Carpel tunnel syndrome

Carpel tunnel syndrome, NEUROPATHY, peripheral neuropathy, mononeuropathy multiplex,

1. Clinical case: A 55 years old, diabetic man, presented with sensory loss over lateral 3 ½ fingers and wasting of thenar eminence in AIIMS BBSR Neurology OPD. The patient gave the history of pain, tingling, numbness, paresthesia over the lateral fingers from last 8 months, symptoms worsen with flexion of wrist.

2. Carpel tunnel syndrome Evaluator: Mr L Anand [ Asso professor, CON AIIMS BBSR] Presenter : Shruti Shirke M.Sc Neuroscience Nursing

3. Introduction The term CTS was coined by MOREISCHER, condition described by JAMES PAGET (1854) Entrapment neuropathy of median nerve Carpal tunnel syndrome (CTS) is a collection of characteristics sign and symptoms that occurs following compression of the median nerve within the carpal tunnel. Usual symptoms include numbness, paresthesia, and pain in the median nerve distribution.

4. Introduction cont..

5. Introduction cont.. Entrapment Neuropathy – Pressure induced injury to peripheral nerve CTS - The most common upper extremity compression neuropathy Carpal Tunnel Syndrome (CTS) - a collection of sign and symptoms that occurs following entrapment of the Median nerve within the carpal tunnel. 90% of all Entrapment neuropathy

6. Introduction cont.. Usual symptoms include numbness, paresthesia , and pain in the median nerve distribution. These symptoms may or may not be accompanied by objective changes in strength of median-innervated structures in the hand.

7. Definition Carpal tunnel syndrome is one of the common cause of entrapment neuropathy, occurs due to repeated and continuous compression of median nerve, it is characterized by pain, numbness, and tingling in hand and arms. -Charles D ( Orthoinfo )

8. Anatomy: Carpal tunnel boundaries Anterior: Transverse carpal ligament Dorsally: Carpal bones, deep volar carpal ligaments and volar interoseeous ligaments Laterally : Scaphoid tuberosity & Trapezium Medially : Pisiform & hook of hamate Because these boundaries are very rigid, the carpal tunnel has little capacity to "stretch" or increase in size.

9. Anatomy: Carpal tunnel boundaries 3 Sides Carpal bones(osseous arch ie floor) + 1 side transverse carpal ligament(roof) 9 tendons in center (finger flexer tendons) + median nerve

10. Anatomy: Carpal tunnel boundaries Contents: 9 Tendons and median nerve Tendons: The tendon of Flexor pollicis longus 4 tendons of Flexor digitorum profundus 4 tendons of Flexor digitorum superficialis

11. Anatomy: Carpal tunnel boundaries Thick fibrous band from the tuberosity of Scaphoid & a portion of Trapezium to the Pisiform & hook of Hamate. Ligament is unyielding thick fibrous tissue - does not allow for changes in volume within the carpal tunnel.

12. Epidemiology Race Whites at highest risk of developing CTS. Very rare in some racial groups ( eg - nonwhite, South Africans) Sex Female-to-male ratio is 3-10:1 Age The peak age range for development of CTS is 45- 60 years. Only 10% of patients with CTS are younger than 31 years

13. Etiology P : Pregnancy R : Rheumatoid arthritis A : Arthritis of the carpal bone, Amaylodosis G : Growth hormone abnormalities like acromegaly M : Metabolic abnormalities like DM, Gout, Hyperthyroidism A : Alcoholism T : Tumor I : Idiopathic C : Connective tissue disorders

14. CTS IN PREGNANCY T hird Trimester Cause - Alteration in fluid balance Symptoms are typically bilateral Management – Conservative Symptoms resolve after delivery in most women.

15. Risk factors Most cases have no known cause – Idiopathic Others- a combination of factors. Heredity/ Genetic - The carpal tunnel may be smaller in some people or there may be anatomic differences that change the amount of space eg Thickened transverse ligament. Repetitive hand use/ Occupation – Tailor, Computer operator, Painter Hand and wrist position. Doing activities that involve extreme flexion or extension of the hand and wrist for a prolonged period of time Injury or trauma Pregnancy- Hormonal changes during pregnancy can cause swelling.

16. Pathophysiology Factors involved in pathogenesis Decrease in Size of Carpal Tunnel Increase in Contents of Canal Inflammatory Conditions Alterations of Fluid Balance

17. Pathophysiology

18. Pressure perfusion relation

19. Sign & Symptoms Numbness, tingling, burning, and pain—primarily in the thumb and index, middle, and ring fingers Occasional shock-like sensations that radiate to the thumb and index, middle, and ring fingers Pain or tingling that may travel up the forearm toward the shoulder Weakness in grip Weakness and clumsiness in the hand—difficult to perform fine movements such as buttoning the clothes Dropping things—due to weakness, numbness, or a loss of proprioception

20. Sign & Symptoms cont.. In most cases, the symptoms of carpal tunnel syndrome begin gradually—without a specific injury. Symptoms relapse and recur with increasing severity over time. To relieve the symptoms, patients often “flick” their wrist as if shaking down a thermometer ( FLICK SIGN ).

21. Stages Stage I : Pain, not localized to the distribution of median nerve Stage II : Pain, tingling, Paresthesia along the distribution of median nerve Stage III : Clumsiness of hands and loss of digital functions Stage IV : Sensory loss in lateral 3 1/2 fingers & wasting of thenar eminence

22. Diagnosis History Physical examination – Special tests Imaging - USG/CT/MRI Electrodiagnostic Studies - NCV/EMG

23. Diagnosis Sensory examination Abnormalities in sensory modalities may be present on the palmar aspect of the first 3 digits and radial one half of the fourth digit. Motor examination Wasting and weakness of the median innervated hand muscles (LOAF) may be detectable.

24. Clinical test (Provocative tests) Phalen’s test: (most sensitive) flex the wrist actively, paresthesia and tingling like symptoms are produced within 60sec, test is considered positive. Tourniquet test: tie pneumatic blood pressure cuff in upper arm raise pressure above systolic blood pressure and if it produces symptoms test is considered positive. Median nerve compression test Median nerve percussion test: using percussion hammer.

25. DIAGNOSIS: PHALEN SIGN Tingling in the median nerve distribution is induced by full flexion (or full extension for reverse Phalen) of the wrists for up to 60 seconds.

26. DIAGNOSIS: HOFFMANN-TINEL SIGN Gentle tapping over the median nerve in the carpal tunnel region elicits tingling in the nerve's distribution.

27. DIAGNOSIS: ARPAL COMPRESSION TEST- DURKAN’S TEST This test involves applying firm pressure directly over the carpal tunnel, usually with the thumbs, for up to 30 seconds to reproduce symptoms. Most specific and sensitive

28. ELECTROPHYSIOLOGICAL GRADING CTS

29. IMAGING - USG Entrapped nerve – Hypoechoic Swollen Flattened Highly sensitive and specific

30. OTHER IMAGINGS MRI scans – very sensitive. Findings with CTS include: flattening or swelling of the nerve, palmar bowing of the flexor retinaculum. May also demonstrate ganglion cysts, lipoma X-rays - To exclude other causes for your symptoms, such as arthritis or a fracture. CT Scan - Displays the bony structures clearly

31. LABORATORY TESTS Recommended in cases where an underlying peripheral neuropathy is suspected (i.e. unclear etiology in a young individual with no risk factors such as repetitive hand use). Thyroid hormone levels: to R/O myxedema R/O amyloidosis R/O chronic renal failure that could cause uremic neuropathy HbA1c and blood glucose: R/O diabetes Multiple myeloma: 24 hour urine for kappa Bence-Jones protein etc

32. Management CONSERVATIVE TREATMENTS – General measures – Wrist splints (Full time - optimal) – Oral Meds (Steroids > NSAIDs) – Local Injection of Steroids (Transient) – USG therapy – Exercise therapy

33. Conservative Management General/ Physical Therapy Given CTS is associated with low aerobic fitness and increased BMI, it is inherent to provide the patient with an aerobic fitness program. Stationary biking, cycling, or any other exercise that puts strain on the wrists probably should be avoided. Occupational Therapy A physical therapist to evaluate the dynamics and ergonomics or the working environment. Activity changes. Nerve gliding exercises.

34. Treatment Stage I, Stage II: NSAIDS and Steroids (Prednisolone for 8 days) Intermittent symptoms: Injection therapy Sensory loss, wasting of thenar eminence: Surgical intervention.

35. Drug therapy NSAIDs – Short (1-2 wk ) courses of regular NSAIDs can be of benefit, particularly if there is any suggestion of inflammation in the wrist region. Diuretic – Conditions that cause edema may increase pressure in the carpal tunnel. Diuretics may be beneficial in reducing edema . Steroids – Steroid injection into the carpal tunnel is of benefit, as is oral prednisone Their effect is sometimes only temporary.

36. Injection therapy A mixture of 10 to 20mg of Lidocaine(Xylocaine) without epinephrine and 20 to 40mg of methylprednisolone acetate or similar corticosteroid preparation is injected with a 25G needle at the distal wrist crease or 1 cm proximal to it. Some prefer 10-25mg Hydrocortisone without local anesthetics After 2-3 injections  Surgery

37. Surgical therapy: Indications Does not improve following conservative treatment or symptoms > 1 year Patients who initially are in the severe CTS Motor Weakness, Thenar atrophy

38. SURGICAL TECHNIQUE – OPEN INCISION Incision – Distal wrist crease to Kaplan’s cardinal Line Layers - Skin  Subcutaneous tissue  Flexor Retinaculum  TCL The carpal ligament is opened. A bulky bandage is applied to the wound, with care taken to ensure that digit movement is NOT restricted. Effective release of TCL has been shown to increase carpal tunnel volume by 24%

39. SURGICAL TECHNIQUE – OPEN INCISION

40. ENDOSCOPIC CARPAL TUNNEL RELEASE A tiny, ½-inch incision is made on the palm side of the wrist at Distal wrist crease. A fiber optic camera is passed through to view the inside of the carpal tunnel. Another tiny incision is made in palm at around distal crease through which surgical tools are passed in and used to incise the carpal ligament.

41. ENDOSCOPIC CARPAL TUNNEL RELEASE

42. Nursing care Advice patient to maintain neutral position of the wrist. Application of wrist splint. Apply cold compression to relieve inflammation. Demonstrating nerve gliding exercises. Explain regarding NSAID’s and steroid therapy. Assist in tendon sheath injection.

43. Complications Arterial Injury, Haematoma Postoperative infection Hypertrophic scarring Injury to Palmar Cutaneous or Recurrent Motor branch of Median nerve (Million Dollar Nerve) Laceration of Superficial Palmar Arch Tendon adhesion Joint stiffness Chronic wrist and hand pain

44. Prognosis CTS is progressive over time and can lead to permanent median nerve damage if untreated. Even after surgical release, the syndrome recurs to some degree in a significant number of cases possibly in up to one third after 5 years. Initially, approximately 90% of mild to moderate CTS cases respond to conservative management. Over time, however, a number of patients progress to requiring surgery.

45. Prevention

46. Clinical case: A 55 years old, diabetic man, presented with sensory loss over lateral 3 ½ fingers and wasting of thenar eminence in AIIMS BBSR Neurology OPD. The patient gave the history of pain, tingling, numbness, paresthesia over the lateral fingers from last 8 months, symptoms worsen with flexion of wrist. What is the most probable diagnosis? Which nerve is involved? The patient is at which stage of disease? What are the clinical test used to diagnose the disease? What is the treatment of choice for this patient?

47. Summary

48. Conclusion Carpal tunnel syndrome is a condition in which the median nerve or tendons of the hand are compressed as they travel through the carpal arch. Most common cause of entrapment neuropathy. Progressive with time, recurrence is also common within 5 years.