Carpal tunnel prognosis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Diagnosis of carpal tunnel syndrome is based on the history, physical exam, neurological examination, and diagnostic tests.

Neurological examination includes testing the muscle that abducts the thumb away from the palm (called the abductor pollicis brevis), as well as the ability to bend the thumb toward the palm (flexion) and ability to move the thumb toward the other fingers (apposition). Tinel’s sign (tapping the palmar side of the wrist sharply produces tingling) and Phalen’s sign (pressing the backs of the hands together for about 1 minute produces pain and numbness) are also performed.

Nerve conduction velocity (NCV) and electromyography (EMG) are used to evaluate nerve and muscle function. NCV involves placing electrodes on the skin above the median nerveproximal to the carpal tunnel as well as distal to the carpal tunnel to monitor the speed at which an impulse travels along the nerve. EMG involves placing small electrodes into the abductor pollicis brevis muscle to detect abnormalities that may indicate that the median nerve supplying the muscle is damaged. These tests may reveal delayed nerve conduction in the median nerve.

Treatment for carpal tunnel syndrome involves activity modification and rest, splinting, medication (including injection therapy), ultrasound-guided needle release, and surgery.

An evaluation of the work station can be useful. Wrist and body positioning can be improved using ergonomically designed equipment and furniture. Improving body position, stretching periodically, and changing positions frequently may help alleviate symptoms.

An ultrasound-guided glucocorticoid injection into the carpal tunnel to reduce inflammation and nerve compression may be helpful.

Surgery is another option when other treatment measures fail. Carpal tunnel release involves cutting the transverse carpal ligament to relieve entrapment of the median nerve. It is usually performed on an outpatient basis.

Carpal tunnel release can be performed as open or endoscopic surgery. In open surgery, an incision is made through underlying tissue in the palm of the hand.

In endoscopic surgery, a smaller incision is made in the wrist and an endoscope is used along with small surgical instruments to cut the ligament.

Recovery usually takes 3 to 12 months. If compression has caused permanent nerve damage, carpal tunnel release surgery may not be effective.

Complications associated with the surgery include the following:

• Adverse reaction to anesthesia
• Burning pain caused by nerve damage (causalgia)
• Incomplete release of the ligament (more common in endoscopic surgery; (requires additional surgery)
• Infection
• Nerve damage (rare)
• Stiffness
• Swelling

Inadvertent cutting of a nerve, blood vessel, or tendon is more common in the endoscopic procedure and this approach is not recommended for patients who have small wrists.

A much newer and much less invasive technique is percutaneous ultrasound guided release. In this technique, a small needle is inserted using local anesthetic and using ultrasound guidance multiple small holes are made in the flexor retinaculum (the tough fibrous roof over the carpal tunnel that compresses the median nerve). At the same time, fluid is injected to spread and weaken the fibers. At the end of the procedure, the wrist is flexed (bent) and the weakened retinaculum is released. A splint is applied and the patient has full use of their hand by the next day.

Nonsurgical and surgical treatments for carpal tunnel syndrome relieve symptoms in approximately 90% of cases.

Roughly, 1 percent of patients with carpal tunnel syndrome develop permanent injury. Most people with CTS recover completely and can avoid re-injury by changing the way they do repetitive motion activities, the frequency at which they do the movements, and the amount of time they rest.

A study that directly addressed the issue of prognosis…

J Neurol. 1984;231(2):83-6.

Carpal tunnel syndrome--course and prognosis.

Muhlau G, Both R, Kunath H.

In a retrospective study 157 patients with electrophysiologically proven carpal tunnel syndrome (CTS) were followed up. Of the 85 operatively treated patients, 86% showed clear improvement or cure, as did 32% of the patients not operated upon. Multivariate analysis of variance (MANOVA) and linear discriminant analyses indicated atrophy and length of history as effective predictors of clear improvement. The optimized discriminant point was ascertained in the receiver operator characteristics (ROC) curve. A predictive value of positive test of 0.89 was found for the course form "not cured" and a predictive value of negative test of 0.75 for the course form "cured" with a prevalence of one-third for the good course form. The prognosis was bad if atrophy occurred or the history exceeded 7 months. The determination of distal motor latency is indispensable for diagnosing CTS. For prognosis, however, length of history and clinical findings have been more helpful.

Maintaining proper posture, body position, and technique when performing repetitive wrist movements may help to prevent carpal tunnel syndrome. It is important to relax, move around, and change positions frequently when performing any one task for an extended period of time. See your physician as soon as possible after symptoms develop.

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