Elbow / Wrist / Hand

Carpal Tunnel Syndrome

Definition

Carpal Tunnel Syndrome (CTS) is a neurological disorder characterised by paraesthesia, pain and numbness in the hand and fingers, due to a lesion (compression) and/or dysfunction of the median nerve.

Aetiology

In the majority of patients, there is no particular cause for CTS. Risk factors are obesity, diabetes, pregnancy, menopause, ovariectomy and uterus extirpation.

Oedema, tendon sheath inflammations, tumours and deposition of metabolic substances can cause entrapment of the median nerve in the carpal tunnel. Moreover, deformation of the carpal tunnel can lead to compression of the median nerve. This occurs in osteoarthritis, rheumatoid arthritis, trauma and acromegaly. A relationship between CTS and repetitive strain injury (RSI) has also been suggested.

Since the aetiology is unknown in the majority of cases, the pathophysiology is also unclear in this group of patients. The same is true of the hormonal conditions associated with CTS, such as in hypothyroidism and menopausal patients. In pregnant women, it is believed that fluid retention can lead to compression phenomena. Congenital and acquired deformations of the carpal tunnel can lead to narrowing and, consequently, to compression of the median nerve.

Signs and symptoms

The symptoms of CTS usually consist of unilateral nocturnal paresthesia in the area of the skin of the median nerve (digits I to III and half digit IV). In addition, pain can exist in the hand, wrist and forearm I. When the patient wakes up due to CTS, waving the hand can alleviate the symptoms.

Atypical localisation of paresthesia (ulnar area) is frequent. However, being of an intermittent character, and having aggravating and alleviating factors, can support the diagnosis of CTS. In most cases, CTS is unilateral, but can occur on both sides. Later on, symptoms may also occur during the day and subjective paresis can occur.

Diagnostics

Physical Examination

In general, CTS can be diagnosis based on the typical clinical complaint pattern. In CTS, the neurological abnormalities found are unspecific. This also applies to many provocation tests (Hoffman-Tinel, Phalen test, etc.).

Additional Somatic Diagnostics

  • Median nerve conduction examination.
  • X-ray, ultrasound and MRI scan of the wrist when there is suspicion of structural abnormalities in the wrist.
  • The vast majority of cases of CTS have a benign course and/or few daily limitations. CTS disappear spontaneously after pregnancy.
  • The seriousness of CTS is decisive in the choice of conservative or operative treatment. In pregnant women, conservative treatment, for example, using a splint, is always the treatment of first choice.
  • In the long term, corticosteroid injections are less effective compared to surgical treatment. However, there is a greater chance of complications when CTS is treated surgically.

Somatic Treatment

Pharmacological treatment:

  • Tricyclic antidepressants
  • Anticonvulsives: carbamazepine, oxcarbazepine, gabapentine en pregabaline.

Interventional Pain Treatment

Invasive Treatment

  • When the complaints are serious, and the patient is experiencing daily limitations, surgical intervention is indicated.