Symptoms in Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused when the space (the carpal tunnel) in the wrist narrows. This presses down on the median nerve and tendons (located inside the carpal tunnel), which cuts off sensation in the fingers and hand.

Symptoms usually begin slowly and can occur at any time. Early symptoms include:

• Numbness at night.
• Tingling and/or pain in the fingers (especially the thumb, index and middle fingers).

In fact, because some people sleep with their wrists curled, night time symptoms are common and can wake people from sleep. Shaking the hands helps relieve symptoms in the early stage of the condition.

Common daytime symptoms can include:

• Tingling in the fingers.
• Decreased feeling in the fingertips.
• Difficulty using the hand for small tasks, like:
  • Handling small objects/ utensils.
  • Writing.

As carpal tunnel syndrome worsens, symptoms become more constant. These symptoms of progression include:

• Weakness in the hand.
• Inability to perform tasks that require delicate motions (such as buttoning a shirt).
• Dropping objects.

In the most severe condition, the muscles at the base of the thumb visibly shrink in size (atrophy) or the patient develops tiny ulcers due to burns on the finger tips

Treatment of Carpal Tunnel Syndrome

Carpal tunnel syndrome can be treated non-surgically or with surgery. Non-surgical treatments are used for less severe cases and allow you to continue with daily activities without interruption. Surgical treatments can help in more severe cases and have very positive outcomes.

Non-surgical treatments

Non-surgical treatments are usually tried first. Treatment begins by:

• Wearing a wrist splint at night.
• Taking nonsteroidal anti-inflammatory drugs, such as ibuprofen.
• Steroid injections.

Other treatments focus on ways to change your lifestyle to decrease symptoms. This is often seen in the workplace, where you can make modifications to help with carpal tunnel. These changes might include:

• Raising or lowering your chair.
• Moving your computer keyboard.
• Changing your hand/wrist position while doing activities.
• Using recommended splints, exercises and heat treatments from a hand therapist.

Surgical treatments

Surgery is recommended when carpal tunnel syndrome does not respond to non-surgical treatments or has already become severe. The goal of surgery is to increase the size of the tunnel in order to decrease the pressure on the nerves and tendons that pass through the space. This is done by cutting (releasing) the ligament that covers the carpal tunnel at the base of the palm. This ligament is called the transverse carpal ligament.

• After all the pre-operative investigations and management of diabetes and hypothyroidism, surgery is planned
• Surgery is done usually in brachial plexus block or General Anesthesia.
• A small incision is given about the wrist and carpal tunnel is released
• Finger movements are started once the effect of brachial plexus block is gone or when the patient is out from in anaesthesia.
• You might be in brief discomfort for about 24 to 72 hours after surgery.
• People usually experience complete night-time symptom relief quickly—even the night after surgery
• Wrist immobilization is done till sutures are removed.
• Sutures are removed after a period of 10-12 days.
• Physiotherapy post operative is most important for hand, wrist and fingers
• Prognosis is good if muscle atrophy has not started.
• You might be unable to do heavier activities with the affected hand for about four to six weeks.

Management of Median Nerve Palsy/ Late cases of the carpal tunnel syndrome

If the patient has presented very late and muscles of hand (base of thumb) have atrophied, then he or she would not be able to bring out thumb in perpendicular direction to the palm when hand is placed flat on the table. There would be loss of coarse movements of the hand with complete loss of sensation over the thumb, index, middle and half of ring finger.

Such condition is usually seen in long standing compression of the median nerve or injuries of the median nerve or in patients with leprosy.

• If the median nerve is damaged, then surgical excision of the damaged part and nerve repair/grafting should be done within 1 year of the injury
• If the patient has presented with sudden onset of paralysis of median nerve, then other neurological causes or leprosy should be investigated for. In many of such cases, release of carpal tunnel nerve is done and a nerve and muscle biopsy is taken to confirm the diagnosis of neurological disease or leprosy.
• If the patient has presented late beyond the timing suitable for nerve repair (after 1 year of the accident), then tendon transfers should be done to strengthen the weak portions of the hand along with the nerve repair and grafting. A strong tendon of the hand is re-routed to substitute a weaker or lost movement of the hand.

During tendon transfers for median nerve palsy, one tendon from the front of the hand is taken, re-routed and sutured to the tendon of the outer aspect of the thumb so that the patient can abduct (bring out thumb) and also make a meaningful pinch with the other fingers so as to hold objects with the thumb and fingers (OPPONENSPLASTY)

The surgery is usually done under brachial block or general anaesthesia and a splint or slab is given for immobilization in the post operative period. The patient is usually discharged second day after the surgery. Sutures are removed 14 days after surgery.

Splint is removed 3 to 4 weeks after the surgery and gradual training of the transferred tendon is started so that it may regain its newly assigned function.

If the patient has presented very late and muscles of hand (base of thumb) have atrophied, then he or she would not be able to bring out thumb in perpendicular direction to the palm when hand is placed flat on the table. There would be loss of coarse movements of the hand with complete loss of sensation over the thumb, index, middle and half of ring finger.

Such condition is usually seen in long standing compression of the median nerve or injuries of the median nerve or in patients with leprosy.

• If the median nerve is damaged, then surgical excision of the damaged part and nerve repair/grafting should be done within 1 year of the injury
• If the patient has presented with sudden onset of paralysis of median nerve, then other neurological causes or leprosy should be investigated for. In many of such cases, release of carpal tunnel nerve is done and a nerve and muscle biopsy is taken to confirm the diagnosis of neurological disease or leprosy
• 6. If the patient has presented late beyond the timing suitable for nerve repair (after 1 year of the accident), then tendon transfers should be done to strengthen the weak portions of the hand along with the nerve repair and grafting. A strong tendon of the hand is re-routed to substitute a weaker or lost movement of the hand.

During tendon transfers for median nerve palsy, one tendon from the front of the hand is taken, re-routed and sutured to the tendon of the outer aspect of the thumb so that the patient can abduct (bring out thumb) and also make a meaningful pinch with the other fingers so as to hold objects with the thumb and fingers (OPPONENSPLASTY)

The surgery is usually done under brachial block or general anaesthesia and a splint or slab is given for immobilization in the post operative period. The patient is usually discharged second day after the surgery. Sutures are removed 14 days after surgery.

Splint is removed 3 to 4 weeks after the surgery and gradual training of the transferred tendon is started so that it may regain its newly assigned function.

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