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Carpal Tunnel Syndrome

Today there are few people in the United States who have never heard of carpal tunnel syndrome. Most have a friend or family member who has had carpal tunnel syndrome and many have had a carpal tunnel release operation themselves. As with any common entity there are all sorts of tales told about carpal tunnel syndrome, various ways to treat it, and even some real horror stories about bad outcomes.

Carpal tunnel syndrome (CTS) has long been regarded in the medical community as a “simple problem” and unfortunately there have been very few comprehensive publications in either the medical or the lay literature to clear up some of the misinformation that surrounds carpal tunnel syndrome.

Carpal tunnel syndrome was a term first used in the 1930’s to describe an entrapment neuropathy of the median nerve at the wrist. There is nothing new whatsoever about carpal tunnel syndrome. Human beings have had carpal tunnel syndrome for as long as there have been carpal tunnels. The first open carpal tunnel release was described in 1947 and nothing changed very much for 50 years until the advent of the endoscopic procedure in 1990. Along about the same time, the media publicized the fact that some individuals involved in repetitive-type work activities, such as those who work on computers all day, have an increased incidence of carpal tunnel syndrome. In point of fact, most people who come in the hand surgeon’s office with carpal tunnel syndrome are perplexed as to why they have this disease because they do not engage in classical repetitive-type work activities.

Carpal tunnel syndrome is easily understood if one begins with the anatomy. The carpal tunnel is formed by a semi-circle of carpal bones on three sides. The fourth side that forms the carpal tunnel is the transverse carpal ligament. The ligament cannot stretch. Thus the carpal tunnel is a defined space that cannot enlarge. There is only so much room in that opening. Through that opening passes the median nerve, nine tendons, and spongy tissue around the tendons called tenosynovium. We start our lives with that extra space. When we run out of extra space due to the swollen tenosynovium, then pressure is placed on the nerve. When this happens, one begins to develop carpal tunnel symptoms.

Classic textbook carpal tunnel syndrome symptoms are tingling and numbness in the thumb, index and middle finger (median nerve distribution), aching in the forearm which can radiate to the shoulder, and clumsiness or weak grip. Only about one or two patients out of ten presents with a classic textbook carpal tunnel picture. Some present with tingling in all fingers while others present with tingling only in the thumb or the middle finger. Some present with aching and pain in the hand while others have radiating pain just medial to the back.

Diagnosis and Treatment
A nerve test is done to confirm the diagnosis. Once the patient has been diagnosed with carpal tunnel syndrome, a decision versus treatment must be made. One must keep in mind what is going on with the nerve. The nerve is being squeezed. If one has a wedding band on the ring finger and the hand is crushed between two objects, then the entire hand begins to swell and the ring acts as a tourniquet cutting off the flow of blood to the finger. It is easy to understand that the ring has to be cut off the finger or else the finger will die. Likewise the nerve is being pinched. The nerve fibers are being pinched and they will be deprived of blood flow and undergo irreversible changes and ultimately die unless the pressure is released before those irreversible changes take place.

Thus the goal of treating carpal tunnel syndrome is not simply to reduce the pressure on the nerve so that the symptoms are tolerable and the patient can live with it, but rather to alleviate the pressure entirely. Waiting “until it gets too bad” is not advised and one may actually end up with permanent nerve damage.

Treatment Myths
Make no mistake; carpal tunnel is big business. Countless millions of dollars have been wasted on gimmicks and gadgets trying to prevent carpal tunnel, treat carpal tunnel, and avoid surgery. Almost all of them do not work. Rarely do ergonomic devices work. “Therapy” and “exercises” do not work. Think about it, repetitive motion contributed to the carpal tunnel to begin with in many cases. It’s not a problem that can be exercised away. Magic lasers waved over the hand have not been proven effective by scientific evaluation. There is no evidence to suggest that they actually decrease the flexor tenosynovium. Splints worn during the day decrease the muscle pumping action of the hand, cause more swelling in the hand, and increase carpal tunnel symptoms. Splints can be helpful at night for positioning the hand to avoid sleeping in marked flexion which puts increased pressure on the nerve. Vitamin B-6 is almost always ineffective. Topical creams by “renowned doctors” don’t work. Magnets don’t work for carpal tunnel syndrome. Dietary supplements don’t work.

Steroid injections are only temporary and can cause permanent injury to the nerve if the needle is accidentally placed in the nerve, which usually happens on the third or fourth injection.

An open carpal tunnel release works, but it can cause weeks or months of pain and inability to work.

What’s the answer?
So why do carpal tunnel sufferers, employers, and insurance carriers fall for all of these worthless remedies? Simple. In the United States, one can sell just about anything if it’s packaged right, even if it is worthless. Carpal tunnel is big business.

Unfortunately, that means a lot of hard-earned money is being wasted and people are going untreated. Not only are they suffering, but also they risk permanent damage to the nerve the longer the condition persists.

There is an excellent treatment however. It’s not magic. It is a quantum leap forward in the treatment of carpal tunnel. It is the first major breakthrough in 50 years. It will almost certainly be the standard by which all other treatments are measured in years to come. Tens of thousands of people have been effectively treated in this manner, which requires about eight days of inconvenience; afterwards one can do whatever they choose to do. This is the treatment that informed people choose.

What is Carpal Tunnel Syndrome?
Carpal tunnel syndrome (CTS) begins with numbness and tingling in the hand and may involve aching in the hand, forearm or shoulder. It is a very common condition that is caused by a pinched nerve in the palm of the hand. The symptoms may occur intermittently during the daytime and sometimes occur at night and awaken one from sleep. It is not uncommon for the sufferer to think that the hands have "poor circulation" and shake the hands in an attempt to "restore circulation".

What causes CTS?
Repetitive motions typically cause carpal tunnel syndrome. Any activity that involves grasping, squeezing or clipping motions such as using a computer, using tools, knitting or playing the piano.

Certain diseases and other situations can significantly contribute to the development of carpal tunnel syndrome.

These include:

  • Diabetes mellitus
  • Hypothyroidism
  • Inflammatory Synovitis (such as rheumatoid arthritis)
  • Smoking
  • Pregnancy

Can I wait until it gets worse?
Maybe it will just go away.
Doing nothing can possibly lead to irreversible damage. If you have CTS, the nerve that provides sensation to the hand and function to the thumb is being "pinched." After remaining in the pinched stage for a period of time, permanent injury to the nerve will result. There is no treatment that can fully restore hand function and sensation once permanent damage is sustained.

Is surgery always necessary?
No. The hand surgeon will first examine your hands and review your symptoms. If you have something other than carpal tunnel syndrome, the doctor will suggest the appropriate treatment. If CTS is suspected, he will first prescribe non-operative treatment with splinting and anti-inflammatory drugs. A test conducted on the nerve will positively determine whether or not it is pinched and if you have carpal tunnel syndrome.

What then?
If all your symptoms go away with splinting and medication, then surgery will not be necessary. If not, then the "carpal tunnel release" surgery is recommended. The procedure is performed on an outpatient basis. No hospital stay is required. With the new endoscopic technique the recovery period is about 10 days compared with several weeks or months with the old technique of cutting through the palm to reach the tight ligament.

What about cost?
The cost of the new endoscopic surgery is comparable to the traditional open carpal tunnel release surgery. Actually, when considering the additional cost of therapy often necessary after the traditional surgery and the loss of work due to a lengthy recovery time, the new endoscopic surgery may in fact be less costly.

Why us?
Dr. Neff is extensively trained in hand and upper extremity surgery. Most orthopaedic surgeons are not trained in the newest techniques of true endoscopic carpal tunnel release. Special training, cadaver surgery, and special certification is necessary before the surgeon should state to the public that he or she is trained and capable of expertly and safely performing the newest endoscopic carpal tunnel release techniques.

What do I have to do now?
Call for appointment today 515-222-3151 or Toll Free 877-348-9341.

Do I have a choice of surgeries?
Yes. You can either have the traditional carpal tunnel release surgery in which a longitudinal incision is performed in the palm of the hand or have it done through the new endoscopic technique. Both are effective, but with the traditional technique, the wound in the palm remains tender for several weeks or months and prevents a quick return to work or recreational activities. With the traditional technique, normal tissues are divided in the palm, whereas, with the endoscopic technique these structures are not injured.

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