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Carpal tunnel syndrome is the most common of the mononeuropathies. In the wrist and palm region, the median nerve is extremely vulnerable to compression and injury. The anatomic boundaries include the bones of the wrist and the transverse carpal ligament. Dymyelination and axonal degeneration result from nerve compression beneath the transverse carpal ligament.
Diagnosis
Electrodiagnostic studies. Nerve conduction studies are considered the standard diagnostic procedure for evaluating carpal tunnel syndromes.These studies define the anatomy and differentiate varying degrees of demyelinization and axonal loss. The results of these studies determine the therapeutic approach. In patients with mild symptomatology, electrodiagnostic studies may be deferred for 3 to 8 weeks. In patients who do not respond to conservative management, and/or for whom surgical intervention is contemplated, electrodiagnostic studies are indicated. They may also be performed in patients with severe initial symptomatology and/ore motor and sensory signs.
The electrophysiologic findings include, in order of appearance, 1) delayed intrapalmar and distal median sensory latencies; 2) delayed distal motor latencies; and 3) denervation of distal median musculature, sparing proximal groups.
Treatment
Treatment modalities are directed at reducing inflammation and swelling in the region affected by the carpal tunnel syndrome. Non-operative approaches include immobilization of the wrist for 3 to 8 weeks, and alteration of the work station. Repetitive motion and ergonomic factors should be addressed. Nonsteroidal antiinflammatory medications; and local injections of steroids may provide temporary relief. Response to steroid injections is considered a good prognostic sign for surgical release.
Surgical intervention is indicated when the history, physical findings, and electrodiagnostic studies are compatible with the diagnosis of carpal tunnel syndrome, and the patient fails conservative management. Acute median nerve compression, due to trauma and/or fracture, may require surgery on an emergent basis. As 50% of the entrapments occur at the distal edge of the flexor retinaculum, section through this area is important.
Post-operative reconditioning programs include strengthening, mobilization, work stimulation, and soft-tissue regimen. In refractory post-operative cases, psychosocial intervention, vocational rehabilitation, and even pain clinics may be useful.
The complete version of this article was original published in the "CNI REVIEW" medical journal, Summer 1996, page 8.
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Colorado Neurological
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