Carpal tunnel syndrome is undoubtedly the most frequent form of peripheral nerve entrapment/compression not only in our Caribbean hand surgery clinic at Trinidad Institute of Plastic Surgery.
The cause of carpal tunnel syndrome is compression of the median nerve at the wrist, where it runs through the carpal canal (carpal tunnel) with nine tendons and their gliding tissue. The volume of the carpal canal is relatively fixed. Thus increase in volume of any structure tends to compress the softer nerve. Nerve compression decreases blood flow into and inside the nerve, which accounts for the symptoms and eventually also for irreversible nerve damage.
Characteristically, patients with carpal tunnel syndrome present with pain in the wrist and/or fingers and a tingling or decreased sensation in the second, third and half of the fourth fingers. Often pain and numbness at night is present and wake the patient up at night.
While history and provocative manoeuvers on physical examination may be sufficient to establish the diagnosis of carpal tunnel syndrome, the current medicolegal climate and insurance requirements make objective testing almost a sine qua non. To this end nerve conduction studies and electromyography may have to be performed to document roadblocks to electrical conduction in the median nerve attributable to the nerve compression and their effects on the median nerve innervated muscles.
Treatment of carpal tunnel syndrome is by carpal tunnel release, which opens the transverse carpal ligament forming the roof of the carpal tunnel and thus permanently increases the available volume taking pressure off the median nerve. Our preferred technique is a mini open release through a small incision in the palm, a fifteen minute operation, which is more than 95% successful.
Postoperative recovery is usually fast and allows return to work in barely more than two weeks unless the patient is a heavy manual laborer or strong incentives for secondary gain such as pending litigation or worker’s compensation claims are present, which may increase the time to return to work to up to two and a half months in some surveys.
Scar tenderness is the main postoperative complaint. Symptom relief is otherwise fairly immediate and the majority of patients experience absence of night-time pain and numbness and tingling in their fingers in the immediate postoperative period. Strength and dexterity in the hand return more gradually. If long-standing median nerve compression has resulted in permanent nerve damage recovery is usually incomplete. Median nerve decompression may then still prevent further progression of nerve damage.
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