Carpal Tunnel SyndromePosted: January 2, 2012
Brandon Masi Parker discusses Carpal Tunnel Syndrome (CTS). The CTS discussion includes definition, epidemiology, pathophysiology, clinical presentation, diagnosis and treatment.
Carpal tunnel syndrome (CTS) is the most commonly diagnosed and treated nerve entrapment syndrome, affecting approximately 3-6% of the population.1 CTS can present as an acute form caused by a major trauma, or more often as a chronic condition.2 Although the etiology of CTS varies, the most common cause is repetitive stress injury to the wrist, leading to flexor tenosynovitis.3 The symptoms of CTS are caused by compression of the median nerve at the wrist, with ischemia and impaired axonal transport of the median nerve across the wrist.4 The standard first line treatment for CTS is rest, immobilization, avoiding aggravating activities and modifying physical activities, and nonsteroidal anti-inflammatory drugs (NSAIDs). Conservative treatment is effective in approximately 80% of patients but if these modalities fail, positive results ranging from 56-73% of patients treated has been seen with local anesthetics and corticosteroid injections.5 If these treatment options are unsuccessful then surgery is indicated. Studies comparing surgical versus non-surgical patients have shown symptoms improving in both groups but with surgical treatment leading to a better outcome than current nonsurgical.6 Complications among these surgical procedures are uncommon. Approximately 1-2% of patients, experience nerve, tendon, and blood vessel laceration, infection, scar tenderness, damage to the median nerve, pain, hematoma, reflex sympathetic dystrophy, and potential repeat surgery if the procedure is unsuccessful.7,8
Among the non-surgical techniques available is osteopathic manipulative treatment (OMT), which was shown to be a safe and effective method of treatment for mild to moderate CTS.9 The goal of OMT in the treatment of CTS is to stretch soft tissues, release tissue adhesions, free restricted metacarpal and carpal bones, increase range of motion, strengthen the muscles, and remove edematous fluid, resulting in improvement in circulation and nerve function.3 Sucher was able to show through MRI measurements that manipulation is capable of increasing the transverse and AP dimensions of the carpal canal. Sucher also showed improvement in nerve conduction studies within 1-3 months of manipulative treatment.9 Median sensory and motor nerve conduction studies have been shown as valid and reproducible clinical laboratory studies that confirm a clinical diagnosis of CTS with a high degree of sensitivity and specificity.10 However, Sucher’s studies were conducted with small sample sizes, with test groups ranging from 4-9 patients and a control group of 13 patients. Although multiple studies have shown the effectiveness of osteopathic manipulative medicine for CTS, future research to enhance the clinical efficacy is still warranted.3
1) Atroshi, I., et al. Prevelance of carpal tunnel syndrome in a general population. Jama 282, 153-158 (1999)
2) Naranjo A, Ojeda S, MendozaD, et al. What is the diagnositc value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome?. Clin /exp Rheumatol. Nov-Dec 2007; 25(6): 853-9.
3) Siu, G. Osteopathic Manipulative Medicine for Carpal Tunnel Syndrome. AOCPMR.
4) Lundborg G, Dahlin LB. The pathophysiology of nerve compression. Hand clin. May 1992; 8(2): 215-27
5) Dammers, J.W., Roos, Y., Veering, M.M. &Vermeulen, M. Injection with methylprednisolone in patients with carpal tunnel syndrome: a randomized double blind trial testing three different doses. J. Neurol 253, 574-577 (2006)
6) Jarvik JG, Comstock BA, Kliot M, Turner JA, Chan L, Haegerty PJ, et al. Surgery bersus non-surgical therapy for carpal tunnel syndrome: a randomized parallel-group trial. Lancet. Sep 26 2009; 374 (9695): 1074-81
7) Gerritsen, A.A., et al. Splinting vs surgery in the treatment of carpal tunnel syndrome : a randomized controlled trial. JAMA 288, 1245-1251 (2002)
8) Boeckstyns, M.E.& Sorensen, A.I. Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? An analysis of published series. J Hand surgery 24, 9-16 (1999)
9) Sucher BM. Palpatory diagnosis and manipulation management of carpal tunnel syndrome. Journal of American Osteopathic Association 1994; 94;647-663
10) Jablecki CK, AndaryMT, So YT, WilkinsDE, Williams FH. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. AAEM Queality Assurance Committee. Muscle Nerve 1994. Dec; 17 (12): 1490-1