Dr Budoff's Blog

Posts Tagged ‘carpal tunnel syndrome’

Myths of Carpal Tunnel Syndrome

Wednesday, November 17th, 2010

There are so many “old wives tales” surrounding carpal tunnel syndrome (CTS) that I thought I’d debunk a few.

Myth #1: CTS is related to typing or computers.
In short, this is simply untrue. This theory is based upon very poorly done “junk science” from years ago. This was made a big deal by plaintiff attorneys and picked up by the press when there was a class-action lawsuit against keyboard manufacturers years ago. However, more recently performed good research studies have shown that not only is there no association between computer use/typing and CTS, but that people who use computers and/or keyboards more may have a decreased risk of CTS than people who do less typing.

Myth #2: CTS is related to my job.
Mainly untrue. To be a significant risk factor for CTS both high force and high repetition over a prolonged period of time need to occur. That’s why typing, which is high repetition but low force, is not a risk factor. Assembly line work and other ‘overuse occupations’ are not related to CTS. Unless you have one of the following high risk jobs, your CTS is much more likely to be due to genetic factors or personal issues (weight, age, diabetes, thyroid issues, rheumatoid diseases, etc) than due to your job. The high risk operations are: jackhammer operator (a significant exposure to vibration over a prolonged period of time can potentially induce CTS; please note that riding in a vehicle is not the type of vibration I’m talking about here), poultry processor, meat packer, meat cutter and cake decorator. Please note that these are not proven to lead to cTS, but some noted authorities have considered these occupations predisposing risk factors for CTS.

Myth #3: CTS should be worse in my right hand if I’m right-handed or worse in my left hand if I’m left-handed.
Untrue. There is no predilection for the dominant hand. Again, CTS is not due to overuse (with the few above exceptions), so you’re just as likely to develop it in either hand.

Myth #4: Exercises and/or therapy can help with my CTS.
Untrue. CTS is a space problem, where the nerve is pinched at the wrist, so exercises won’t help. Confusion occurs because many things, such as massage, exercise, a few drinks, etc. can make almost any problem feel better in the short run. But they are not curative and will make no difference in the long run.

Myth #5: Lasers or laser surgery can help CTS.
Untrue. This has been totally debunked by scientific studies. And the only laser surgery that is currently done, as far as I’m aware, is in the eyes. In the body, lasers generate too much heat, kill much more tissue than does a knife and scissors, and have led to serious problems where ever they’ve been used in the arms and legs.

I hope that helps.

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When is Carpal Tunnel Syndrome Not Carpal Tunnel Syndrome?

Saturday, September 25th, 2010

Carpal tunnel syndrome is the most common nerve compression in the arm. It causes the fingers of the hand to fall asleep, become numb, burn or tingle. But that doesn’t mean that everything that causes numbness about the hand is carpal tunnel syndrome.

If the small and ring fingers are the only digits involved, then the numbness is probably caused by cubital tunnel syndrome, ie. compression of the ulnar (funny bone) nerve about the elbow.

Sometimes elbow or shoulder pain, from tennis elbow, rotator cuff disease, etc. can cause pain to radiate down the arm as far as the hand. But these referred pains don’t go all the way down to the fingers and make them numb.

The median nerve, the same nerve that is pinched by carpal tunnel syndrome at the wrist, can also be pinched further ‘upstream’ about the elbow. This is known as pronator syndrome. Often times, pronator syndrome can occur at the same time with carpal tunnel syndrome; this is known as a ‘double crush’, because the nerve is compressed in two places at once.

Pinched nerves at the neck can also cause numbness in the fingers. These usually affect the thumb, but any fingers can be involved, depending on the nerve root that is being pinched.

Of course, the opposite also happens. People often think that they have a pinched nerve in their neck when they’ve really got carpal tunnel syndrome. This happens fairly often because carpal tunnel syndrome is so common and nerve studies fail to diagnose carpal tunnel syndrome in approximately 20-33% of patients.

So how do you know where the problem is?

First, you should see a hand surgeon, who should be an expert in diagnosing conditions affecting the hand. General orthopaedic surgeons, plastic surgeons, and other types of physicians may have some knowledge about hand disorders, but don’t have the subspecialty training and experience to predictably diagnose some of the less common conditions, especially when the signs are subtle. You know what they say about jacks of all trades. You want to see a specialist to give you the best chance of getting the correct diagnosis. The physical examination that a specialist does can usually determine the real source of the problem.

For some ‘quick and dirty’ rules, that aren’t 100% accurate, but can point you in the right direction: carpal tunnel syndrome usually bothers people more at night and when gripping things: a book, a steering wheel, etc. It can affect the thumb, index, middle and ring fingers in any combination. It can also affect the small finger, but not the small finger alone; if the small finger (and maybe the ring finger) are the only fingers involved, then it’s not carpal tunnel syndrome. It may be cubital tunnel syndrome, thoracic outlet syndrome or a pinched nerve in the neck.

Numbness that is worse with activities and is associated with an ache in the forearm near the front of the elbow is often pronator syndrome. Numbness that is worse when the neck is moved all the way to one side is often due to a pinched nerve at the neck. Numbness on the back of the hand is often referred from the elbow or shoulder, and not due to carpal tunnel syndrome.

However, for the best chance of an accurate diagnosis, go see a hand surgeon specialist who has the extra training and experience to best diagnose conditions of the hand.

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Endoscopic Carpal Tunnel Release – There are Different Types

Saturday, August 28th, 2010

Endoscopic carpal tunnel release (ECTR) provides the same cure from carpal tunnel syndrome as does open carpal tunnel release (open CTR), but with less pain, less problems and a quicker return to work and other activities. Compared to open CTR, ECTR leads to less pain and weakness, and a quicker return to work.1-3

However, many people are not aware that there are two different types of ECTR: the one-incision technique and the two-incision technique. Both techniques use an incision over the wrist. But the two-incision ECTR places ana second incision in the palm of your hand. This palmar wound causes additional discomfort. In addition, this wound needs to be protected, meaning that immediately after surgery your hand is wrapped, decreasing how much you can do. For the one-incision ECTR there are no bandages over your hand because there are no incisions in your hand. Because of this, there is less palmar tenderness, and most patients regain motion and return to work and other activities quicker following single-incision ECTR compared to following two-incision ECTR.1 So while the two-incision ECTR may be shown in more advertisements, the one-incision ECTR is currently the least invasive technique for carpal tunnel release, the one that can get you back the quickest.

So if you want to get back to the activities you like to do the fastest, forget the hype and focus on the facts. The one-incision ECTR is the way to go.

References:
1) Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK, Olson JD: Endoscopic carpal tunnel release: a comparison of two techniques with open release. Arthroscopy 9:498-508, 1993.
2) Feuerstein M, Burrell LM, Miller VI, Lincoln A, Huang GD, Berger R: Clinical management of carpal tunnel syndrome: a 12-year review of outcomes. Am J Ind Med 35:232-45, 1999.
3) Kerr CD, Gittins ME, Sybert DR: Endoscopic versus open carpal tunnel release: clinical results. Arthroscopy 10:266-9, 1994.

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Basilar Thumb Arthritis

Monday, June 28th, 2010

The base of the thumb (the trapeziometacarpal joint) is commonly affected by arthritis. The arthritis often causes pain during pinching and gripping. It may be especially severe when opening jars or turning a key. It may progressively worsen until most/all hand activities become painful.
The basilar thumb joint is especially stressed by pinching and gripping small objects. When gripping or pinching a small object, for every 1 pound of force you apply to your thumb tip, the basilar joint experiences 12 pounds of force. To decrease stress on this joint it’s better to avoid manipulating small objects and to pinch and grip big. Big, thick pens with rubber grips on them are much easier on your joint than are small, metal pens. Kitchen-aid or simlar devices can slip over jar lids to make them larger and easier to grasp. You can buy devices that slip over keys to make turning them easier. Whatever you grab with your arthritic thumb, try to make it bigger.
A splint can also be helpful. Most patients prefer a soft, neoprene, rubber-like splint that doesn’t interfere much with hand function. A steroid injection can also provide good relief. If the symptoms are mild, these measures may be all that you need. However, unfortunately, they will not provide permanent relief from the pain of significant arthritis.
If nonoperative management is not effective and the pain is significant, surgery can be a very effective cure. There are many different types of surgery for this problem. I prefer the LRTI (ligament reconstruction tendon interposition). It is the current ‘gold standard’, the most popular and most effective procedure, with a low complication rate. It’s been around since the mid-1980s. It uses your body’s natural tissues to provide both stability and a new joint.
This is one case where newer procedures that use artificial materials to create artificial joints are less effective with a higher complication rate. Artificial joint replacements almost always have a higher complication rate and a lower success rate than the LRTI procedure.
During the LRTI, the arthritic bone that your thumb rests on (the trapezium) is removed. A small cut is made in the forearm to release a tendon, which is moved to the base of the thumb to fill in the area from which the trapezium bone was removed. So now instead of your thumb resting on a hard piece of arthritic bone (which is painful), it rests on a soft tendon pillow. A small suture anchor is placed into a thumb bone. It’s like a small harpoon with stitches on it to hold everything together. It stays in forever.
Basilar thumb arthritis often co-exists with carpal tunnel syndrome. If this happens, an endoscopic carpal tunnel release can be performed at the same time.
Following the LRTI, a post-operative splint is worn for one week, then a cast is worn for three weeks. Once the case is removed, you may get the hand wet. Some patients may need some hand therapy to regain thumb motion, but most don’t need much therapy at all. The stitches are absorbable, and there are no stitches to remove. Once the cast is removed a removeable splint is worn full-time for two weeks, except when bathing, and then only as needed.
While some patients note a fair amount of pain for the first few days after surgery, the surgical pain quickly decreases. It is important to avoid forceful gripping and heavy lifting for 3-4 months after this surgery. Typing and computer use are fine, and may be performed the day after surgery.

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Carpal Tunnel Syndrome

Friday, May 28th, 2010

There are so many myths and so much misinformation regarding carpal tunnel syndrome (CTS) that I thought it might be good for a hand surgeon to go through the facts. Here are some common questions that I often hear:

What is the carpal tunnel?
The carpal tunnel is a passage for the median nerve (one of the major nerves to your hand) and the nine tendons that flex (bend) your fingers and thumb. It is located under the base of your palm. It has rigid, unyielding boundaries: Its back and sides are made of bone and the front is made up of the very thick transverse carpal ligament.

What is carpal tunnel syndrome?
Carpal tunnel syndrome occurs when the median nerve becomes compressed in the carpal tunnel. The carpal tunnel has a limited amount of space. Therefore, anything that takes up too much space in the carpal tunnel can compress and damage the median nerve. Carpal tunnel syndrome is, pure and simple, a space problem: there’s too much stuff in too little space. The most common thing that takes up too much space is the lining of the nine tendons, which can swell up.

What are the symptoms of carpal tunnel syndrome?
The symptoms of carpal tunnel syndrome come from irritation of the median nerve. People with carpal tunnel syndrome feel that their fingers become “numb”, “fall asleep”, or have “pins and needles” in them. This is often worse at night and when driving, writing or gripping objects. As carpal tunnel syndrome advances the fingers may permanently lose sensation. With more advanced carpal tunnel syndrome, some of the muscles in the hand may become weak can atrophy (die).

Carpal tunnel syndrome is usually worst at night, or upon awakening in the morning because we all sleep with our wrists flexed down, which further “pinches” the median nerve. If you wake up at night with your hand numb or painfully asleep, and have to “shake out” your hand to get relief, you’ve got carpal tunnel syndrome. This is why splinting the wrist at night often helps people with mild carpal tunnel syndrome – it keeps the median nerve from getting pinched while you sleep. The other reason why carpal tunnel syndrome is worst at night is because we tend to swell more at night. This swelling takes up space, further compressing the median nerve.

How is the diagnosis of carpal tunnel syndrome made?
The diagnosis of carpal tunnel syndrome should be made by your physician talking to you and examining your arm. Occasionally, there are other places in the arm where the median nerve can be compressed, which can lead to symptoms very similar to carpal tunnel syndrome. It is also important to determine whether or not the ulnar (funny bone) nerve is involved.

Nerve conduction studies are usually obtained, mainly to confirm the diagnosis of carpal tunnel syndrome. However, these studies are not perfect. In fact, they fail to diagnose approximately 20-33% of people with carpal tunnel syndrome. In the event that your history and physical examination strongly suggests carpal tunnel syndrome, but the nerve conduction study is negative, a steroid injection is indicated. An injection into the carpal tunnel is probably a better diagnostic test than the nerve conduction study. If the injection helps your problem, even for only a few days, then you almost certainly have carpal tunnel syndrome.

How is carpal tunnel syndrome treated?
Unless your carpal tunnel syndrome is causing constant symptoms or permanent nerve damage, initial treatment is often wrist splinting at night. If that doesn’t work, CTS should be cured by carpal tunnel release, which is a quick outpatient procedure. During a carpal tunnel release, the transverse carpal ligament that compresses your median nerve is cut. By cutting this ligament 25% more room is created for your median nerve, relieving the pressure on it, stopping the progression of the disease and allowing the nerve to heal. Unless irreversible nerve damage is already present, this decreases the symptoms of carpal tunnel syndrom in over 95% of patients.

Are all Carpal Tunnel Releases the Same?
An endoscopic carpal tunnel release is done through smaller incisions, with less pain, less suffering and a quicker return to work and other activities compared to open surgery. There are two types: 1) A one-incision endoscopic carpal tunnel release and 2) a two-incision endoscopic carpal tunnel release. The two-incision endoscopic carpal tunnel release puts a scar in both the wrist crease and in the palm. While it’s an improvement over the open carpal tunnel release, the wound in the palm still causes additional discomfort. The single-incision endoscopic carpal tunnel release is the least invasive technique. The incision is made in your wrist crease, which tends to hide it, and there is no incision in your palm. This leads to decreased palmar tenderness. Most patients return to work and other worthwhile activities sooner following single-incision endoscopic carpal tunnel release compared to following two-incision endoscopic carpal tunnel release.

How soon can I “get back” after Endoscopic Carpal Tunnel Release?
You can type and use computers as much as you want starting the day after surgery. You can do as much other activity as you want, but if you want to minimize pain and swelling, you should probably avoid heavy lifting and gripping for 4-6 weeks. You won’t damage yourself, but this stress will cause extra pain, discomfort and swelling that most people would rather avoid. You need to keep the wound clean and dry for 4 days. After 4 days you can remove your dressings and shower, but don’t submerge the incision under water for 10 days. There are no stitches to remove (they’re buried and absorbable).

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DeQuervain’s Tendinitis

Sunday, March 28th, 2010

DeQuervain’s tendinitis is a space problem, like carpal tunnel syndrome. However, instead of a nerve getting compressed (as in carpal tunnel syndrome), this time it’s a tendon that’s getting compressed. It’s the tendons on the thumb side of your wrist. You get swelling in the tunnel that the tendons travel in, so that there’s not enough space for the tendons to comfortably pass. This leads to sharp wrist pain, just above your thumb.

It’s common in mothers with small children, who lift their growing children up a lot. This leads to tendon overuse and tendinitis. Gardeners who do a lot of weeding also develop it, as can manual laborers, or anyone else who lifts up heavy objects often.

Initial treatment is to avoid the activites that cause pain. In other words, avoid lifting with your thumb up. If you have to lift, lift with the palm up or the palm down. To lift up small kids, keep your palm up and ‘scoop under’ their bottoms to lift them. Or you can use your other hand to bear most of their weight. Splinting can be helpful. And a single steroid injection is helpful, and can often be curative, especially if you catch it early and are able to avoid repeating the stressful activities.

If those measures fail, the tendon can be surgically released through a small incision. It’s outpatient surgery, under local anesthesia and not very painful it all. Note that if a surgeon simply releases the tendons and allows early motion, the tendons can occasionally sublux (move back and forth), leading to an annoying, painful snapping. To prevent this, after releasing the tunnel around the tendons, I prefer to lengthen the fascia (the material that makes up the tunnel) and repair it with plenty of room for the tendons, like a seatbelt around them. This helps prevent subluxation. After only 1 week in a splint you can move the wrist normally, and use it within the limits of pain. I use absorbable stitches, so there are no stitches to remove. DeQuervain’s release is extremely effective and the vast majority of patients return quickly to their regular activities.

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Carpal tunnel syndrome during pregnancy

Sunday, March 21st, 2010

Carpal tunnel syndrome is very common during pregnancy. It’s probably caused by all of the swelling and fluid shifts that the mother goes through. Extra fluid collects throughout the body, including inside the carpal tunnel. This compresses the median nerve about the wrist, leading to carpal tunnel syndrome.

Night splints can be tried to prevent the wrist from flexing down during sleep. However, these are often ineffective. We don’t perform elective surgery on pregant women, so there are usually no carpal tunnel releases performed on women during pregancy. Fortunately, a single steroid injection usually provides significant relief by decreasing the severity of symptoms for the remainder of the pregnancy. Steroid use is widely believed to be safe during pregnancy. And it’s very effective. I’ve injected many pregnant women for carpal tunnel syndrome, including pregnant pediatricians and pregnant OB/GYNs (obstetrician-gynecologists).

The carpal tunnel syndrome resolves in approximately 50% of cases upon child birth, and no further treatment is needed. For the other 50%, an endoscopic carpal tunnel release can be performed as soon as the new mother is no longer breast feeding. This usually provides a permanent solution to the problem.

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Pronator Syndrome

Monday, March 8th, 2010

Pronator syndrome is compression of the median nerve about the elbow / upper forearm. It has symptoms similar to those of carpal tunnel syndrome, but is much less common. The two syndromes are therefore often confused. In addition, the two syndromes can occur simultaneously, meaning that the median nerve is compressed in two places at the same time, ie. the “double crush” syndrome.

As opposed to causing numbness of the fingers at night, pronator syndrome often causes numbness with heavy use. It is also associated with pain over the upper forearm.

A nerve study can diagnose pronator syndrome. However, the results of the nerve study should be confirmed on physical examination. If there’s any question, a diagnostic injection into the carpal tunnel to see if that temporarily resolves the symptoms (implying that the problem is solely due to carpal tunnel syndrome), or if another source of symptoms, such as pronator syndrome, exists. If surgery is elected, it can be performed through a small cosmetic incision. The surgical results are very good.

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