journal of World Institute of Pain.2013.
Yang CP, Hsieh CL, Wang NH, et al. Acupuncture in patients with carpal tunnel syndrome: A randomized controlled trial. The Clinical journal of pain.2009;25(4):327-333.
Jarvik JG, Comstock BA, Kliot M, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial. Lancet.2009;374(9695):1074-1081.
Kang HJ, Koh IH, Lee TJ, Choi YR. Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trial. Clinical orthopaedics and related research.2013;471(5):1548-1554.