Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a peripheral neuropathy caused by chronic or acute compression of the median nerve by the transverse carpal ligament. It is characterized by both sensory disturbances (pain, tingling, and numbness) and motor symptoms (weakness and clumsiness of the thumb) in the area innervated by the median nerve distal to the carpal tunnel. Several occupational and non-occupational risk factors (e.g., manual labor, age, sex, diabetes) have been associated with the syndrome. The presence of clinical symptoms and signs of CTS (e.g., the hand elevation test, carpal compression test, and Phalen test) should raise suspicion, but the diagnosis must be confirmed with specific neurological tests (e.g., EMG, ENG). Conservative management (i.e., immobilization with a splint, local steroid injections, and ultrasound therapy) may be effective in patients who only experience mild to moderate symptoms. Surgical release of the transverse carpal ligament with decompression of the median nerve is indicated in acute cases or patients with moderate to severe symptoms (atrophy of the thenar eminence).

• Most common entrapment neuropathy in the upper extremity (90% of all cases) ^[1]
• The prevalence and yearly incidence of CTS may change according to several occupational and non-occupational factors.

Epidemiological data refers to the US, unless otherwise specified.

The following risk factors are associated with CTS: ^[2]

• Previous fracture of the distal radius (most important risk factor)
• Traumatic dislocation of the lunate
• Manual work; : increased risk in workers using vibrating tools or prolonged, forceful, and repetitive flexion/extension of the wrist ^[3]
• Rheumatoid arthritis and other types of chronic inflammation of the tendon sheaths ^[2]
• Pregnancy and puerperium; : hormone-mediated weight gain and edema of the wrist can narrow the carpal tunnel ^[4]
• Obesity
• Osteoarthritis
• Systemic amyloidosis
• Renal failure; : due to dialysis-associated deposition of amyloid ^[5]
• Diabetes with peripheral polyneuropathy
• Hypothyroidism ^[6]
• Acromegaly

• The carpal tunnel is a narrow fibro-osseous structure at the level of the palmar aspect of the wrist, delimited by the carpal bones and the transverse carpal ligament, which contains flexor tendons and the median nerve.
• Pressure increase within the carpal tunnel → compression of contained structures → impaired blood flow and altered microvascular structure of the median nerve → inflammatory reaction → edema and hypoxia → axonal degeneration ^[7][8]

Mild to moderate

• Symptoms develop in the areas innervated by the median nerve: palmar surface of the thumb, index, and middle fingers, and radial half of the ring finger. ^[7][9]
  • Paresthesia: burning sensation, tingling
  • Loss of sensation/numbness
  • Pain
• Symptoms worsen at night.
• Usually, there is no loss of sensation of the palmar surface of the thenar eminence, because it is innervated by the superficial branch of the median nerve, which arises 5–7 cm proximal to the carpal tunnel and is, therefore, not compressed.

Sensory innervation of the thenar eminence is not affected in CTS.

Moderate to severe

Motor symptoms in addition to the symptoms mentioned above: ^[9]

• Weakened pinch and grip; : Patients often complain of dropping objects.
• Severe, sustained median nerve compression may lead to thenar atrophy and, subsequently, impaired thumb opposition.

The "pope's blessing" (inability to flex the first three digits when making a fist) is not a symptom of CTS. It is only seen in proximal lesions of the median nerve

Tarsal tunnel syndrome ^[10]

• Definition: peripheral neuropathy caused by chronic or acute compression of the tibial nerve by the flexor retinaculum of the foot at the medial ankle
• Etiology
  • Trauma (most common): fracture or sprain of the ankle (talus, calcaneus, medial malleolus)
  • Rheumatoid arthritis
  • Bone spurs, tumors, cysts, nerve ganglions
• Clinical features
  • Symptoms develop in areas innervated by the tibial nerve (distal to the medial malleolus):
    • Neuropathic pain and paresthesia in the heel, sole of the foot, and first three toes
    • Weakness and atrophy of intrinsic foot muscles (severe cases)
  • Symptoms worsen with walking, prolonged standing, and at night
• Diagnostics
  • Usually a clinical diagnosis
    • Positive Tinel sign: radiating paresthesia triggered by tapping the flexor retinaculum posterior to the medial malleolus
    • Pain upon foot dorsiflexion with eversion
    • Diminished sensation on the plantar area of the foot
  • Nerve conduction studies: slow conduction velocity in the medial and lateral plantar nerves
• Treatment
  • Initially conservative
    • Rest, NSAIDs, physiotherapy, use of orthotic shoes
    • Corticosteroid injection (if no improvement)
  • Surgery
    • Indications: lack of response to conservative treatment or documented entrapment of the tibial nerve
    • Procedure: Division of the flexor retinaculum of the foot to decompress the tibial nerve

Provocative tests

There is no agreement as to which provocative test should be used to support the diagnosis of CTS. Several authors suggest combining two or more provocative tests to improve the specificity of the diagnosis. ^[9][11]

• Hand elevation test: : The hand is held above the head of the patient for approx. two minutes. The test is considered positive if the symptoms of CTS (paresthesia and numbness) are reproduced. This test is easy to perform in a clinical setting and has higher sensitivity and specificity than all other tests. ^[12]
• Carpal compression test: By applying moderate compression with the finger directly over the proximal edge of the carpal tunnel, the examiner may elicit paresthesia in the median nerve distribution.
• Phalen test: The examiner actively or passively holds the patient's wrist in full flexion (90°). The test is positive if paresthesia occurs or worsens in the areas innervated by the median nerve within one minute. This finding is considered highly specific (approx. 85%) for the diagnosis of CTS.
• Tinel sign: Percussion or tapping with the fingertips over the carpal tunnel leads to shooting pain and/or tingling in the areas innervated by the median nerve.

Electrophysiological tests

• Nerve conduction studies (NCS; confirmatory test): prolongation of the distal motor and sensory latency ^[13]
• Electromyogram
  • Pattern of neurogenic disorder: abnormal spontaneous activity
  • Decreased activity, potentials with large amplitude

There is strong evidence against the use of clinical signs alone to diagnose CTS because of their questionable sensitivity and specificity. Thus, electrodiagnostic studies (particularly NCS) are essential for diagnosis.

Mild to moderate symptoms ^[14]

• Conservative treatment
  • Immobilization of the wrist with a padded, volar splint worn during the night
  • Steroid injection (e.g., triamcinolone)
  • Short-term oral glucocorticoid therapy
  • Ultrasound therapy may be considered.

Moderate to severe symptoms (or no response to conservative treatment)

• Open or endoscopic release of the transverse carpal ligament

Recurrence of CTS is rare (0.5–3%). ^[15]

We list the most important complications. The selection is not exhaustive.

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4. Ablove RH, Ablove TS. Prevalence of Carpal Tunnel Syndrome in Pregnant Women. WMJ. 2009; 108 (4): p.194-196.
5. Haddiya I, Yacoubi H, Bentata Y. Why does Carpal Tunnel Syndrome Still Occur in our Chronic Hemodialysis Patients?. Journal of Nephrology & Therapeutics. 2018; 08 (03). doi: 10.4172/2161-0959.1000310 . | Open in Read by QxMD
6. Karne SS, Bhalerao NS. Carpal Tunnel Syndrome in Hypothyroidism. J Clin Diagn Res. 2016; 10 (2): p.OC36-OC38. doi: 10.7860/JCDR/2016/16464.7316 . | Open in Read by QxMD
7. Ghasemi-rad M, Nosair E, Vegh A, Mohammadi A, Akkad A, Lesha E et al.. A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment. World J Radiol. 2014; 6 (6): p.284-300. doi: 10.4329/wjr.v6.i6.284 . | Open in Read by QxMD
8. Aroori S, Spence RAJ. Carpal tunnel syndrome. Ulster Med J. 2008 .
9. Rutkove SB. Overview of lower extremity peripheral nerve syndromes. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-lower-extremity-peripheral-nerve-syndromes?search=tarsal%20tunnel%20syndrome&source=search_result&selectedTitle=1~25&usage_type=default&display_rank=1#H450886655.Last updated: February 20, 2020. Accessed: August 3, 2020.
10. Ma H, Kim I. The Diagnostic Assessment of Hand Elevation Test in Carpal Tunnel Syndrome. J Korean Neurosurg Soc. 2012; 52 (5): p.472-475. doi: 10.3340/jkns.2012.52.5.472 . | Open in Read by QxMD
11. Ahn DS. Hand elevation: a new test for carpal tunnel syndrome. Ann Plast Surg. 2001; 46 (2): p.120-124.
12. Kohara N. [Clinical and electrophysiological findings in carpal tunnel syndrome].. Brain Nerve. 2007; 59 (11): p.1229-1138.
13. Clinical Practice Guideline On The Treatment Of Carpal Tunnel Syndrome. http://www.aaos.org/research/guidelines/CTSTreatmentGuideline.pdf. Updated: September 1, 2008. Accessed: December 23, 2016.
14. Concannon MJ, Brownfield ML, Puckett CL. The incidence of recurrence after endoscopic carpal tunnel release. Plast Reconstr Surg. 2000; 105 (5): p.1662-1665.
15. Aboong MS. Pathophysiology of carpal tunnel syndrome. Neurosciences (Riyadh). 2015; 20 (1): p.4-9.