Carpal Tunnel Syndrome Treatment - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes treatment of carpal tunnel syndrome.
Clinical picture of carpal tunnel syndrome
Pain, numbness, and paresthesia in the palmar aspect of the thumb, index and long finger (median nerve distribution).
Symptoms of carpal tunnel syndrome occur at night. These symptoms awake the patient from sleep, causing the patient to shake the hand in an attempt to resolve these symptoms.
Positive Tinel’s sign
Percussion of the volar wrist produces electric sensation distally to the fingers.
Phalen's test
•Phalen’s maneuver is performed by flexing the wrist for 60 seconds.
•This will increase the carpal tunnel pressure temporarily and produce the symptoms.
•If the test is positive, the patient will have numbness and tingling in the hand and wrist.
Positive compression test (Durkan’s test)
•This is the most sensitive test.
•The examiner places even pressure with two thumbs directly over the patients’ median nerve in the carpal tunnel for about 30 seconds.
•Reproduction of symptoms in the distribution of the median nerve means that the test is positive for carpal tunnel syndrome.
Self-administered hand diagram
•Self-administered hand diagram is extremely helpful (most specific for carpal tunnel syndrome).
•The patient should highlight the areas where they are experiencing the symptoms.
The patient may complain of thenar atrophy, weakness or clumsiness of the hand.
The patient’s history and examination is an indication for carpal tunnel syndrome. Carpal tunnel syndrome is a clinical diagnosis.
What is the treatment of carpal tunnel syndrome?
1-Anti-inflammatory medication
2-Activity modification: avoid activities that aggravate the symptoms.
3-Neutral wrist splints help night time symptoms because it lowers the carpal tunnel pressure.
•Functional wrist splints will aggravate the carpal tunnel syndrome because it increases the carpal tunnel pressure.
4-Sometimes I use vitamin B6
5-Steroid injection
•Used for the treatment and for diagnosis of carpal tunnel syndrome if the clinical examination or electrodiagnostic test is not clear.
•If the patient temporarily improves from injection, then the patient will definitely improve from surgery.
6-Surgery
Carpal tunnel release (open or endoscopic)
•Usually done when there is persistence of the symptoms and failure of nonoperative treatment.
•The injection is a good prognosis for improvement after surgery when the splint no longer works, and when steroid injection only gives temporary improvement (injection is a good prognosis for improvement from surgery).
•The median nerve is much like a truck passing through a tunnel. The truck (nerve) should be able to pass through the tunnel with ease and without friction. If the tunnel is narrow, then the nerve (truck) cannot pass. If you want the nerve to pass, then widen the tunnel. The tunnel widened by cutting the transverse carpal ligament, as seen in this example.
•The American Academy of Orthopaedics Surgeons (AAOS) recommends doing electrodiagnostic studies before performing carpal tunnel release surgery.
•Endoscpic procedure will give a better early rehab.
•The result is the same as with an open release, however incomplete release is a complication of the endoscopic procedure.
•The pinch strength returns to normal by 6 weeks.
•The grip strength returns to normal by 12 weeks.
•At one year, 20% of patients with severe carpal tunnel symptoms will continue to have symptoms.
•Revision carpal tunnel usually occurs when there is incomplete release, 25% will have NO relief and only 25% will have complete relief.
•The recurrent motor branch of the median nerve can be injured during the surgery.
The recurrent motor branch of median nerve
•After passing through the carpal tunnel, the median nerve gives a branch on the radial side called the recurrent motor branch.
•The recurrent motor branch is an important nerve supply to the thenar muscles.
•The recurrent motor branch of the median nerve has multiple variations:
o50% are extra-ligamentous with recurrent innervation.
o30% are sub-ligamentous with recurrent innervation.
o20% are trans-ligamentous with recurrent innervation.
•If this nerve is injured, the patient will get progressive thenar atrophy due to that injury.
•It is important to cut the transverse carpal ligament far ulnarly to avoid cutting the recurrent motor branch of the median nerve.
•If you see a patient after carpal tunnel release and that patient has progressive thenar atrophy, this can be explained by the fact that there is an injury to an unrecognized trans-ligamentous motor branch of the median nerve.

Follow me on twitter:
https://twitter.com/#!/DrEbraheim_UTMC