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CARPAL TUNNEL SYNDROME Many patients have been told by their physicians they have Carpal Tunnel Syndrome (CTS) or come across the term in the lay press and are somewhat confused about exactly what CTS is. Put simply it is a compression of the median nerve; the nerve that runs along the palm side of the wrist. This is a relatively large nerve and supplies sensation to the thumb, the index finger, and the long finger. There is a ligament in the wrist under which the median nerve runs and in many cases and for many different reasons the ligament can exert pressure on the nerve causing numbness and tingling in the fingers that are supplied by the median nerve. Many times the numbness and tingling is most severe in the evening or after the patient retires to bed. She (it is more common in women than men) is awakened by the pain and numbness in the fingers and needs to shake her hand to relieve the numbness. Some patients put their hand behind their head or elevate the hand to relieve the numbness. Your physician can usually make the diagnosis of CTS simply by taking a careful history and can diagnose the syndrome by several simple tests that can be performed on the hand. In some cases the diagnosis it is not clear or there are complicating circumstances necessitating a laboratory test to confirm or deny the presence of CTS. This laboratory test is called an EMG and nerve conduction study and is usually carried out by a neurologist or a physician trained in physical medicine. This test is somewhat uncomfortable and relatively expensive but will give very valuable information not only as to the presence or absence of CTS but also as to the degree or severity of the condition. It will allow your physician to decide what sort of treatment would be the best and how successful that treatment should be. This treatment of CTS is three tiered and fairly straight forward. In mild cases the diagnosis is made and no treatment is necessary. However the patient is encouraged to avoid strenuous or repetitive activities that involve wrist flexion since this is the activity that most experts agree causes the ligament to impinge upon the nerve most severely. In moderate cases of CTS treatment consists of splinting with either a pre- fabricated wrist splint or a plaster splint. The splints prevent the wrist from going into flexion at the wrist especially at night which can aggravate the condition. Another treatment in moderate conditions is to inject cortisone or steroids along the course of the nerve underneath the ligament. In selected cases this can give dramatic
results. However most severe cases of CTS do not respond to cortisone injections and some patients are even made worse. In moderate cases of CTS where the above methods of treatment have not worked or in severe cases surgery is indicated. The concept of the surgery is very simple. If the ligament is compressing the nerve, simply divide the ligament. This is accomplished by incising the skin in the mid palm (if you believe in palmistry we extend people's lives anywhere from ten to thirty years). The ligament is in this area and using fine dissection the ligament can be divided without injuring the nerve. This surgery, when properly carried out in appropriately selected patients, can lead to dramatic results and the healing time for most patients is less than two weeks. Endoscopic carpal tunnel release can be done in uncomplicated cases. During convalescence patients are kept in a splint to prevent motion at the wrist. This appears to allow the wounds to heal much better and much quicker. Most patients are able to return to light duty within one week and are able to resume their normal activities within three to four weeks following this surgery. No formal physical therapy is required in the average case. The success rate in this operation is very high -- over 95%. The complication rate is very low since the operation can be carried out under local anesthesia or regional anesthesia avoiding the hazards of general anesthesia. The infection rate is also very low and most wounds heal very well with minimal scar. Recurrence of CTS following surgery is a distinct possibility since the underlying causes for developing the syndrome were addressed by simple cutting the ligament and ligament can re-form. However, in practice recurrence of CTS following surgery is relatively rare. CTS is a straight forward disease as far as diagnosis and treatment and unlike many of the other disorders of the nervous systems that we commonly encounter this is one can be cured.
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