Syndroma Canalis Carpi
SYNDROMA CANALIS CARPI (Or) CARPAL TUNNEL SYNDROME
Also called as Carpal Tunnel Syndrome.
The most common nerve entrapment syndrome, characterized by nocturnal hand paresthesia and pain, and sometimes sensory loss and wasting in the median hand distribution; affects women more than men and is often bilateral; caused by chronic entrapment of the median nerve at the wrist, within the carpal tunnel.
To understand how Syndroma Canalis Carpi arises, it is important to know the parts of the hand and wrist that are involved.
The Carpal Tunnel: The carpal tunnel is a passageway that forms beneath the strong, broad transverse ligament. This ligament is a bridge that extends across the lower palm and connects the bones of the wrist (carpals) that form an arch below the tunnel.
The Median Nerve and Flexor Tendons: The median nerve and nine flexor tendons pass under the ligament bridge and through the carpal tunnel (similar to a river). They extend from the forearm and up into the hand.
The median nerve plays two important roles. It supplies sensation to the palm to side of the thumb, index, middle, and ring fingers, and to the flexor tendons. It provides function for the muscles at the base of the thumb (the thenar muscle).
The flexor tendons are fibrous cords that connect the muscles in the forearm to the fingers (two to each finger) and one to the thumb. They allow flexing of the fingers and clenching of the fist.
Syndroma Canalis Carpi affects approximately 2% to 3% of the general population. It is more common in women than in men.
Recently, there has been an increase in work-related cases of carpal tunnel syndrome. This may be because of greater awareness about the condition and because many people at work use forceful or repetitive hand movements (such as performing assembly-type work) or have hand-arm vibration, all of which may be related to carpal tunnel syndrome. Obesity, smoking, and medical conditions such as pregnancy, rheumatoid arthritis, hypothyroidism, and diabetes can also contribute to symptoms of Syndroma Canalis Carpi, especially when combined with forceful or repetitive hand and wrist movement or the use of vibrating equipment.
When compared with other illnesses and injuries, Syndroma Canalis Carpi is one of the most common causes of absences from work. It is most often found in people whose jobs require repeated motions, especially people who work on assembly lines in industries such as manufacturing.
Symptoms of carpal tunnel syndrome usually progress gradually over weeks and months and sometimes years. Anyone with recurrent or persistent pain, numbness and tingling, or weakness of the hand should consult a doctor for a diagnosis. Symptoms often develop as follows:
Early on, the patient also usually reports numbness, tingling, burning, or some combination of symptoms on the palm side of the index, middle, and ring fingers. (Typically the fifth finger has no symptoms.) Such sensations may radiate to the forearm or shoulder.
Over time, the hand may become numb, and patients may lose the ability to feel heat and cold. Patients may experience a sense of weakness and a tendency to drop things.
Patients may feel that their hands are swollen even though there is no visible swelling. This symptom may actually prove to be an important indicator of greater CTS severity.
Initial symptoms include pain in the wrist and palm side hand. Symptoms commonly occur in both hands. (Even when only one hand is painful, the other hand often shows signs of nerve conduction abnormalities on testing.).
Symptoms may occur not only when the hand is being used but also at night when the patient is at rest. Even in cases where work is suspected as the cause, symptoms typically first occur outside of work. In fact, the disorder may be distinguished from similar conditions by pain occurring at night after going to bed.
Causes and Risk factors:
Carpal tunnel syndrome occurs when a combination of health conditions and activities puts pressure on the median nerve as it passes through the carpal tunnel in your wrist. This pressure leads to tingling, numbness, pain, and/or weakness in parts of your hand and, sometimes, up into your arm. Anything that decreases the amount of space in the carpal tunnel increases the amount of tissue in the tunnel, or increases the sensitivity of the median nerve can lead to carpal tunnel syndrome.
Factors that help cause Syndroma Canalis Carpi include:
Repeated hand and wrist movements that cause the membranes surrounding the tendons (tendon sheaths) to swell (tenosynovitis).
Buildup of fluid (edema) in the carpal tunnel that can occur from pregnancy or such conditions as rheumatoid arthritis or diabetes.
Broken wrist bones, dislocated bones, new bone growth from healing bones, or bone spurs. These can take up space in the carpal tunnel and put more pressure on the median nerve.
Tumors and other growths (such as ganglions). These uncommon causes of Syndroma Canalis Carpi are usually benign.
Normal wear and tear of the tissues in the hand and wrist caused by aging and repeated movements of the hand or wrist.
Smoking, which may contribute to Syndroma Canalis Carpi by affecting the blood flow to the median nerve.
Conditions or illnesses that can cause or contribute to arm pain or swelling in the joints and soft tissues in the arm, or to reduced blood flow to the hands. These conditions and illnesses include obesity, rheumatoid arthritis, gout, diabetes, lupus, or hypothyroidism.
Syndroma Canalis Carpi is a common work-related injury. Work that requires forceful or repetitive hand movements, hand-arm vibration, or working for long periods in the same or in awkward positions-especially when combined with other health conditions-may cause carpal tunnel syndrome.
Age: Older people are at higher risk than younger adults. CTS is very rare in children.
Women: Many studies indicate that women have a significantly higher risk for carpal tunnel syndrome than men do. According to the National Institutes of Health, women are three times more likely than men to have Syndroma Canalis Carpi. The explanation for this greater risk is unknown, but it may be related to the smaller size of women's carpal tunnel.
Obesity and Lack of Fitness: Being overweight consistently turns up as a risk factor for CTS and may play a direct causal role on CTS. Greater body mass appears to reduce nerve flow speed into the hand. Obesity is also related to poor physical fitness, which may also increase risk. A 2005 analysis indicated that weight is strongly linked to the onset of CTS in patients under the age of 63 years, but may be a less important factor as they get older.
Smoking and Alcohol Abuse: Cigarette smoking slows down blood flow, so that smokers have worse symptoms and slower recovery than nonsmokers do. Increased alcohol intake has been associated with CTS in people with other risk factors.
Other Factors: Poor nutrition, previous injuries, and stress can increase one's risk for Syndroma Canalis Carpi. In addition, high levels of so-called "bad" cholesterol (low-density lipoprotein, or LDL) have also been linked to an increased risk of CTS.
Carpal tunnel syndrome is most accurately diagnosed using the patients' descriptions of symptoms, and electrodiagnostic tests that measure nerve conduction through the hand. If electrodiagnostic testing is not available, symptom descriptions and a series of physical tests are useful.
Diagnosing CTS, however, is not straightforward. Only a small fraction of patients exhibit all three factors necessary for a clear diagnosis:
Specific physical findings.
Abnormal electrodiagnostic test results.
Classic CTS symptoms.
Many people have abnormal electrodiagnostic test results without classic symptoms or any symptoms at all. Furthermore, about 15% of the population has symptoms consistent with CTS, but most do not show test results indicating the disorder.
Ruling out Underlying Medical Disorders: One of the most important first steps in diagnosing CTS is to rule out any underlying medical disorders that may be contributing to the condition. Experts emphasize the need to fully examine patients presenting with symptoms of CTS. Relying only on CTS symptoms, and personal or work histories may result in the failure to detect (and thus properly treat) underlying medical conditions that could be serious. If the doctor suspects that an underlying medical condition may be exacerbating the symptoms of CTS, laboratory tests will be performed. The doctor may take an x-ray, for example, to check for arthritis or fractured bones.
Arthritic Conditions: Arthritic conditions, including rheumatoid arthritis, gout, and osteoarthritis, can all cause pain in the hands and fingers that may mimic carpal tunnel disease. The treatment for these conditions, however, is different.
Muscle and Nerve Diseases: Any disease or abnormality that affects the muscles and nerves, including those in the spine, may produce symptoms in the hand that mimic Syndroma Canalis Carpi.
Ruling out Other Cumulative Trauma Disorders: About 25% of patients with suspected work-related cumulative trauma or repetitive stress disorders have evidence of other conditions that resemble, but are not, carpal tunnel syndrome. A definitive diagnosis is often difficult. Most require treatments similar to those used for CTS: rest, immobilization, steroid injections, and even surgery if conservative treatment is unsuccessful.
Physical Assessment Tests for Syndroma Canalis Carpi
The following findings are helpful in identifying carpal tunnel syndrome:
Inability to tell the difference between one and two sharp points on the fingertips (this is a late sign of carpal tunnel).
Less sensitivity to pain where the median nerve runs through to the fingers.
Flick Signal: One important and simple test of carpal tunnel is the "flick" signal:
If the patient responds with a motion that resembles shaking a thermometer, the doctor can strongly suspect carpal tunnel.
The patient is asked, "What do you do when your symptoms are worse?"
Testing for Thumb Weakness: Two questions are useful in determining thumb weakness:
Can the thumb stretch so that its pad rests on the pad of the little finger pad?
Can the thumb rise up from the plane of the palm?
Phalen's Test: In Phalen's test, the patient rests the elbows on a table and lets the wrists dangle with fingers pointing down and the backs of the hands pressed together. If symptoms develop within a minute, CTS is indicated. (If the test lasts for more than a minute even patients without CTS may develop symptoms.) This test may be particularly important in determining the severity of CTS and assessing the results of treatment.
Tinel's Sign: In the Tinel's sign test, the doctor taps over the median nerve to produce a tingling or mild shock-sensation.
Tourniquet Test: This test employs an inflatable cuff that applies pressure over the median nerve to produce tingling or small shocks.
Hand Elevation Test: The patient raises their hand overhead for 2 minutes to produce symptoms of CTS. The test was recently proven to be accurate and may provide useful information when combined with the Tinel's and Phalen's tests.
Electrodiagnostic Tests: Electrodiagnostic tests analyze the electric waves of nerves and muscles. These tests can help detect median nerve compression in the carpal tunnel.Electrodiagnostic tests are the best methods for confirming a diagnosis of CTS at this time. Doctors who perform these tests should be certified by the American Board of Electrodiagnostic Medicine, which uses rigorous standards in qualifying doctors. Specific electrodiagnostic tests, called nerve conduction studies and electromyography, are the most common ones performed: Nerve conduction tests can also detect causes of symptoms that mimic CTS but are caused by other problems, such as pinched nerves in the neck or elbow, or thoracic outlet syndrome.
Ultrasound: Ultrasound imaging, a relatively inexpensive technique that uses sound waves, is showing some promise. Studies indicate that it can identify up to 85% of CTS cases, and some suggest it is as effective as electrodiagnostic tests. It may be effective for ruling out other causes of hand pain, such as tendon injuries, tenosynovitis (swelling of the tendon lining), cysts, and blood clots in the median artery (a rare complication that can cause the sudden onset of CTS symptoms). However, studies of ultrasound accuracy in CTS diagnosis yield mixed results. In addition, there are no accepted standard diagnostic criteria for Syndroma Canalis Carpi using ultrasound.
MRI: Magnetic resonance imaging (MRI) has been studied as a tool to evaluate the median nerve. It requires special expertise, has limited diagnostic accuracy, and is still too expensive for routine use. Electrodiagnostic tests remain the preferred method of diagnosis. MRI may be most effective for detecting any internal injuries, tumors, arthritis, or joint damage that might be causing the problem. It may also be valuable in selecting surgical candidates when electrodiagnostic tests produce unusual results or indicate more severe disease than expected. Additionally, an MRI may be useful for evaluating patients if surgery fails to bring relief.
It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses. A conservative approach to CTS, which may include corticosteroid injections and splinting, is the first step in treating this disorder. The conservative approach is most successful in patients with mild Syndroma Canalis Carpi.
Wrist Splints: Wrist splints can keep the wrist from bending. They are not as beneficial as surgery for patients with moderate-to-severe CTS, but they appear to be helpful in specific patients. In one study, the best success rates were in patients with mild-to-moderate nighttime symptoms of less than a year's duration. In selected patients, up to 80% reported fewer symptoms, usually within days of wearing the splint.
Typically the splint is worn at night or during sports. The splint is used for several weeks or months, depending on the severity of the problem, and may be combined with hand and finger exercises. Benefits may last even after the patient stops wearing the splint.
Corticosteroids: Corticosteroid Injections: Corticosteroids (also called steroids) reduce inflammation. If restriction of activities and the use of painkillers are unsuccessful, the doctor may inject a corticosteroid into the carpal tunnel. Some experts recommend them for patients with CTS whose symptoms are intermittent, and there is no evidence of a permanent injury. In CTS, steroid injections (such as cortisone or prednisolone) shrink the swollen tissues and relieve pressure on the nerve. Evidence strongly suggests that they offer short-term relief in a majority of CTS patients. It should be noted that the pain may increase for a day or two after the injection, and skin color may change. Unfortunately, in many cases, steroid injections provide only temporary relief (from 1 - 6 months), particularly in patients with more severe symptoms. Generally a second injection does not provide any added benefit. Another concern with use of these injections in moderate or severe disease is that nerve damage may occur even while symptoms are improving.
Low-dose use of corticosteroids may provide long-term relief, but long-term use of moderate-to-high doses can cause serious side effects, including high blood pressure and high blood sugar levels. People with diabetes should not take oral corticosteroids.
Yoga: Very limited evidence suggests that yoga practice may provide some benefit for patients with carpal tunnel syndrome. Yoga postures are designed to stretch, strengthen, and balance upper body joints.
Physical Therapy and Carpal Bone Mobilization: If symptoms subside, the patient may proceed with a supervised program of joint mobilization and hand and wrist strengthening and stretching, usually offered by physical or occupational therapists. Hand and wrist exercises may be most beneficial for patients with mild-to-moderate disease who are also treated with splints and other conservative measures. Graston Instrument-Assisted Soft-Tissue Mobilization (GISTM) and Soft-Tissue Mobilization (STM) techniques have been shown to improve nerve conduction, wrist strength, and wrist motion.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin and ibuprofen (Advil), are the most common pain relievers used for CTS. They block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Unfortunately, as with most other medications used for Syndroma Canalis Carpi, there are few well-conducted studies to determine their role in CTS. To date, there is no evidence that they offer any significant relief, and regular use can have serious side effects. Therefore, they are generally not used for long-term treatment of carpal tunnel symptoms.
Many alternative therapies are offered to sufferers of carpal tunnel syndrome and other repetitive stress disorders. Few, however, have any proven benefit. People should carefully educate themselves about how alternative therapies may interact with other medications or impact other medical conditions, and should check with their doctor before trying any of them.
Vitamin B6: Vitamin B6 (pyridoxine) is often used for carpal tunnel syndrome. Studies have not supported its benefits, however, either in oral or cream form. It should also be noted that excessively high doses of vitamin B6 can be toxic and cause nerve damage.
Acupuncture: Acupuncture may be beneficial. New techniques employing painless laser acupuncture may prove to be particularly effective. The National Institutes of Health issued a Consensus Statement on Acupuncture in 1997, which declared this ancient form of treatment useful as a supplement to standard treatment or even as part of a comprehensive management program for CTS.
Chiropractic Therapies: Chiropractic techniques have been useful for some people whose condition is produced by pinched nerves. There is little evidence, however, to support its use for carpal tunnel syndrome.
Magnets: Magnets are a popular but unproven therapy for pain relief. One small study of patients who wore magnets attached to their wrists showed no benefits over those who wore a nonmagnetic placebo (sham) device, although both groups did experience pain relief, perhaps due to a placebo response.
Botulinum toxin type A: Intracarpal injections of botulinum toxin type A (Botox) has not been well studied. One very small trial found it no better than placebo.
Ice and Warmth: Ice may provide benefit for acute pain. Some patients have reported that alternating warm and cold soaks have been beneficial. (If hot applications relieve pain, most likely the problem is not caused by CTS but by another condition producing similar symptoms.)
Low-Level Laser Therapy: Some investigators are working with low-level laser therapy (LLLT), which generates extremely pure light in a single wavelength. The procedure is painless. Two trials comparing laser therapy to conservative treatment or a placebo laser treatment from no real benefit for this therapy.
Open Release Surgery: Traditionally, surgery for CTS entails an open surgical procedure performed in an outpatient facility. In this procedure, the carpal ligament is cut free (released) from the median nerve. The pressure on the median nerve is therefore relieved. The surgery is straightforward.
The Mini-Open Approach: In recent years, more surgeons have adopted a "mini" open -- also called short-incision -- procedure. This surgery requires only a one-inch incision, but it still allows a direct view of the area (unlike endoscopy, which is viewed on a monitor). The mini-open approach may allow for quicker recovery while avoiding some of the complications of endoscopy, although few studies have investigated its benefits and risks. The recovery time in patients receiving the mini-open approach may be shorter than with the open approach, and results are generally the same.
Endoscopy: Endoscopy for Syndroma Canalis Carpi is a less invasive procedure than standard open release.
The surgeon then inserts a tiny camera and a knife through the lighted tubes.
While observing the underside of the carpal ligament on a screen, the surgeon cuts the ligament to free the compressed median nerve.
A surgeon makes one or two 1/2-inch incisions in the wrist and palm, and inserts one or two endoscopes (pencil-thin tubes).
Complications after surgery may include the following:
Nerve damage with tingling and numbness (usually temporary)
Medicine and medications:
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used medicines for carpal tunnel syndrome. NSAIDs relieve pain and inflammation and are available with or without a prescription. But a review of research suggests that NSAID treatment for 2 and 4 weeks may not improve carpal tunnel symptoms. NSAIDs may be most effective if the tendon is inflamed. Although studies have not shown NSAIDs to be effective for carpal tunnel syndrome, they may help relieve your symptoms.
Corticosteroids may be an effective treatment option when NSAIDs do not effectively relieve pain and inflammation, but corticosteroids are powerful anti-inflammatory medicines and have side effects that should be considered. Corticosteroids can be taken in pill form or injected into the wrist by a doctor.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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