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Overview |
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Definition |
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Carpal tunnel syndrome is the most common entrapment neuropathy of the upper
extremity. The volar surfaces of the carpal bones on the dorsal side and the
carpal ligament on the palmar surface form the carpal tunnel. The carpal tunnel
is a rigid enclosure through which the median nerve and nine flexor tendons
pass. Carpal tunnel syndrome occurs when, for a variety of reasons, the median
nerve is compressed within or adjacent to the carpal canal. The prevalence rate
is approximately 1 per 1,000 people a year. |
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Etiology |
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- Thickening of the transverse carpal ligament or synovial sheath
hypertrophy causes median nerve compression
- Acromegaly
- Idiopathic causes
- Repetitive motion, repetitive minor trauma
- Trauma to area, Colles' fracture
- Infections—Lyme disease, rubella
- Retention of fluid in the soft tissue of the wrist may cause median
nerve compression during pregnancy or menopause
- Palmar mass—ganglion, calcification, uric
acid crystals, hypertrophic fat
- Carpal canal mass—neurofibroma,
neurilemoma
- Dislocation of carpal bones
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Risk Factors |
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- Women > men (3 to 6:1)
- Age—40 to 60 years
- Caffeine
- Tobacco
- Alcohol—especially former
abuse
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Signs and Symptoms |
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Paresthesia—80% of patients:
- Burning
- Prickling
- Tingling—in thenar aspect; aggravated by
grasping from a flexed position or by repetitive rotary or repetitive
flexion-extension movements
- Sensory loss/numbness—usually with gradual
onset
- Cold intolerance
- "Volar hot dog" sign—swelling on the ulnar
side of the palmaris longus tendon
- Phalen's sign
- Tinel's sign
Pain:
- Usually bilateral
- Worse at night, after strenuous activity
- Appears in thumb, index, and long fingers, and the radial half of the
ring finger
- May radiate into forearm
- Hand weakness, clumsiness
- Symptoms improve with hand shaking or motion
restriction
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Differential
Diagnosis |
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- Pregnancy
- Myxedema
- Turberculous wrist
- Gout
- Amyloidosis
- Myeloma
- Cervical disk syndrome
- Brachial plexus lesion
- Arthritis (osteo or
rheumatoid)
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Diagnosis |
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Physical Examination |
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Physical examination will reveal loss of sensibility in thumb and all or some
of the digits. There may be weakness on abduction or opposition of the thumb. In
serious cases the thenar muscle may be damaged to the point of
atrophy. |
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Laboratory Tests |
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- Sedimentation rate
- Thyroid function studies
- Rheumatoid factor
- Uric acid
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Pathology/Pathophysiology |
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- Median nerve with momentary obliteration of vascular
markings—indicates mild compression
- Median nerve with appearance of an isthmus and both proximal and
distal bulging masses—indicates severe
compression
- Prolonged nerve conduction across the carpal
tunnel
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Imaging |
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- Magnetic resonance imaging—may define
cause
- X ray or CT scan—reveals heterotophic
calcification
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Other Diagnostic
Procedures |
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- Phalen's test—forearms are vertical while the
wrists are fully flexed for 60 seconds; paresthesia or numbness are positive for
carpal tunnel syndrome; sensitivity 76%, specificity 80%
- Tinel's test—median nerve at the volar crease
of the wrist is repeatedly tapped; paresthesia or pain are positive; sensitivity
64%, specificity 55%
- Venous tourniquet at 60 mm Hg causes tingle
- Nerve conduction study—shows presence and
extent of peripheral nerve pathology; sensitivity 90%; uncomfortable, expensive,
technically demanding
- Electromyography (EMG)—gold standard; needle
electrode is inserted in muscle; reveals motor or sensory latency and the
location of the nerve compression; abnormal 85% of
cases
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Treatment Options |
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Treatment Strategy |
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- Splinting wrist in slight dorsiflexion—full
time for three to four weeks then slowly reduce to nighttime only
- Treat underlying metabolic disorder
- Weight reduction, if needed
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Drug Therapies |
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- Nonsteroidal anti-inflammatory drugs—relieve
symptoms; ibuprofen 400 mg tid; side
effects—gastrointestinal
- Corticosteroid (e.g., 20 to 40 mg prednisolone) mixed with 1%
lidocaine—inject into the tendon sheaths of the carpal
tunnel canal to decrease synovitis and swelling, carefully avoiding both the
median and ulnar nerves; two weeks' response time, relapse
time—18 months; after three injections consider
surgery
- Potassium-sparing diuretics, if needed
- Avoidance of habitual repetitive hand
motions
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Surgical Procedures |
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- For symptoms persisting beyond three months, for thenar atrophy, and
for extremely prolonged sensory or motor latencies from nerve conduction or EMG
tests; incision of the transverse carpal ligament at the wrist allows for medial
nerve decompression; aids regeneration of the compressed sensory and motor
fibers; improves thumb muscle strength and sensation in other digits; complete
relief 95% of cases
- Endoscopic surgery—smaller incision, less
postoperative pain, quicker recuperation, but limited visibility during
procedure has inherent disadvantages
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Complementary and Alternative
Therapies |
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Many cases will respond to vitamin B6 supplementation with partial
to full recovery. It may take up to three months for the full effectiveness.
Homeopathic treatment, especially arnica gel topically, and contrast
hydrotherapy can be useful adjunctive therapies. |
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Nutrition |
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- Vitamin B6 (50 to 200 mg/day) may be deficient, up to 85%
of patients improve in pain relief and increased function. Pyridoxal phosphate
supplementation should reduce risk of sensory neuropathy with doses of 200
mg/day of other forms of B6.
- B-complex to prevent imbalance of other B vitamins and for optimum
functioning of B6 pathways
- Essential fatty acids (1,500 to 3,000 mg/day) for at least one month;
anti-inflammatory and reduce symptoms
- Modify diet to reduce or eliminate saturated fats and fried foods,
which increase inflammation.
- Curcumin (250 to 500 mg), and bromelain (250 to 500 mg), both between
meals. Anti-inflammatory without the side effects of cortisone treatments. May
also reduce post-operative edema, swelling, and pain
- Lipoic acid (100 mg bid) is an antioxidant and
anti-inflammatory.
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Herbs |
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Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1
heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).
Antispasmodic and diuretic herbs may help symptoms by relaxing muscle spasm and
decreasing swelling.
- Cramp bark (Viburnum opulus): spasmolytic
- St. John's wort (Hypericum perforatum): anti-inflammatory,
historically used specifically for nerve pain
- Wild yam (Dioscorea villosa): anti-inflammatory,
anti-spasmodic
A combination of the above herbs, equal parts, may decrease inflammation,
provide some pain relief, and enhance healing. Dose is 1 to 3 cups of tea/day or
30 drops tincture tid. |
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Homeopathy |
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An experienced homeopath would consider an individual's constitutional type
to prescribe a more specific remedy and potency. Some of the most common acute
remedies are listed below. Acute dose is three to five pellets of 12X to 30C
every one to four hours until symptoms resolve.
- Apis mellifica for joints that are red, hot, swollen,
especially with irritability
- Arnica montana qid, for a bruised, beat-up feeling, soreness,
achy muscles after trauma or overuse; may be especially effective if arnica gel
or cream is used topically
- Guaiacum for carpal tunnel syndrome that is improved by cold
applications
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Physical Medicine |
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Contrast hydrotherapy: alternating hot and cold applications brings nutrients
to the site and diffuses metabolic waste from inflammation. The overall effect
is decreased inflammation, pain relief, and enhanced healing. Immerse the wrists
fully. Alternate three minutes hot with one minute cold and repeat three times.
This is one set. Do two to three sets/day. Some relief of symptoms may be
achieved by washing hands in hot water and rinsing them in cold throughout the
day. |
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Acupuncture |
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May provide pain relief and decrease inflammation |
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Massage |
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May help symptomatically and preventatively, especially with rosemary and/or
St. John's wort oil. |
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Patient Monitoring |
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Evaluation of treatment during use of splints and corticosteroids needs to be
ongoing. Patient may need to be referred for surgery. Without complication, a
single follow-up visit is all that is required following
surgery. |
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Other
Considerations |
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Prevention |
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Avoid repetitive motion for long periods of time. |
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Complications/Sequelae |
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Recurrent symptoms may result from any of the following.
- Damaged median nerve from injection of corticosteroids directly into
the nerve
- Compression resulting from perineural fibrosis, tenosynovitis, or
prior trauma to the palmar cutaneous branch of the median nerve
- Incomplete neurolysis
- Incomplete lesions of the median nerve between the wrist and the
axilla may result in causalgia (severe burning
pain)
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Prognosis |
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Most patients' symptoms resolve within several months. If not treated, carpal
tunnel syndrome in advanced stages can become quite serious, involving sensory
deficit, muscle atrophy, and permanent loss of function. |
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Pregnancy |
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While hand symptoms are common during pregnancy and the median nerve is at
greater risk for compression, as few as 2.3% women have carpal tunnel syndrome.
Others more likely have median and ulnar nerve traction or peripheral edema.
Corticosteroid injections reduce symptoms well during pregnancy. For most women,
the symptoms will completely resolve post partum. |
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References |
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Publishers;1995:100, 369-370.
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Gruenwald J, Brendler T, Jaenicke C, et al, eds. PDR for Herbal
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Koopman WJ, ed. Arthritis and Allied Conditions.13th ed. Baltimore,
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Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
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Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing Inc.;1987:123-125. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. |