Early Treatment
Conservative Therapy
It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses. The patient should avoid if possible activities at work or home that may aggravate the syndrome.
The affected hand and wrist should be rested for at least two weeks; this allows the swollen, inflamed tissues to shrink and relieves pressure on the median nerve. Ice may provide relief. Some patients have reported that alternating warm and cold soaks have been beneficial. If hot applications relieve pain, most likely the problem is not caused by CTS but by another condition producing similar symptoms.
Some people wear a rigid wrist splint or brace at night or during sports to help keep the wrist from bending. The splint is used for several weeks or months depending on the severity of the problem. Except for anecdotal reports, no evidence exists that rigid supports actually help. Some experts believe that immobilizing the wrist it may actually exacerbate the problem by reducing circulation and restricting movement so that the shoulder muscles tense up.
Physical Therapy
If symptoms subside, the patient may proceed with a supervised hand and wrist strengthening exercise program usually offered by physical or occupational therapists. One study found that most people with CTS felt improvement after two months of physical therapy that included exercises to improve balance and posture.
Laser Light Therapy
One recent study found that automobile workers with CTS who were treated with a process known as cold laser light had greater improvement in grip strength and range of wrist movement than those engaged in physical therapy. The process uses low-energy laser light that penetrates, but does not cut the skin and stimulates cells activity in the injured areas.
Ultrasound
Ultrasound treatment is a safe procedure that bombards the wrist with sound waves. In one study, ultrasound reduced symptoms, and relief lasted for at least six months.
Drug Treatments
Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, may help reduce swelling and pain. If these painkillers are unsuccessful, the doctor may inject an anesthetic or a corticosteroid (such as cortisone) into the carpal tunnel to shrink the swollen tissues and relieve pressure on the nerve. To avoid attrition of the tendon, no more than three injections of cortisone should be given. It should be noted that the pain may increase for a day or two after the injection and skin color may change.
Diuretics, such as trichlormethiazide, which reduce fluid in the body, may also be used. In one study, a short-term regimen of low doses of the oral corticosteroid prednisolone was more effective than either an NSAID (tenoxicam) or the diuretic trichlormethiazide. In fact, neither the NSAID nor the diuretic was any more effective than a placebo (a "sugar" pill).
Oral corticosteroids can have serious side effects if used for long periods, however, and the study did not continue beyond one month, so long-term risks and benefits of this treatment for CTS are unknown. The drug naftidrofuryl (Praxilene) dilates bloods vessels, increases oxygen transport, and appears to have some capability for nerve regeneration. In Europe, it was used after surgery to treat the palm of the hand that had atrophied due to carpal tunnel syndrome. All patients who were treated in the study showed total or partial recovery. High doses of this drug can cause kidney problems. More work is needed on this interesting treatment.
Release Surgical Procedures
This report discusses four different surgical procedures for carpal tunnel syndrome: open release; mini open release; endoscopy; and percutaneous balloon carpal tunnel-plasty. The decision for whether and when to have surgery to correct CTS is a troubling one for patients. In one long-term study most patients experienced CTS symptoms for only an average length of time of six to nine months, but 22% of the subjects had symptoms for eight or more years. There is no test that can determine whether symptoms will resolve or become worse in most people
.
Candidates for Surgery
A number of experts believe that release surgery is performed too often and that CTS sufferers should pursue conservative treatment and physical therapy as aggressively as possible before choosing this more invasive option. Nevertheless, other experts argue that often the condition is progressive and will worsen over time without surgery, which generally brings good results. Waiting too long may also significantly reduce the benefits of surgery; one study indicated that surgery was most successful when it was performed within three years of the diagnosis of the disorder.
Electrodiagnostic tests for nerve conduction might be helpful in determining who would most benefit from surgery. The results suggested that workers who had normal or near-normal nerve conduction results before surgery were least likely to benefit from surgery.
Those with significantly slow nerve conduction and other abnormal results showed the most improvement after surgery. One study indicated that patients most likely to be satisfied with the surgery are those who had less preoperative muscle weakness and whose symptoms were worse at night.
Patients with CTS from nerve damage due to medical conditions, such as diabetes, rheumatoid arthritis, or hypothyroidism, appear to have the same outcome as those without such conditions and so such disorders should not preclude them from sugery.
It is generally recommended that if symptoms persist for four to six months and if muscles begin to atrophy in the base of the palm, the patient may require surgery. The procedure does not cure all patients and because it permanently cuts the carpal ligament, some wrist strength is often lost.
Open Release Surgery
Traditionally, surgery for CTS entails an open surgical procedure performed in an outpatient facility. A local anesthetic is injected either into the wrist and hand or higher up the arm. The surgeon makes a two-inch incision in the palm and cuts the carpal ligament free from the underlying median nerve. The ligament is literally released and therefore the pressure on the median nerve is relieved. Carpal tunnel release is the most commonly performed hand surgery, with more than 100,000 procedures each year. The risk of complications with this surgery is less than one percent. Although other techniques are being developed, this procedure is still the most cost effective.
Mini-Open Release
A more recent variation known as a mini-open release technique uses an incision that is only about an inch and a half, and it can be performed in the doctor's office with only a local anesthetic. The operation takes only about 12 minutes. The results of one small study reported no infection, no injury to the median nerve, and no loss of finger mobility, or recurrence of CTS after a year. It is more expensive at this time than standard open release but is less costly than the other less invasive procedure -- endoscopy (see below).
Endoscopy
Endoscopy for carpal tunnel syndrome is a less invasive procedure than standard open release. One or two 1/2-inch incisions are made in the wrist and palm, and one or two endoscopes -- pencil-thin tubes -- are inserted. A tiny camera and a knife are inserted through the lighted tubes. While observing the underside of the carpal ligament on a screen, the surgeon cuts the ligament to free the compressed median nerve.
Patients do not end up with a surgical scar and can often return to work within half the time as in standard open surgery. In one study, 98% of patients experienced relief of numbness and weakness and in 90% pain was reduced. Only 12% of patients required more than two doses of pain relievers after the operation. Nearly 85% of patients who were not on workers compensation returned to work within a month. One 1998 analysis reported that success rates average about 96%; complication rates are 2.7%; and failure rates are 2.6%. As surgeons gain more experience with this procedure, studies are now reporting similar success and complications rates to standard open surgeries.
In some studies, patients had better grip strength after endoscopy than after standard release, and, in many studies, patients reported less pain and returned to normal activities earlier than those who had the open release procedure. Complications, including tingling or loss of sensation in the fingers, increase with surgeons who are less experienced.
Usually, such complications are temporary. Patients should not be shy about asking for the number of endoscopic procedures their surgeons have performed. Some experts believe that there may be a higher recurrence rate of CTS with endoscopy because the view of the hand is limited during this procedure and surgeons may not see complicating conditions that may require treatment. (In the open release procedure, the surgeon has a full view of the structures in the hand.) Long-term studies are needed to determine this.
Postsurgery
For some patients, release surgery relieves CTS symptoms of numbness and tingling immediately. In one study, grip and pinch strengths exceeded preoperative status within six weeks. Peak improvement may take a long time -- in one study an average of almost 10 months. Post surgery complications may include nerve damage, infection, scarring, pain, and stiffness. The incision site may remain sore for months, and some patients experience some scar pain for years with open release. People who have the operation on both hands are completely incapacitated for about two weeks and must have someone to help them at home.
Returning to strenuous work right after surgery may cause the symptoms to recur, and patients generally stay out of work for at least month and often much longer, depending upon the type of surgery and severity of the condition. To help rebuild wrist strength, physical therapy is very important. Hand exercises can help restore circulation, muscle strength, and joint flexibility in the hand and wrist.
Long-Term Outcome
Although carpal tunnel surgery is one of the most common procedures in the U.S., few studies have been done to determine the long-term outcome for patients after they return to work. In one such study, five years after the operation, 30% of patients experienced poor to fair strength and some scar pain, and in 57% some symptoms returned, especially pain. Certain people will always experience residual numbness in the fingertips. In spite of these negative findings, 87% of the patients in the study reported that, in general, their outcomes were good to excellent.
Another 18-month study reported that over 70% of those who had the open release operation experienced improvement in at least one of three symptoms (pain, numbness, and tingling) and only about half experienced reduction in all three symptoms. Over 90% had normal grip and pinch strength.
The elderly, those with very severe preoperative symptoms, and people involved with heavy manual labor, particularly those working with vibrating tools, appear to have a poorer outcome than others. One five-year study found that people who had been working at heavy labor stayed out longer and appeared to have slower improvement, but responses after five years did not differ among occupational groups. In some studies, however, only slightly more than half the people who used vibrating hand-held tools were symptom-free three years after their operations.
Because between 10% and a third of patients lose some wrist strength with both endoscopy and open release, patients who have jobs requiring high amounts of force to the hand and wrist may not be able to perform them after surgery. Such workers may also have problems in other parts of the upper body, including elbows and shoulders, that are not resolved with surgery and can persist. Studies indicate the between 10% and 15% of patients change jobs after the operation.
Percutaneous Balloon Carpal Tunnel-Plasty
Percutaneous balloon carpal tunnel-plasty is a technique that alleviates CTS without cutting the carpal ligament. Through a 1/4-inch incision in the base of the palm, the doctor inserts a balloon through a catheter under the ligament and inflates the balloon with saline solution to stretch the ligament and free the nerve. In one small study, all of the patients reported relief of symptoms with no postoperative complications. Most of them were back to work within two weeks. This experimental technique is not yet widely available.
Vitamins
In some -- but not all -- studies, deficiencies of vitamin B6 (pyridoxine) have been associated with CTS. A recent study supported this association and, furthermore, reported that high levels of vitamin B6 were associated with fewer CTS symptoms. The same study also reported that high levels of vitamin C relative to low vitamin B6 levels were associated with a higher prevalence and greater frequency of symptoms. It should be noted that high doses of vitamin B6 can be toxic and cause nerve damage.
Alternative Therapies
Many alternative therapies are offered to sufferers of carpal tunnel syndrome and other repetitive stress disorders. Most are harmless, but the benefits are unproved. Acupuncture has helped some people relieve pain. Chiropractic therapy has been useful for some people whose condition is produced by pinched nerves. Some patients have reported possible benefit from using certain herbal oils, such as arnica oil. People should
approach non-traditional methods very cautiously and should check with their
physician before trying any.
