Carpal Tunnel Syndrome

As if having one disease is bad enough, most RA sufferers also have to worry about other illnesses they have as well.  Personally, I suffer from at least 7 different ailments.  A few people very close to me suffer from Carpal Tunnel Syndrome, I know a little bit about it, but not too much. So, since I'd like to know about what my family and friends suffer from, I figured it'd be a great topic for my next blog post.

First off, the carpal tunnel is a passageway in the wrist through which nerves and the flexor muscles of the hands pass (see the photo to the left).  The tunnel consists of bones and connective tissue. Several tendons and a nerve pass through it.   The canal is narrow and when any of the nine long flexor tendons passing through it swells or degenerates, the narrowing of the canal often results in the median nerve getting entrapped or compressed, a medical condition known as carpal tunnel syndrome.

The median nerve controls the feelings of sensation on the palm side of the fingers and thumb, but not the pinky finger.  As well, it controls impulses to some small muscles in the hand that allow the fingers and thumb to move. The carpal tunnel, a narrow, rigid passageway of ligament and bones at the base of the hand, houses the median nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. The result may be pain, weakness, or numbness in the hand and wrist, radiating up the arm.

Symptoms of carpal tunnel include frequent burning, tingling, or itching numbness that occurs in the palm of the hand and fingers, especially the thumb, index and middle fingers.  These feelings start slowly, and gradually increase with time.  Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent.  It usually starts at night, in one or both hands, since most people sleep with flexed hands.  Usually the person wakes up with the need to "shake out" the hand or wrist.  As the symptoms worsen, people will feel the tingling during the day as well.  This syndrome can also cause a decreased strength in grip, which will make it difficult to form a fist, grasp small objects and even perform normal tasks.  In chronic, and untreated cases, the muscles at the base of the thumb may waste away.

Carpal Tunnel Syndrome is caused by a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself (see photo to the right).  In most cases the disorder is due to the fact that the carpal tunnel is simply smaller in some people than in others.  Other contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture; over activity of the pituitary gland; hypothyroidism; rheumatoid arthritis; mechanical problems in the wrist joint; work stress; repeated use of vibrating hand tools; fluid retention during pregnancy or menopause; or the development of a cyst or tumor in the canal. In some cases no cause can be identified.

Who is at risk for developing Carpal Tunnel Syndrome? Women are three times more likely than men to develop carpal tunnel syndrome, perhaps because the carpal tunnel itself may be smaller in women than in men. The dominant hand is usually affected first and produces the most severe pain. People with diabetes or other metabolic disorders that directly affect the body's nerves and make them more susceptible to compression are also at high risk. Carpal tunnel syndrome usually occurs only in adults.

How is Carpal Tunnel Syndrome diagnosed? First a physical examination of the hands and wrist are done to rule out any other underlying causes.  The wrist is examined for tenderness, swelling, warmth, and discoloration. Each finger should be tested for sensation, and the muscles at the base of the hand should be examined for strength and signs of atrophy. Routine laboratory tests and X-rays can reveal diabetes, arthritis, and fractures.   I also found this from a Carpal Tunnel website: "Physicians can use specific tests to try to produce the symptoms of carpal tunnel syndrome. In the Tinel test, the doctor taps on or presses on the median nerve in the patients wrist. The test is positive when tingling in the fingers or a resultant shock-like sensation occurs. The Phalen, or wrist-flexion, test involves having the patient hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together. The presence of carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute. Doctors may also ask patients to try to make a movement that brings on symptoms."

How is it treated?  Immediate treatment includes immobilizing the wrist for at least two weeks.  Avoiding activities that may further injure the wrist, and wearing a splint helps keep the wrist from moving and twisting.  Also, applying ice helps alleviate any swelling.  There is also some medications that are used to treat CTS in severe cases.  Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, and other nonprescription pain relievers, may ease symptoms that have been present for a short time.  Corticosteroids (such as prednisone) or the drug lidocaine can be injected directly into the wrist or taken by mouth (in the case of prednisone) to relieve pressure on the median nerve and provide immediate, temporary relief to persons with mild or intermittent symptoms.  Additionally, some studies show that vitamin B⁶ supplements may ease the symptoms of carpal tunnel syndrome. 

In serious cases, surgery may be required to treat the Carpal Tunnel Syndrome.  There are a couple different types of surgery.  Open release surgery, the traditional procedure used to correct carpal tunnel syndrome, consists of making an incision up to 2 inches in the wrist and then cutting the carpal ligament to enlarge the carpal tunnel. The procedure is generally done under local anesthesia on an outpatient basis, unless there are unusual medical considerations. Endoscopic surgery may allow faster functional recovery and less postoperative discomfort than traditional open release surgery. The surgeon makes two incisions (about ½" each) in the wrist and palm, inserts a camera attached to a tube, observes the tissue on a screen, and cuts the carpal ligament (the tissue that holds joints together). This two-portal endoscopic surgery, generally performed under local anesthesia, is effective and minimizes scarring and scar tenderness, if any. Single portal endoscopic surgery for carpal tunnel syndrome is also available and can result in less post-operative pain and a minimal scar.  It generally allows individuals to resume some normal activities in a short period of time.

Surgery may relieve most symptoms right away, but a full recovery from carpal tunnel surgery can take months. Since it is surgery, an open wound, normal complications after surgery could be infection, nerve damage, stiffness, and pain at the scar. Since the carpal tunnel ligament is cut, some patients may lose their strength in that wrist. Physical therapy after surgery is a must, to help restore that wrist's strength. Some patients may need to adjust job duties or even change jobs after recovery from surgery. Recurrence of carpal tunnel syndrome following treatment is rare. The majority of patients recover completely.

Since Carpal Tunnel Syndrome is a serious and debilitating disease, especially if left untreated, you should see a doctor right away if you have any symptoms of it.  I know a few people who suffer from this disease, and it has affected their lives very much so.  A friend of mine had to have surgery for her Carpal Tunnel Syndrome in both of her hands, back in 2009.  She also has RA, so to have both at such a young age, must be tough.  She is a tough cookie though, she works and is in her first year of college.  A lot to go through, but she manages well.  The key to any illness is to stay strong, and always get treatment at the first sign of any symptoms.