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Carpal Tunnel Syndrome

Constitutes the most common peripheral constrictive neuropathy (5% of population).

It was initially described in 1854 by Sir James Paget, while 1933 Sir James Learmoth performed the first operation.


Anatomy

At the palm’s base there is an unyielding almost closed canal (tunnel) with a diameter as much as our thumb and an internal pressure of 5-10mmHg, containing 9 tendons and medial nerve. 

Over 32mmHg pressure increase inside the tunnel causes nerve ischemia, its myelinolysis, delayed conductivity and the beginning of symptoms of the acute or chronic (idiopathic) form of the disease.


Etiology – Predisposing factors

Past fractures, abnormal muscular mazes, tumors, hypertrophic tissues, rheumatoid arthritis, inheritance (25%), menopause, pregnancy, diabetes mellitus, hypothyroidism, alcoholism and renal insufficiency constitute appearance causes.

The syndrome appears more often to workers, farmers, cashiers and to anyone submitted to vibrations and repeated movements. It seems that women 30-60 present the syndrome more often and 3 to 1 proportionally to men.

 

 

Diseases that imitate the syndrome

In our diagnosis we always take under consideration diseases that imitate the syndrome, such as cervical discus hernia between A6 and A7, tendonitis, carpal (of the wrist) or cervical arthritis, diabetic neuropathy, circulatory disorders, angina (when referring to the left arm).

 

Symptoms

The complaints’ types conclude paresthesia, numbness, feeling of burning and edema, as well as pain that initially awaken the patient who tries to be relieved by shaking his hand. As the condition evolves, the complaints appear during the day too. Numbness appears at the first 3½ fingers.

 

 

If the syndrome evolves even more, muscular weakness and some muscles’ atrophy is established, while everyday activities like driving, using the hairdryer, writing, etc may become intolerable.

 

CLINICAL EXAMINATION

There are various clinical tests (Phallen, Tinnel, Durcan, etc), which, combined with the medical history, put the diagnosis with an accuracy over 90%. Furthermore, electroneurogram and electromyogram complete the diagnosis by registering parameters about nerve conductivity, and the lesion’s degree.

 

THERAPEUTICAL APPROACH

Conservative treatment

When the patient appears at the initial phase of the syndrome (usually the first 6 months), most probably conservative treatment is in order. This includes medication (anti-inflammatory drugs, vitamins as well as specific night splints which keep the wrist from taking positions that cause the symptoms)
 

A specific exercise pattern is considered necessary with purpose in expanding the canal and increasing the muscles’ elasticity.

Cortisone injections offer pain improvement with a transient character though. A big part of our discussion with our patients includes the modification of working habits (ergonomic keyboards, chair and wrist adjustment, frequent breaks at work, elasticity exercises)

 

 

Surgical treatment

It constitutes the 1st treatment in posttraumatic carpal tunnel syndrome. Also, when conservative treatment fails or the patient appears after 6-12 months of established lesion, incision is the best choice before muscular atrophy and irreversible damage to the neural axons is created.

A 2cm skin section is made at the palm’s area and a transverse carpal ligament transection at the roof of the carpal tunnel follows. The nerve is checked, while epineurolysis (clearing of the nerve by any symphysis – adhesions created) is achievable

  

 

The operation takes place under local anesthesia and lasts approximately 10-15 minutes, while the patient leaves at home right after. 

 

Postoperative care

Cotton dressing and suspension for 1-2 days

1st week : using the hand for simple daily shores

No weight lifting for the 1st 2 weeks, while an exercise program is practiced

Stitches get cut after 10 days approximately

At last, preparation for returning to work is in order, after the measuring of muscle power and desensitization of the incision area.

 

Complications

The lesser complications that may occur include nerve or nerve’s branches trauma, incomplete incision of the transverce ligament as well as complaints late resolved.

 

 

 
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