Carpal tunnel syndrome ( CTS ) is a medical condition due to compression of the median nerve as it passes through the wrist in the carpal tunnel. The main symptoms are pain, numbness, and tingling, on the thumb, index finger, middle finger, and the thumb of the ring finger. Symptoms usually begin gradually and at night. Pain may extend arms. Weak strength of the grip can occur and after a long period of time the muscles at the base of the thumb can disappear. In more than half of cases, both parties are affected.
Risk factors include obesity, recurrent wrist work, pregnancy, and rheumatoid arthritis. There is tentative evidence that hypothyroidism increases risk. Diabetes mellitus is strongly associated with CTS. The use of birth control pills does not affect the risks. The types of work involved include computer work, working with vibrating tools, and jobs that require a strong handle. Diagnosis is suspected based on signs, symptoms, and specific physical tests and can be confirmed by electrodiagnostic tests. If the exhaust muscle at the base of the thumb is present, the diagnosis may be.
Being physically active can lower the risk of developing CTS. Symptoms can be increased by wearing a splint on the wrist or with a corticosteroid injection. Taking NSAIDs or gabapentin does not seem to be beneficial. Surgery to bypass the effective transverse carpal ligament with better results in a year compared to non surgical options. Further splinting after surgery is not required. Evidence does not support magnetic therapy.
About 5% of people in the United States have carpal tunnel syndrome. It usually begins in adulthood and women are more often exposed than men. Up to 33% of people can improve without special treatment for about one year. Carpal tunnel syndrome was first described fully after World War II.
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Signs and symptoms
People with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, especially the index finger and the middle and the half fingers coiled from the ring finger, as these receive their sensory and motor function (muscle control) of the median nerve. Pain and discomfort may feel more proximal in the forearm or even the upper arm. Less specific symptoms may include pain in the wrist or hand, loss of grip strength, and loss of manual dexterity.
Some suggest that the symptoms of the median nerve may arise from compression at the level of the thoracic outlet or region where the median nerve passes between the two pronator heads in the forearm, although this is disputed.
Numbness and paresthesia in the distribution of the median nerve are symptomatic neuropathic signs (NS) carpal tunnel trap syndrome. Weakness and atrophy of the thumb muscles may occur if conditions remain untreated, because the muscles do not receive sufficient nerve stimulation. Discomfort is usually worse at night and in the morning.
Maps Carpal tunnel syndrome
Cause
Most cases of CTS are not known. Carpal tunnel syndrome can be associated with any condition that causes pressure on the median nerve on the wrist. Some common conditions that can cause CTS include obesity, hypothyroidism, arthritis, diabetes, prediabetes (impaired glucose tolerance), and trauma. Genetics play a role. The use of birth control pills does not affect the risks. Carpal tunnel is a feature of Charcot-Marie-Tooth type 1 syndrome form called hereditary neuropathy with susceptibility to pressure palsi.
Other causes of this condition include intrinsic factors that provide pressure in the tunnel, and extrinsic factors (pressure provided from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformations. Severe carpal tunnel syndrome is often a symptom of amyloidosis-associated polyneuropathy transthyretin and carpal tunnel syndrome surgery previously very common in individuals who later present with amyloid-associated cardiomyopathy transthyretin, suggesting that amyloid transthyretin depilium may cause carpal tunnel syndrome in these people.
The median nerve can usually move up to 9.6 mm to allow flexing wrists, and to a lesser extent during extension. Long-term compression of the median nerve may inhibit the glide, which can cause injury and scarring. When scar tissue occurs, the nerves are attached to the surrounding tissue and become locked in a fixed position, resulting in fewer visible movements.
The normal pressure of the carpal tunnel has been defined as a range of 2-10 mm, and wrist flexion increases this pressure 8-fold, while the extension increases it 10-fold. Repeated flexions and extensions at the wrist significantly increase the fluid pressure in the tunnel through the thickening of the synovial tissue lining the tendon inside the carpal tunnel.
The international debate on the relationship between CTS and repetitive motion in work is under way. Occupational Safety and Health (OSHA) has adopted rules and regulations concerning cumulative trauma disorders. Occupational risk factors of repetitive tasks, strength, posture, and vibration have been cited. The relationship between work and CTS is controversial; in many locations, workers diagnosed with carpal tunnel syndrome are entitled to rest and compensation.
Some speculate that carpal tunnel syndrome is triggered by repetitive motion and manipulate activity and that exposure can be cumulative. It has also been suggested that symptoms are usually exacerbated by the use of strong and repeated hand and wrist in industrial work, but it is unclear whether this refers to pain (which may not be due to carpal tunnel syndrome) or more typical of numbness symptoms.
A review of the scientific data available by the National Institute for Occupational Safety and Health (NIOSH) suggests that job tasks involving repetitive manual action or certain wrist posture are associated with CTS incidents, but causes are not formed, and differences in non-related arm pain work carpal tunnel syndrome is unclear. It has been proposed that repeated use of the arm may affect the biomechanics of the upper limb or cause damage to the tissues. It has also been suggested that postural and spinal assessments along with ergonomic assessments should be included in determining overall conditions. Addressing these factors has been found to improve comfort in some studies. A 2010 survey by NIOSH showed that 2/3 of the 5 million cases of carpal tunnel in the US that year were associated with work. Women have more carpal-related tunnel syndromes than men.
Speculation that CTS is related to work is based on claims such as CTS found mostly in the working adult population, although the evidence is lacking for this. For example, in a series of recent representatives of successive experiences, most patients are older and do not work. Based on claims of increased incidents in the workplace, arm wear is implied, but the weight of evidence suggests that this is a progressive, genetic, progressive but progressive idiopathic peripheral mononeuropathy.
Related conditions
Various patient factors can cause CTS, including hereditary factors, carpal tunnel size, associated local and systematic disease, and certain habits. Non-traumatic causes generally occur over a period of time, and are not triggered by a single event. Many of these factors are manifestations of physiological aging.
Examples include:
- Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendon.
- With hypothyroidism, generalization of myxedema causes deposition of mucopolysaccharides in both the median perineurium nerve, as well as the tendon passing through the carpal tunnel.
- During pregnancy, women experience CTS due to hormonal changes (high progesterone levels) and water retention (which swells in the synovium), which is common during pregnancy.
- Previous injuries include a wrist fracture.
- Medical disorders leading to fluid retention or associated with inflammation such as: inflammatory arthritis, fracture colles, amyloidosis, hypothyroidism, diabetes mellitus, acromegaly, and the use of corticosteroids and estrogens.
- Carpal tunnel syndrome is also associated with repeated activity on the hands and wrists, especially with a combination of strong and repetitive activity
- Acromegaly causes excessive growth hormone secretion. This causes the soft tissues and bones around the carpel tunnel to grow and suppress the median nerve.
- Tumors (usually benign), such as ganglion or lipoma, may protrude into the carpal tunnel, reducing the amount of space. This is very rare (less than 1%). Obesity also increases the risk of CTS: individuals who are classified as obese (BMI & gt; 29) are 2.5 times more likely than lean individuals (BMI & lt; 20) to be diagnosed with CTS.
- double-crush syndrome is a debatable hypothesis that compression or irritation of the nerve branches that contribute to the median nerve in the neck, or anywhere above the wrist, increases the sensitivity of the nerves to compression at the wrist.. There is little evidence, however, that this syndrome really exists.
- heterozygous mutations in the SH3TC2 gene, associated with Charcot-Marie-Tooth, provide susceptibility to neuropathy, including carpal tunnel syndrome.
Pathophysiology
The carpal tunnel is an anatomical compartment located at the base of the palm of the hand. Nine flexor and median nerve tendons pass through a carpal tunnel surrounded on three sides by the carpal bones that make up the arch. The median nerve provides a feeling or sensation of the thumb, index finger, index finger, and half ring finger. At the wrist level, the median nerve supplies the muscles at the base of the thumb that allow it to kidnap, away from the other four fingers, and move out of the palm of the hand. The carpal tunnel is located in the middle third of the base of the palm, bordered by bony protrusions from scaphoid and trapezium tubes at the base of the thumb, and crooked hooks that can be palpated along the finger axis. From the anatomical position, the carpal tunnel is bordered on the anterior surface by the transverse carpal ligament, also known as flexor retinaculum. The flexor retinaculum is a strong fibrous band attached to the pisiform and hamulus of the hamate. The proximal boundary is the distal wrist skin fold, and the distal boundary is estimated by a line known as Kaplan's cardinal line. This line uses surface markings, and is drawn between the peaks of the skin between the thumb and forefinger to a palpable hamate hook. The median nerve can be compressed by decreased channel size, increased fill size (such as swelling of lubrication tissue around the flexor tendon), or both. Since the carpal tunnel is limited by the carpal bone on one side and the ligaments on the other, when the pressure accumulates inside the tunnel, there is no place to escape and thus end up pressing and destroying the median nerve. Simply flexing the wrist up to 90 degrees will reduce the channel size.
The compression of the median nerve as it travels deep into the transverse carpal ligament (TCL) causes laterar eminence atrophy, weakness of the flexor pollicis brevis, the opposite pollicis, the abductor pollicis brevis, as well as the sensory loss in digits provided by the median nerve. The sensory branches are shallow to the median nerve, which gives sensation to the base of the palm, branches proximal to TCL and walks superficially to it. Thus, this branch is spared from carpal tunnel syndrome, and there is no loss of palmar sensation.
Diagnosis
There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. The combination of described symptoms, clinical findings, and electrophysiological testing can be used. The correct diagnosis involves identification if the phenomenon corresponds to the median nerve distribution pattern (which usually excludes the 5th digit).
The CTS work is the most common referral to the electrodiagnostic laboratory. Historically, diagnoses have been made with a combination of thorough history and physical examination along with the use of electrodiagnostic tests (EDX) for confirmation. In addition, emerging technologies have included the use of ultrasound in the diagnosis of CTS. However, it has been proven that the provocative maneuvers of the physical exam have no sensitivity and specificity. In addition, EDX can not completely exclude the diagnosis of CTS due to lack of sensitivity. A Joint report published by the American Association of Neuromuscular and Drug Electrodagiectomy (AANEM), the American Academy of Medicine and Physical Rehabilitation (AAPM & amp; R) and the American Academy of Neurology define the practice, standard and guidance parameters for EDX CTS study based on an extensive review of extensive literature. This joint review concluded that the median and sensory neural conduction studies are valid and reproducible in clinical laboratory settings and CTS clinical diagnosis can be performed with sensitivity greater than 85% and specificity greater than 95%. Given the key role of electrodiagnostic testing in the diagnosis of CTS, The American Association of Neuromuscular & amp; Electrodiagnostic drugs have issued evidence-based practice guidelines, both for the diagnosis of carpal tunnel syndrome.
Numbness in median nerve distributions, nocturnal symptoms, muscle weakness/laterar atrophy, Tinel positive signs in the carpal tunnel, and abnormal sensory tests such as two-point discrimination have been standardized as clinical diagnostic criteria by the consensus panel of experts. Pain may also be an emerging symptom, although it is less common than a sensory disorder.
Electrodiagnostic tests (electromyography and nerve conduction velocity) can objectively verify median nerve dysfunction. A normal neural conduction study, however, does not exclude the CTS diagnosis. Clinical assessment with anamnesis and physical examination can support the diagnosis of CTS. If clinical suspicion of CTS is high, treatment should be initiated despite normal electrodiagnostic tests.
Physical exam
Although widely used, the presence of positive Phalen tests, Tinel signs, Flick marks, or upper limb nerve tests alone is not sufficient for diagnosis.
- The Phalen maneuver is done by flexing the wrists gently as far as possible, then hold this position and wait for the symptoms. Positive tests are tests that produce numbness in the distribution of the median nerve when holding the wrist in an acute flexion position in 60 seconds. The faster the numbness, the more advanced the condition. The Phalen sign is defined as the pain and/or paresthesias of median initiated fingers with one minute of wrist flexion. Only these tests have been shown to correlate with CTS severity when prospectively studied. The characteristics of the Phalen maneuver test vary in various studies ranging from 42-85% sensitivity and specificity of 54-98%.
- The Tinel sign is a classic test for detecting median nerve irritation. The Tinel sign is performed by slightly tapping the skin over the flexor retinaculum to obtain a tingling sensation or "pins and needles" in the median nerve distribution. Tinel marks (pain and/or parasesi median radius innervated with percussion over the median nerve), depending on the study, had a sensitivity of 38-100% and a specificity of 55-100% for the diagnosis of CTS.
- Durkan test, carpal compression test , or apply strong pressure to the palm during nerve up to 30 seconds to get the symptoms have also been proposed.
For the record, a person with true carpal tunnel syndrome (the median nerve trap within the carpal tunnel) will not experience a sensory loss above the fame eminence (muscle bulge in the palm of the hand and at the base of the thumb). This is because the palmar branch of the median nerve, which conserves the palm area, branches off the median nerve and passes through the carpal tunnel. This median nerve feature can help separate carpal tunnel syndrome from chest outlet syndrome, or teron pronator syndrome.
Other conditions can also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination show CTS, the patient will sometimes be electrodiagnostically tested by a study of neural conduction and electromyography. The role of confirmatory neural conduction studies remains controversial. The purpose of electrodiagnostic testing is to compare the conduction velocity in the median nerve by conduction of the other nerves supplying the hand. When the median nerve is compressed, as in CTS, it will perform slower than usual and slower than other nerves. There are many electrodiagnostic tests used to make the diagnosis of CTS, but the most sensitive, specific, and reliable test is the Combined Sensory Index (also known as the Robinson index). Electrodication rests on showing the interruption of median nerve conduction across the carpal tunnel in the context of normal conduction elsewhere. The compression results on the damage of the myelin sheath and manifests as delayed latency and slowing conduction velocity. However, normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, since the nerve injury threshold must be achieved before the results of the study become abnormal and cut-off. the values ​​for abnormality are variable. Carpal tunnel syndrome with normal electrodiagnostic tests is very, very mild at worst.
The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear. Their regular use is not recommended.
Differential diagnosis
There are several disorders in the differential diagnosis for carpal tunnel syndrome. Cervical radiculopathy can be misconstrued as carpal tunnel syndrome because it can also cause abnormal sensation or pain in the hands and wrists. In contrast to the carpal tunnel syndrome, the symptoms of cervical radiculopathy usually begin in the neck and run on the affected arm and can be aggravated by the movement of the neck. Electromyography and imaging of the cervical spine can help distinguish cervical radiculopathy from carpal tunnel syndrome if the diagnosis is unclear. Carpal tunnel syndrome is sometimes used as a label for anyone suffering from pain, numbness, swelling, and/or burning on the radial side of the hand and/or wrist. When pain is the main symptom, carpal tunnel syndrome is unlikely to be a source of symptoms. Overall, the medical community today does not accept or accept trigger point theory because of the lack of scientific evidence to support its effectiveness.
Prevention
Suggested healthy habits such as avoiding recurrent stress, modification of work through the use of ergonomic equipment (mouse pad, proper rest, using an alternative keyboard (digital pen, voice recognition, and dictation), and has been proposed as a method to help prevent carpal tunnel syndrome. vitamin B in preventing or treating carpal tunnel syndrome has not been proven.
There is little or no data to support the concept that activity adjustments prevent carpal tunnel syndrome. Evidence for wrist breaks is debatable.
There is also little research that supports that ergonomics associated with CTS. Because of the multifactorial and highly complex risk factors for hand and wrist dysfunction and wrist it is difficult to assess the actual CTS physical factors.
Stretching and isometric exercises will help prevent people at risk. Stretching before the activity and during rest will help reduce the tension in the wrist. Place your hands firmly on a flat surface and gently press for a few seconds to stretch your wrists and fingers. Examples for isometric exercises of the wrist are made by clenching the fists tightly, releasing and obscuring the fingers. None of these stretches or exercises should cause pain or discomfort.
Biological factors such as genetic predisposition and anthropometric features have a stronger causal relationship with carpal tunnel syndrome than occupational/environmental factors such as repetitive use of hands and stressful manual work. This suggests that carpal tunnel syndrome may not be preventable simply by avoiding certain activities or types of occupations/activities.
Treatment
Commonly accepted treatments include: physiotherapy, steroids either orally or locally injected, splinting, and transversus carpal ligament surgery. Limited evidence suggests that gabapentin is no more effective than placebo for CTS treatment. There is not enough evidence for ultrasound therapy, yoga, acupuncture, low-level laser therapy, vitamin B6, and exercise. Changes in activity may include avoiding activities that aggravate symptoms.
The American Academy of Orthopedic Surgeons recommends continuing conservatively with non-surgical therapy a try before surgery is considered. Different treatments should be tried if current treatment fails to resolve symptoms within 2 to 7 weeks. Early operation with carpal tunnel release is indicated where there is evidence of median nerve denervation or people who choose to proceed directly to surgical treatment. Recommendations may be different when carpal tunnel syndrome is found in relation to the following conditions: diabetes mellitus, coexistence of cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.
Splints
The importance of braces and splints on carpal tunnel syndrome therapy is known, but many people do not want to use braces. In 1993, The American Academy of Neurology recommended non-invasive care for CTS at baseline (except for sensitive deficits or motor reports in EMG/ENG): splint therapy is indicated for mild and moderate pathology. Current recommendations generally do not suggest paralyzing braces, but activity modification and non-steroidal anti-inflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve.
Many health professionals suggest that, for best results, a person should wear braces at night and, whenever possible, during such activities mainly cause stress on the wrist.
Corticosteroids
Corticosteroid injections can be effective for temporary relief of symptoms while one develops a long-term strategy that suits their lifestyle. This form of treatment is considered to reduce discomfort in those with CTS because of its ability to reduce median nerve swelling. The use of ultrasound during injection is more expensive but leads to faster resolution of CTS symptoms. The injection is done under local anesthesia. This treatment is not suitable for a long time. In general, local steroid injections are only used until more treatment options are used. Corticosteroid injections do not seem to be very effective at slowing the progression of the disease.
Surgery
The release of the transverse carpal ligament is known as the "carpal tunnel release" operation. Recommended when there is static numbness (constant, not just intermittent), muscle weakness, or atrophy, and when night-splinting interventions or other conservative interventions no longer control intermittent symptoms. Surgery may be performed under local or regional anesthesia with or without sedation, or under general anesthesia. In general, milder cases can be controlled for months to years, but severe cases show no symptoms and tend to produce surgical treatments.
Surgery is more useful in the short term to relieve symptoms (up to six months) than to use orthosis for at least 6 weeks. However, surgery and clamping use result in the same long-term symptom relief (yield 12-18 months).
Physical therapy
A new evidence-based guideline produced by the American Orthopedic Surgeons Academy provides various levels of recommendations for physiotherapy (also called physical therapy) and other non-surgical treatments. One of the main problems with physiotherapy is that it tries to reverse (often) years of pathology inside the carpal tunnel. Practitioners warned that physiotherapy such as myofascial release could take weeks to effectively manage carpal tunnel syndrome.
Again, some claim that proactive ways to reduce stress on the wrist, which reduces the pain and tension of the wrist, including adopting a more ergonomic work and life environment. For example, some people claim that switching from a QWERTY computer keyboard layout to a more optimized ergonomic layout such as Dvorak is often cited as useful in early CTS studies; However, some meta-analyzes of this study claim that the evidence they present is limited.
Prognosis
Most people are free of their carpal tunnel symptoms with conservative management or surgery finding minimal residual or "nerve damage". Long-term chronic carpal tunnel syndrome (usually seen in the elderly) can cause permanent "nerve damage", ie irreversible numbness, muscle wasting, and weakness. Those who underwent carpal tunnel removal were nearly twice as likely as those who did not undergo surgery to develop thumb triggers within months after the procedure.
While results are generally good, certain factors may contribute to worse outcomes that have nothing to do with the nerve, anatomy, or type of surgery. One study showed that the parameters of mental status or the use of alcohol resulted in far worse treatment outcomes overall.
The recurrence of carpal tunnel syndrome after successful surgery is rare.
Epidemiology
Carpal tunnel syndrome is thought to affect one in ten people during their lifetime and is the most common nerve compression syndrome. It accounts for about 90% of all nerve compression syndromes. In the US, 5% of people have carpal tunnel syndrome effects. Caucasians have the highest risk of CTS compared to other races such as non-white South Africa. Women suffer more from CTS than men with a 3: 1 ratio between the ages of 45-60 years. Only 10% of cases of CTS are reported to be younger than 30 years. Increasing age is a risk factor. CTS is also common in pregnancy.
Jobs
In 2010, 8% of US workers reported ever having carpal tunnel syndrome and 4% reported carpal tunnel syndrome in the last 12 months. The prevalence rate for carpal tunnel syndrome in the last 12 months was higher among women than among men; among workers aged 45-64 compared with those aged 18-44. Overall, 67% of the current carpal tunnel syndrome cases among current/recent workers were reportedly attributed to work by health professionals, suggesting that the prevalence rate of work-related carpal tunnel syndrome among workers was 2%, and that there were about 3.1 million cases of carpal-related tunnel syndrome among US workers in 2010. Among the current cases of carpal tunnel syndrome associated with a particular job, 24% were associated with work in the manufacturing industry, a a proportion of 2.5 times higher than the current/recent proportion of workers employed in the manufacturing industry, indicates that employment in the industry is associated with an increased risk of carpal tunnel syndrome associated with occupations.
History
The condition known as carpal tunnel syndrome has had a great appearance over the years but it was most commonly heard in the years after World War II. Individuals who suffer from this condition have been described in the surgical literature for the mid-19th century. In 1854, Sir James Paget was the first to report median nerve compression on the wrist in two cases.
The first to look at the relationship between carpal ligament pathology and median nerve compression was Pierre Marie and Charles Foix in 1913. They described the postmortem results of an 80-year-old man with bilateral carpal tunnel syndrome. They suggest that the division of the carpal ligament will be curative in such cases. Putman had previously described a series of 37 patients and suggested the origin of the vasomotor. The association between muscular atrophy and compression was recorded in 1914. The name 'carpal tunnel syndrome' appears to have been created by Moersch in 1938.
At the beginning of the 20th century there were various cases of median nerve compression under the transverse carpal ligament. Dr. George S. Phalen of the Cleveland Clinic identified pathology after working with a group of patients in the 1950s and 1960s.
- Care
Paget described two cases of carpal tunnel syndrome. The first is due to an injury in which the rope has wrapped around a man's wrist. The second is due to distal radial fracture. For the first case Paget did a hand amputation. For the second case, Paget recommends a splint of the wrist - a treatment that is still in use today. Surgery for this condition initially involves removal of the womb ribs even though Marie and Foix suggest treatment. In 1933, Sir James Learmonth described the method of nerve decompression on the wrist. This procedure appears to have been initiated by Canadian surgeons Herbert Galloway and Andrew MacKinnon in 1924 in Winnipeg but not published. Endoscopic release was described in 1988.
See also
- Repetitive strain injury
- Tarsal tunnel syndrome
- The Ulnar nerve trap
References
External links
- Carpal Tunnel Syndrome Fact Sheet (National Institute of Neurological Disorders and Stroke)
- The NHS carpal-tunnel.net website provides self-validated free self-diagnostic online questionnaires for CTS
Source of the article : Wikipedia
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