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Lending a Hand Lending a Hand With the Carpal With the Carpal Tunnel SyndromeTunnel Syndrome
Robert Lieberson, M.D., F.A.C.S.Robert Lieberson, M.D., F.A.C.S.Northern California Neurosurgery Medical Group, Inc.Northern California Neurosurgery Medical Group, Inc.
Specializing in Spine and Peripheral NerveSpecializing in Spine and Peripheral Nerve
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
OverviewOverviewHistoryHistoryAnatomyAnatomyPhysiologyPhysiologySymptomsSymptomsDifferential diagnosisDifferential diagnosisPhysical examinationPhysical examinationSpecial studiesSpecial studiesTreatmentTreatmentOutcomesOutcomes
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
HistoryHistory
Carpal tunnel syndrome first described by Carpal tunnel syndrome first described by Paget in 1854Paget in 1854First carpal tunnel release in 1924 by First carpal tunnel release in 1924 by Galloway and Mackinnon or in 1933 by Galloway and Mackinnon or in 1933 by LearmonthLearmonthWorld war IIWorld war II
Her majesty’s guide to the peripheral nervous Her majesty’s guide to the peripheral nervous systemsystem
U.S. And British studies describing recovery U.S. And British studies describing recovery from peripheral nerve injuriesfrom peripheral nerve injuries
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
HistoryHistory
Increase in frequency of CTS since Increase in frequency of CTS since the 1980’sthe 1980’s
50 to 150 cases per 100,000 population50 to 150 cases per 100,000 population Cause of the increase not clearCause of the increase not clear
ComputersComputers Reimbursement issuesReimbursement issues
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
PhysiologyPhysiology
Repetitive traumaRepetitive traumaTraumaTrauma
Old fractureOld fracture New fractureNew fracture DislocationDislocation Hyper-flexion or Hyper-flexion or
hyper-extension hyper-extension injuryinjury
PregnancyPregnancyDiabetesDiabetes
Renal failureRenal failure
GoutGoutMass lesionsMass lesions
Ganglion cystsGanglion cysts LipomasLipomas TumorsTumors HematomaHematoma OsteophytesOsteophytes
Generalized edemaGeneralized edema HypothyroidismHypothyroidism AcromegallyAcromegally Multiple myelomaMultiple myeloma MucolipidosesMucolipidoses MucopolysaccharidosesMucopolysaccharidoses
Hereditary predisposition to Hereditary predisposition to pressure palsiespressure palsies
Familial carpal tunnel syndromeFamilial carpal tunnel syndrome
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Anatomy: MacroAnatomy: MacroThe median nerve The median nerve is and extension of is and extension of the C6 nerve rootthe C6 nerve root
It can be It can be compressed at compressed at several locationsseveral locations
Compression at Compression at the carpal tunnel is the carpal tunnel is most commonmost common
C6 also commonC6 also common
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Anatomy: MacroAnatomy: MacroThe median nerve is The median nerve is immediately beneath the flexor immediately beneath the flexor retinaculum, superficial to the retinaculum, superficial to the tendons and above the carpal tendons and above the carpal bonesbones
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Anatomy: MicroAnatomy: Micro
Axons are wrapped by Axons are wrapped by Schwann cellsSchwann cellsEndoneurium includes the Endoneurium includes the wrapped nerves, wrapped nerves, connective tissue and connective tissue and extracellular fluidextracellular fluidPerineurium is a sheath Perineurium is a sheath the bundles fibers together the bundles fibers together into fasiclesinto fasiclesEpineurium ensheaths Epineurium ensheaths fasicles to form nervesfasicles to form nerves
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Anatomy: AbnormalAnatomy: Abnormal
The The abnormal abnormal carpal carpal tunnel is tunnel is too small too small for the for the median median nervenerve
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Anatomy: AbnormalAnatomy: Abnormal
DemyelinationDemyelination is loss of the is loss of the coverings of coverings of the nerve fiberthe nerve fiber
Axonal lossAxonal loss is is damage to the damage to the fiber itselffiber itself
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
SymptomsSymptoms
Frequently bilateralFrequently bilateralImproved by “shaking out” the Improved by “shaking out” the hands (the “flick test”)hands (the “flick test”)Worse at night, worse with Worse at night, worse with positioningpositioningParasthesias/numbness, Parasthesias/numbness, median nerve distributionmedian nerve distributionHand pain, sometimes to the Hand pain, sometimes to the shouldershoulder““Dropping things” common Dropping things” common (possibly due to numbness)(possibly due to numbness)
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Differential DiagnosisDifferential Diagnosis
Cervical radiculopathyCervical radiculopathy (C6)(C6)
Physiologic “soreness”Physiologic “soreness”
Tendonitis, focal or diffuseTendonitis, focal or diffuse
““Overuse” injuryOveruse” injury
Other focal peripheral neuropathyOther focal peripheral neuropathy
Thoracic outlet syndromeThoracic outlet syndrome
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Physical Examination: Physical Examination: “Rule In’s”“Rule In’s”
Motor, sensory and reflex examinationMotor, sensory and reflex examination Specific numbnessSpecific numbness Weakness in APBWeakness in APB No reflex changeNo reflex change
Tinel’sTinel’s sign and sign and Phalen’sPhalen’s sign sign Moderately sensitive (20% to 70%)Moderately sensitive (20% to 70%) Moderately specific (70%-83%)Moderately specific (70%-83%)
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Physical Examination: Physical Examination: “Rule Out’s”“Rule Out’s”
Motor, sensory and reflex examinationMotor, sensory and reflex examination
Spurlings testSpurlings test
Cervical muscle spasmCervical muscle spasm
Adson’s testAdson’s test
Finkelstein’s signFinkelstein’s sign
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Physical Examination: Physical Examination: “The Double Crush”“The Double Crush”
The combination of a C6 radiculopathy The combination of a C6 radiculopathy and a carpal tunnel syndromeand a carpal tunnel syndrome
Both are commonBoth are common
Both may result from similar stressesBoth may result from similar stresses
Symptoms and signs overlapSymptoms and signs overlap
EMG/NCV useful to delineateEMG/NCV useful to delineate
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Special Studies: EMG/NCVSpecial Studies: EMG/NCV
Electromyography (EMG) Electromyography (EMG) and nerve conduction and nerve conduction studies (NCV’s)studies (NCV’s)
Accurate localization of the Accurate localization of the lesion (focal peripheral lesion (focal peripheral neuropathy, not neuropathy, not radiculopathy, etc.)radiculopathy, etc.)
Determine the severityDetermine the severity Exclude non-neurologic Exclude non-neurologic
causescauses
Sensitivity of 60% to 82%, Sensitivity of 60% to 82%, specificity of 95% to 100%specificity of 95% to 100%
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Special Studies: EMG/NCVSpecial Studies: EMG/NCV
Variety of specific accepted protocolsVariety of specific accepted protocols
Generally compare the median nerve Generally compare the median nerve velocities with the ulnar or radial velocities with the ulnar or radial velocitiesvelocities
A difference in velocities is significantA difference in velocities is significant
If all nerves show delayed conduction, If all nerves show delayed conduction, consider a generalized neuropathyconsider a generalized neuropathy
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Special Studies: Special Studies: MRI ScanningMRI Scanning
First used in the mid-1980’sFirst used in the mid-1980’sCan clearly show the carpal Can clearly show the carpal tunnel syndrometunnel syndromeT2-weighted imagesT2-weighted images
Swelling of the median nerve Swelling of the median nerve proximal to the carpal tunnelproximal to the carpal tunnel
Flattening of the nerve in the Flattening of the nerve in the tunneltunnel
Bowing of the flexor retinaculumBowing of the flexor retinaculum Thickening of the tendon sheathsThickening of the tendon sheaths
Sensitivity 27% to 87%Sensitivity 27% to 87%
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Special Studies: Non-Special Studies: Non-standardstandard
Calibrated sensory testing (von Frye Calibrated sensory testing (von Frye hairs, et al.)hairs, et al.)
Two-point discriminationTwo-point discrimination
Many other “unusual tests” such as Many other “unusual tests” such as functional testing, SSEP’s and surface functional testing, SSEP’s and surface EMG’s of dubious valueEMG’s of dubious value
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
TreatmentTreatment
MildMild Blood-nerve barrier Blood-nerve barrier
breakdown, symptoms breakdown, symptoms but no signs, sensory but but no signs, sensory but notnot motor slowing by NCV motor slowing by NCV
ModerateModerate Demyelination, symptoms Demyelination, symptoms
and signs, sensory and and signs, sensory and motor slowingmotor slowing
SevereSevere Axonal loss, symptoms Axonal loss, symptoms
and signs, sensory and signs, sensory conduction blockconduction block
MildMild Workplace ergonomics, Workplace ergonomics,
task rotationtask rotation Occupational therapyOccupational therapy Nocturnal splintingNocturnal splinting
ModerateModerate Anti-inflammatory Anti-inflammatory
medicationsmedications Corticosteroid injectionsCorticosteroid injections Twenty-four hour splintingTwenty-four hour splinting
SevereSevere Surgery (open or Surgery (open or
endoscopic)endoscopic)
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Treatment: Treatment: Open SurgeryOpen Surgery
Better exposureBetter exposure
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Treatment: Endoscopic Treatment: Endoscopic SurgerySurgery
Decreased scar Decreased scar formationformationNo palmar incisionNo palmar incisionLess painLess painEarlier return to workEarlier return to workPossibly more risk of Possibly more risk of nerve injury or nerve injury or incomplete releaseincomplete releaseNo more or less costlyNo more or less costly
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Treatment: Endoscopic Treatment: Endoscopic SurgerySurgery
Higher risk of injury Higher risk of injury to the recurrent to the recurrent branchbranch
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Treatment: ControversialTreatment: Controversial
More aggressive surgeryMore aggressive surgery Lysis of the epineurium is indicated only Lysis of the epineurium is indicated only
for thinned, internally scarred nervesfor thinned, internally scarred nerves
ChiropracticChiropractic There is no demonstrated efficacy for There is no demonstrated efficacy for
adjustmentadjustment External laser therapy of no valueExternal laser therapy of no value Massage, ultrasound, heat, etc. Provide Massage, ultrasound, heat, etc. Provide
temporary comfort at besttemporary comfort at best
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
Treatment: Postoperative Treatment: Postoperative CareCare
Bulky dressingBulky dressing Delayed suture removalDelayed suture removal Physical therapyPhysical therapy Return to work in four to six weeksReturn to work in four to six weeks
The most common complication is The most common complication is recurrencerecurrence
7% to 20% depending on series7% to 20% depending on series Inadequate releaseInadequate release Recurrent scarRecurrent scar Wrong diagnosisWrong diagnosis
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
OutcomesOutcomes
Biopsychosocial model does applyBiopsychosocial model does apply ““Workers’ comp” patients are differentWorkers’ comp” patients are different
In non-compensible injuries there is In non-compensible injuries there is rarely any residual disabilityrarely any residual disability
Significant time off work uncommonSignificant time off work uncommon
No repetitive or forceful activities No repetitive or forceful activities translates into approximately a 30% translates into approximately a 30% standard in Californiastandard in California
Approximately $ 20,000 (current rates)Approximately $ 20,000 (current rates) Often off work a year or moreOften off work a year or more
Robert Lieberson, M.D.Robert Lieberson, M.D. Lending a Hand With the Lending a Hand With the Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Northern California Neurosurgery Northern California Neurosurgery Medical Group, Inc.Medical Group, Inc.
The EndThe End