Recent advances in carpal tunnel management including the use of ultrasound for carpal tunnel diagnosis and endoscopic carpal tunnel release techniques have allowed for timely diagnosis, less painful surgery and faster return to work than prior treatments.

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome (CTS) is the most common condition affecting one of the main nerves in the wrist. The carpal tunnel is a space created by the wrist bones and a thick band called the transverse carpal ligament. The nine tendons that bend the fingers, thumb and the median nerve pass through the tunnel. The median nerve provides sensation to the skin of the thumb, index and middle fingers, as well as half the ring finger, and provides innervation to the muscles at the base of the thumb (thenar muscles).

Carpal Tunnel Symptoms

The main symptom of carpal tunnel syndrome is numbness and/or tingling in the thumb, index and middle fingers, and all or half of the ring finger.

Other common symptoms can include:

• Numbness that is worse at night
• Waking up at night, having to shake hand or hold over the side of the bed
• Numbness while driving or typing
• Dropping objects
• Discomfort and swelling in the wrist, hand or fingers

If mild, the symptoms may come and go for months or even years without worsening. However, if symptoms continue to progress without treatment, the most severe cases of carpal tunnel can result in irreversible atrophy of the thenar muscles and permanent numbness in the digits.

How is Carpal Tunnel Diagnosed?

The initial diagnosis of carpal tunnel is made on the patient’s history of symptoms and physical exam. Sensation should be tested to assess the location of the patient’s numbness and if the patient has progressed to baseline numbness, which can be a sign of more advanced compression. Physical exam maneuvers such as the Phalen’s maneuver, Tinel’s test and a compression test can also be used to help guide diagnosis.

It is important to rule out other possible etiologies of numbness before finalizing the diagnosis and possible treatment of carpal tunnel. Other conditions such as cervical stenosis, compression conditions in the forearm, elbow, or shoulder, fibromyalgia and peripheral neuropathy can all mimic the symptoms of carpal tunnel and are important to rule out prior to starting treatment.

Ultrasound vs EMG/Nerve Conduction Studies

Traditionally, electromyography (EMG) and nerve conduction studies have been used to confirm the diagnosis of carpal tunnel. In recent years, imaging techniques such as ultrasonography have gained importance in the diagnosis of carpal tunnel.

In recent literature and in our own practice, we have found that ultrasound provides numerous benefits compared to traditional EMG/nerve conduction studies. These benefits include:

• Lower overall cost for the patient
• Better visualization of anatomy and nerve forms
• Increased comfort for the patient as ultrasound only involves a superficial transducer
• Reduced number of visits as ultrasound can be performed at the point of care in the specialist’s office

Data has also shown that ultrasound diagnosis has similar sensitivity and specificity as EMG/nerve conduction studies. Recent comparative studies and systematic reviews have shown sensitivity and specificity values of approximately 80% and 90% for ultrasound diagnosis of carpal tunnel. Similar studies have also started looking at ultrasound for other peripheral nerve compression such as cubital tunnel.

As a result, patients with concerns for carpal tunnel can now be sent directly to an orthopaedic hand surgeon’s office without the need for any nerve conduction studies. A point of care ultrasound can be performed in the clinic, and diagnosis and treatment options can be made during the visit without the need for more costly – and painful – nerve conduction studies.

Treatment Options

Depending on the severity and duration of symptoms, nonoperative and/or operative treatment options are considered. The goal is to achieve resolution of symptoms with the least invasive treatment as possible.

Non- Surgical Treatment

Some non-surgical treatment options may include:

• Oral anti-inflammatory medicine
• Steroid injections
• Wrist splint(s)

Oral medications and injections are more effective when symptoms are present for a short period, infrequent and mild. Wrist splinting, mainly at night, keeps the wrist out of a bent position, reducing pressure on the nerve. Splints are also more helpful when the symptoms are mild and when symptoms have been present for a shorter period. However, splints have been shown to improve, but not cure symptoms, especially when carpal tunnel is severe. It can also be useful to limit activities that bring on numbness and tingling.

Surgical Treatment: Endoscopic vs. Open Carpal Tunnel Release

Surgical release of the carpal tunnel is one of the most effective treatments. It reliably takes the pressure off the nerve immediately and can provide significant pain relief. Several approaches and techniques exist to release the transverse carpal ligament – these can be classified as either endoscopic or open release. Both techniques provide similar long-term outcomes and resolution of symptoms, but short-term benefits can be seen immediately with endoscopic techniques.

In open carpal tunnel releases (OCTR), an incision is made in the palm through which the transverse carpal ligament is identified and released. In endoscopic techniques, a small incision is made in the wrist through which a camera is introduced into the wrist and the ligament is released through the camera portal without an additional larger incision in the palm.

Recent studies have evaluated the outcomes of endoscopic versus open techniques. While long-term outcomes are similar, short-term and patient satisfaction scores have been higher with endoscopic techniques. A recent meta-analysis showed endoscopic release gave better recovery of daily life functions compared to OCTR, as revealed by higher satisfaction rates, greater pinch strengths, earlier return to work times and fewer scar-related complications.

Overall, both open and endoscopic carpal tunnel release (CTR) have demonstrated comparable long-term results, though endoscopic CTR has more of an immediate effect and allows patients to return to work the same or the next day with less pain and quicker return of grip strength. Our team of specialty trained orthopeadic hand surgeons at Wake Orthopaedics have transitioned to utilizing endoscopic carpal tunnel as our preferred technique for treating carpal tunnel, especially in those patients who value an expedited return to work.

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About G. Aman Luther, MD

Dr. G. Aman Luther is a board-certified hand and upper extremity surgeon at Wake Orthopaedics. His clinical interest includes nerve injuries and reconstruction, peripheral nerve surgery, hand and upper extremity fractures, minimally invasive surgery, ligament and tendon disorders, rheumatoid and osteoarthritis, joint replacement and pediatric hand surgery.

He completed his orthopedic surgery residency at Harvard Medical School- training at Massachusetts General Hospital, Brigham & Women’s Hospital, Boston Children’s Hospital and Beth Israel Deaconess Medical Center. He was a chief resident at Massachusetts General Hospital then went on to pursue a subspecialty fellowship in hand and upper extremity surgery at the Harvard Hand Fellowship in Boston.

Over his career Dr. Luther has published over 20 peer-reviewed papers, several book chapters, and lectured nationally and internationally on hand and upper extremity disorders. He is the recipient of numerous research and teaching awards and an active member of the American Academy of Orthopaedic Surgeons (AAOS) and American Society for Surgery of the Hand (ASSH). He currently serves on national committees focused on medical education and value-based healthcare delivery. Throughout his career, he has focused on delivering exceptional patient care by combining his interests in education, research and clinical care.