CTS is a compression of the median nerve in the carpal tunnel. Excluding trauma, this neurologic disorder is the most frequently encountered occupationally related disease of the hand in the US. Women account for the majority of cases. Interestingly, it is very rare to find this disease in the teenage population in spite of the heavy use of their hands for text messaging and text messaging and computer games.
The predominant symptom of CTS is numbness of the thumb, index and long finger, sometimes half of the ring finger as well. It can only be this way because the entrapped median nerve in the carpal tunnel goes only to these fingers. It never goes to the little finger or to the back of the hand. So if one complained of tingling and numbness of the back of the hand or of the entire hand, the chances of having CTS would be slim to none. It is not unusual to have pain spread from the hand up the forearm and sometimes up to the neck. Patients often describe their symptoms in the extremity as a loss of circulation to the hand when, in fact, it has nothing to do with blood flow to the hand. In established CTS, the aggravating symptoms are unmistakable.
They occur primarily at night between midnight and 5 o’clock in the morning. Patients are often awakened from sleep with numb fingers which feel very swollen even though they may not be. Vigorous shaking of the affected hand often relieves the symptoms temporarily. Other patients wake up in the morning with numb fingers relieved by the resumption of activities of daily living. Driving or holding the telephone for extended periods of time or simply holding a cup of tea or coffee often initiates numbness of the hand. On the other hand, engaging in vigorous manual activity rarely provokes CTS symptoms. Although CTS is frequently seen in the workplace setting, the causes of this disease are not always straightforward. Any condition, pathologic or not, which leads to fluid retention can potentially lead to CTS. This includes pregnancy, diabetes, thyroid disease and birth control pills to name a few. Inflammatory diseases like rheumatoid arthritis, osteoarthritis and gout are high on the list. Severe trauma around the wrist to include wrist fractures and dislocations, crush injuries, IV fluid extravasations and frequent use of the palm as a hammer can all lead to severe CTS.
Most of the patients (~70% in my practice), however, do not fall into any of the previously mentioned categories. We place them in a group labeled idiopathic because we do not know the exact cause of their CTS. This happens to be the majority of patients who develop CTS. So there is still much work to be done to determine the true cause of CTS. Once one develops CTS, confirmed by history and clinical examination, you are wondering how this diagnosis can be confirmed. Keep in mind that all tingling and numbness in the hand may not be CTS. A nerve conduction study is the most accurate objective test for CTS. This is most often done by a neurologist and frequently read by him or her or the hand surgeon. Frequently other neurologic abnormalities can be picked up on the NCS, unrelated to CTS, e.g. a pinched nerve in the neck. How is CTS treated? In the early stages of the disease, conservative treatment can be very effective. Indeed, symptoms are sometimes reversed in many patients. Sleeping in a splint to prevent the wrist from remaining flexed all night will prevent the annoying numbness and allow one to sleep better. Anti-inflammatory drugs also play an important role. If these methods fail, I inject a steroid into the carpal tunnel which can be very effective. However, if the nerve conduction study is severe, conservative methods often fail, leaving surgery as the most appropriate choice. Surgical decompression is very effective, often getting rid of the numbness which does not usually recur, contrary to popular belief. It is a simple outpatient procedure done under local anesthesia very often in an office setting. There is very little down time since the morbidity is very low. Very often I do this procedure on a Thursday and the patient can return to work the following Monday. Vigorous use of the hand is encouraged immediately after surgery.
The most effective way to prevent rapid progression of CTS symptoms is to seek early treatment when symptoms might be reversible. Treat any underlying diseases associated with CTS and begin to live a healthy life style.