DR G AVINASH RAO

FELLOW HAND AND

MICROSURGERY

CARPAL TUNNEL
SKIMS

SYNDROME
INTRODUCTION
 Carpal tunnel syndrome– most common
compressive neuropathy of upper extremity.
 Symptoms of median nerve compression– were
first described with distal radius fractures by Sir
James Paget in 1854.
 The term carpal tunnel--- coined—Mersch
8 decades later.
Anatomy
 Carpal tunnel is bordered dorsally by concave arch
of carpus & volarly by transverse carpal ligament
(TCL).
 10 structures pass--- 9 flexor tendons & median
nerve.
 Median nerve is most superficial structure, entering
just radial to midline.
Recurrent motor branch.
 It usually originates in extraligamentous position
distal to TCL.
  Extraligamentous (46%)
  Subligamentous (31%)
  Transligamentous(23%)
The PALMAR CUTANEOUS BRANCH OF THE MEDIAN
NERVE lies between the FCR and PL tendons in the distal
forearm, but its branches may be found upto 6mm ulnar to the
thenar crease in the palm.
ETIOLOGY
Idiopathic
Women > men (2-3:1)
Age – 30-60 (MC)

Use of vibrating hand tools, smokers,

High body mass index (BMI) – obesity.
Wrist ratio – If the anterior to posterior distance is ≥70% of the
medial to lateral distance, there is a significant association with
idiopathic CTS.
Pregnant women – Symptoms relieve after Delivery,
Children – Rare (macrodactyly, lysosomal storage disorders, strong
family history – predisposes).
 Trauma caused by repetitive hand motions
especially in works requiring repeatetive forceful
finger and wrist flexion and extension.
 Habitual sleeping posture in which the wrist is
kept actely flexed.
FACTORS INVOLVED IN PATHOGENESIS
OF CTS. Kerwin G, Williams CS, Seiler JG: The pathophysiology of carpal
tunnel syndrome, Hand Clin 12:243, 1996.
Pathogenesis
 Median nerve is susceptible to compression within
carpal canal because of unyielding fibro osseous
borders.
 Normal pressure--- 2.5mm Hg.
 Elevation of carpal tunnel pressures impedes
epineurial blood flow, and nerve function is
impaired
 A decrease in epineural blood flow & edematous
changes occur--- pressure reaches 20-30 mm Hg.
 At > 30 mm Hg, nerve conduction diminishes,
continued rise--- complete nerve block.
Diagnosis of CTS
 History & physical examination are the key.
 CTS is primarily a clinical Diagnosis.
 Pain (nocturnal > day) , deep aching/throbbing
 Numbness , tingling and Paresthesia in typical median
nerve distribution.
 Daytime paresthesias– elicited with activities involving
prolonged wrist flexion/ extension.
 Shaking & Exercises--- sometimes REDUCE symptoms.
 B/L CTS - Check opposite hand for early diagnosis
 Atypical presentation– paresthesias in radial digits but
with pain radiating proximally along median nerve to
forearm, elbow sometimes shoulder.
CHRONIC CTS
 Chronic median nerve compression--- gritty or
numb sensation in fingers, grip & pinch weakness,
& diminished finger dexterity with H/o dropping
objects (Prominent Thenar wasting).
 RSD/ CRPS.
Clinical Evaluation
 Thorough physical examination--- including
cervical spine & entire upper extremities. (Double
crush phenomenon)
 Soft tissues are assessed for skin & muscle atrophy.
 Cold intolerance, dryness & unusual textures in
radial digits signify disruption of sympathetic
fibres carried by median nerve.
TINEL’S SIGN (NERVE
PERCUSSION)
Tinel’s sign
The examiner taps directly over the carpal tunnel
with his or her long and index fingers.

A positive test consists of paresthesia or pain in a

median nerve distribution.
Phalen’s test
The patient’s wrist is held in a flexed position for
upto minute or until onset of symptoms.

A positive test consists of the onset of numbness

or paraesthesia in the median nerve distribution.
Carpal tunnel compression test /
Durcan’s Test
The examiner applies direct pressure to the carpal tunnel with
his or her thumb for upto 1minute or until onset of symptoms.
A positive test consists of the onset of numbness or
paresthesia in the median nerve distribution.
More specific (90%) and more sensitive (87%) than either the
Tinel or Phalen test.
Semmes-Weinstein monofilaments
Semmes-Weinstein monofilaments
 Monofilament evaluator size was started from 2.83
to 6.65.
 2.83 – Green – Normal
 3.61 – Blue – Diminished light touch
 4.32 – Purple – Diminished protective
sensation
 4.56 – Red – Loss of protective
sensation
Two-point discrimination
 Two-point discrimination
 STATIC
• Determine minimal separation of two distinct points when
applied to palmar fingertip
• Innervation density of slow-adapting fibers
• Failure to determine separation of at least 5 mm
 DYNAMIC
• As above, with movement of the points
• Innervation density of fast-adapting fibers
• Failure to determine separation at least 4 mm

BOTH INDICATE ADVANCED NERVE DYSFUNCTION

 Katz & Stirrat hand diagram

Ryan P. Calfee, MD, Ann Marie Dale, PhD, Daniel Ryan, MS, Alexis Descatha, MD,
Alfred Franzblau, MD, Bradley Evanoff, MD
 The MOST SENSITIVE TESTS - Durkan nerve
compression, the hand diagram score, night pain,
and Semmes-Weinstein testing after a Phalen test.

 The MOST SPECIFIC TESTS were the hand

diagram and Tinel sign.
GRAHAM B’S CTS – 6
CRITERIA
 Szabo et al determined a probability of 0.86 in
correctly diagnosing CTS in presence of positive
median nerve compression test, positive hand
diagram, night pain, & abnormal Semmes-
Weinstein monofilament testing.
NCS & EMG
 It tells weather pt has the disease
 It is useful to judge severity of disease
 Prognostic value after treatment
 If NCS shows axonal loss then surgery has to be
advised.
 Diagnose incomplete release or Iatrogenic Nerve injury
 Double crush syndrome (cervical myelopathy /
pronator syndrome)
 Medicolegal issues
 If pt has obvious thenar muscle wasting.
 NCS &EMG
 According to the American Association of Electrodiagnostic
Medicine recommendations:
 Median nerve distal sensory latency, upper limit of normal –
3.6 ms
 Difference between the median and ulnar nerve distal sensory
latencies, upper limit of normal – 0.4 ms
 Distal motor latency over the thenar, upper limit of normal –
4.3 ms
 Median motor nerve conduction velocity – lower limit of
normal – 49 m/s
 Median sensory nerve conduction velocity – lower limit – 49
m/s
SONOGRAPHY
 Non invasive

 Presence of median nerve edema

 Measurements of cross-sectional area of median nerve at carpal tunnel

inlet proximally and outlet distally were taken

 The shape, size, echogenecity and relationship of median nerve to

overlying retinaculum

 Amount of synovial fluid and any presence of masses (cysts /lumps)

 Anatomy of median nerve and continuity

 Considered in reccurent cases (not routinely done)

MEASUREMENT OF CSA OF THE MEDIAN NERVE
 The cut-off value for pathological cross-sectional
area of median nerve is 9.4 mm square.

 Mild – 9.4 to 11.3

 Moderate –11.3 to 13.5

 Severe – 13.5 and above

OTHER INVETIGATIONS
 Imaging studies
Three-view radiographs of the wrist (posteroanterior,
lateral, oblique) plus carpal tunnel view: obtained when
there is antecedent wrist trauma.
MRI (diffusion tensor imaging) - not routinely used for
diagnosis. A major advantage of MRI is its high soft-tissue
contrast, which gives detailed images of bones and soft
tissues.

 Serologic studies
No blood tests specifically support diagnosis of CTS
Diabetes & Hypothyroidism are common diseases--- FBS &
Thyroid function test.
AAOS GUIDELINES – for Non Sx
Rx
 Considered in early CTS.
 Trial of conservative Rx for 2-7weeks if it fails,
attempt one more time.
 Local Sterid and splint recommended prior to
surgery
 Neurotonics – Placebo affect
 Massage / acupunture /any other conservative
options not recommended
 Kaplan, Glickel, and Eaton - five important factors in
determining the success of nonoperative treatment:

(1) age older than 50 years,

(2) duration longer than 10 months,
(3) constant paresthesia,
(4) stenosing flexor tenosynovitis,
(5) (5) a positive Phalen test result in less than 30 seconds.

0 - Two thirds of patients were cured by medical treatment

1 - 59.6% were cured.
2 - 83.3% when two factors were note
3 - 93.2% did not experience any improvement
No patient with four or five factors was cured by medical
management.
Treatment – Conservative options
 Nerve Gliding Exercises.
 Local Triamcinolone (steroid) Injection
 Night Splints.
 Strict control of medical illness
 Treatment of double crush syndrome
 contraversial
Oral medications
Diuretics, NSAIDs, oral corticosteroids & vitamin B6.--- thought to decrease
interstitial fluid pressure within carpal canal .
 Celiker et al compared the effectiveness of
NSAIDs & splinting with corticosteriods injections
in treating CTS.
 Found that both methods of treatment led to
statistically significant improvement in symptoms
at 2 months.
 Aufiero et al cited several studies supporting &
disproving the efficacy of vit B6.
 Only 2 studies were randomized & blinded in
design--- no improvement.
Corticosteroid injection
 Gelberman et al found single injection improved
CTS symptoms in 76% of pts after 6 weeks.
 However only 22 % remained symptom free at 1
year.
 Effective in mild CTS symptoms,< 1 year,normal
sensibilty testing & only minor electrodiagnostic
study abnormalities.
 Transient elevation in blood glucose can be
anticipated--- thus a less soluble corticosteroid
preparation (triamcinolone).
 Diabetic pts should be instructed to monitor their
serum glucose.
 No absolute contradiction to injection during third
trimester of uncomplicated pregnancy or healthy
breast feeding woman.
Splinting
 Immobilization of wrist at night & intermittently
during the day.
 Pressure in carpal tunnel is lowest with wrist in 2*
-/+ 9* of extension & 2* +/- 6* of ulnar deviation.
Ultrasound Therapy
 In randomized study ultrasound improved
symptoms at 2 weeks, 7 weeks, 6 months.
 However another study demonstrated no
appreciable benefit at 2 weeks from this form of
treatment.
Ergonomics
 Ergonomic changes---specialized desk chairs &
computer keyboard proved to prevent CTS.
Exercises

 Nerve & tendon gliding exercises enhance venous

blood flow & decrease pressure within carpal
tunnel.
 Rozmaryn et al evaluated 240 pts with CTS, half of
whom were instructed to perform nerve & tendon
gliding exercises.
 Patients who did not do these exercises, 71 %
eventually underwent carpal tunnel release surgery,
in other group 43% had surgery.
AAOS GUIDELINES- for Sx Rx
 Regardless of technique used – complete release of
Flexor Retinaculum is recommended
 Epineurotomy , Neurolysis, Tenosynovectomy are
not recommended in all cases
 Wrist immobilization is not required
Surgical treatment - Options
 OPEN CTS RELEASE

 MINI OPEN CTS RELEASE

 ENDOSCOPIC CTS RELEASE

- SINGLE PORTAL (AGEE)
- TWO PORTAL (CHOW)
OPEN CTS
OPEN CTS RELEASE

 The palmar incisions should be well ulnar.

 A curved incision ulnar and parallel to the thenar crease
but the palmar cutaneous branch of the median nerve
proximally may be more at risk of injury.
 Maintain longitudinal orientation so that the incision is
generally to the radial border of the ring fourth ray.
 Incise and reflect the skin and subcutaneous tissue.
 Identify the palmar fascia from the wrist flexion crease
distally and the distal forearm antebrachial fascia proximally by
subcutaneous blunt dissection.

Split the palmar fascia and expose the underlying transverse carpal
ligament and carefully divide it and avoid damage to the median nerve
and its recurrent branch

Fibers of the transverse carpal ligament can extend distally farther than
expected. The flexor retinaculum includes the distal deep fascia of the
forearm proximally, the transverse carpal ligament, and the aponeurosis
between the thenar and hypothenar muscles.

A successful carpal tunnel release usually requires division of all these

components.
MINI OPEN CTS INCISION
 Mark surgical incision with a skin pen
 The longitudinal incision - just distal to the distal wrist
flexion crease and slightly ulnar to the midline of the wrist.
 Extend Distally - 2.0 to 3.0 cm in line with the third web
space.
 Expose the transverse carpal ligament - by splitting the
parallel palmar fascia fibers and retract hypothenar fat
ulnarly.
 Intrinsic muscles obscure the midline of the TCL and can
be released from their origin and reflected away from the
underlying TCL.
 Carefully open the carpel tunnel by division of the
TCL with a no15 blade. Ensure complete release.
 The TCL divided in such a way that 3 to 4 mm of it
is left attached to the hamate hook to avoid flexor
tendon ulnar subluxation.
 Make sure the contents of the carpal tunnel are not
adherent to the undersurface of the TCL.
 Close the incision in routine fashion and apply a
compressive dressing.
Endoscopic carpal tunnel release
Problems related to endoscopic carpal tunnel release
include
(1) a technically demanding procedure;

(2) a limited visual field that prevents inspection of

other structures;
(3) The vulnerability of the median nerve, flexor

tendons, and superficial palmar arterial arch;

(4) The inability to control bleeding easily;

(5) The limitations imposed by mechanical failure.

Agee, McCarroll, and North - 10 guidelines for the
single-incision ECTR

1. Know the anatomy.

2. Never over commit to the procedure.
3. Ascertain that the equipment is working properly.
4. If scope insertion is obstructed, abort the procedure.
5. Ascertain that the blade assembly is in the carpal tunnel and
not in the Guyon canal.
6. If a clear view cannot be obtained, abort the procedure.
7. Do not explore the carpal canal with the scope
8. If the view is not normal, abort the procedure.
9. Stay in line with the ring finger.
10. When in doubt, get out.
CONTRAINDICATIONS FOR ECTR (DESCRIBED BY
CHOW)

(1) The patient requires neurolysis, tenosynovectomy,

Z-plasty of the transverse carpal ligament, or
decompression of the Guyon canal.
(2) The surgeon suspects a space-occupying lesion or
other severe abnormality of the muscles, tendons,
or vessels in the carpal tunnel.
(3) The patient has localized infection or severe hand
edema, or the vascular status of the upper
extremities is tenuous.
Fischer and Hastings further added

(1) Revision surgery for unresolved or recurrent carpal

tunnel syndrome
(2) Anatomic variation in the median nerve.
(3) Previous tendon surgery or flexor injury that would
cause scarring in the carpal tunnel.
(4) Limitation of wrist extension is (endoscopic
instruments cannot be introduced into the carpal
tunnel).

AS CONTRAINDICATIONS FOR ECTR.

AZEE TECHNIQUE
AZEE
CHOW TECHNIQUE
Open vs endoscopic
 Open vs endoscopic
Endoscopic– shorten recovery time
 However no substantial differences in final outcome.

 One study in 25 pts, one hand open & another

endoscopic was done.

 3 months later, no significant differences

 With ECTR - Less palmar scarring and ulnar “pillar”

pain, rapid and complete return of strength, and

return to work and activities at least 2 weeks sooner
than for open release.
Post-OP Rehabilitation
 Wrist immobilisation after carpal tunnel surgery---
no benefit in pain relief or surgical outcome.

 Active motion exercises of wrist & fingers are to be

encouraged.
SURGICAL COMPLICATIONS
 Median nerve injury.
 Hypertrophic scar formation.
 Pillar pain.
 Injury to superficial arterial arch.
 Incomplete release of TCL.
 Tendon adhesions.
 Infections.
 Wound hematoma.
 Finger stiffness.
 Recurrence.
ECTR COMPLICATIONS
 Intraoperative injury to flexor tendons.
 Injury to median, ulnar, and digital nerves.
 Injury to superficial palmar arterial arch.

Need to exercise great care and caution when

performing the endoscopic procedure.
Considerations before Sx
 Young pt with symptoms of CTS and decreased grip
stength consider – CTS release + Flexor
Tenosynovectomy.
 If symptoms persists in previously operated case (tingling
and Paresthesia with Tinels positive) – Consider
sonography - incomplete release / Neuroma in continuity
formation 20 to iatrogenic injury
 Elderly with chronic CTS and thenar wasting and
inability to do finer activities – consider CTS with
Tendon Transfer for thumb opposition (opponensplasty)
UNCOMMON – REQUIRE ATTENTION

BE AWARE OF POTENTIAL ANOMALIES:

 connections between the FPL and the index FDP
tendon;
 anomalousFDS;PL, hypothenar, lumbrical muscle
bellies;
 median and ulnar nerve branches and
interconnections.
 RARE – BIFID MEDIAN NERVE
Summary
 CTS– common problem.
 Several risk factor are associated.
 Thorough history & physical examination is the key.
 Non-surgical & surgical techniques are beneficial.
 Both open & endoscopic have same results.

 Look for S/O CRPS (RSD) in Chronic cases,

Before surgery.