Carpal Tunnel Syndrome

1. What it is

Carpal tunnel syndrome occurs due to the median nerve compression at the wrist. The carpal tunnel is a narrow, rigid passageway located on the palm side of your wrist. It is formed by carpal (wrist) bones at the bottom and sides, and a strong band of connective tissue called the transverse carpal ligament over the top.

The median nerve, which provides feeling to your thumb, index, middle, and ring fingers, travels through this tunnel along with nine flexor tendons. In terms of pathophysiology, any condition that decreases the space inside the tunnel or swells the tissue around the tendons can compress the median nerve, leading to the characteristic neurological symptoms.

2. Causes and Risk Factors

In many cases, carpal tunnel syndrome is idiopathic, meaning there is no single, clear cause. It is usually the result of a combination of factors that increase pressure on the median nerve. Common risk factors include:

• Anatomic factors: Being female (the carpal tunnel is naturally smaller in women) or having a wrist fracture/dislocation.
• Hormonal changes: Fluid retention during pregnancy or menopause can increase pressure within the carpal tunnel.
• Medical conditions: Diabetes, hypothyroidism, rheumatoid arthritis, and obesity are strongly associated with higher risks.
• Occupational exposure: Highly repetitive movements, prolonged use of vibrating hand tools, and extreme wrist flexion or extension. It holds high potential to be recognized as an occupational disease.

3. Symptoms

Symptoms usually start gradually and may come and go at first, eventually becoming more constant. The hallmark signs include:

• Tingling and numbness: Primarily affecting the first three fingers (thumb, index, middle) and half of the ring finger.
• Night-time awakenings: Symptoms are often much worse at night, causing individuals to wake up and feel the need to "shake out" their hands to relieve the numbness.
• Loss of strength: In advanced forms, you may experience weakness in your grip and a tendency to drop objects.
• Functional impact: Difficulty performing fine motor tasks like buttoning a shirt or handling small coins.
• Thenar wasting: In severe, chronic cases, the muscles at the base of the thumb (thenar eminence) may visibly shrink or atrophy.

4. Diagnosis

Early diagnosis is key to preventing permanent nerve damage. The diagnostic process involves:

• Clinical examination: Provocative tests such as Tinel's test (tapping over the median nerve) or Phalen's test (flexing the wrist for 60 seconds) are used to reproduce the tingling symptoms.
• EMG (Electromyography): This is the reference test to measure how well the median nerve conducts electrical signals. It confirms the diagnosis and determines the severity grading.
• Ultrasound: Used as complementary imaging to visualize the swelling of the nerve and check for anatomical anomalies (like a cyst or tumor) causing the compression.

5. Medical Treatment

When diagnosed early and symptoms are mild to moderate, conservative medical treatment is the first line of defense. Surgery is generally only considered when these methods fail or if the condition is already severe.

• Night splint: Wearing a rigid wrist splint during sleep keeps the wrist in a neutral position, relieving nerve compression and preventing night-time awakenings.
• Corticosteroid injection: Injecting a corticosteroid into the carpal tunnel decreases inflammation and swelling around the nerve. This is highly effective but limited to a maximum of 2-3 injections to prevent tendon damage.
• Anti-inflammatory medications: Oral NSAIDs can help relieve temporary pain associated with inflammation.
• Activity modification: Adjusting daily activities and making ergonomic workplace adjustments to avoid aggravating wrist positions.

6. Surgical Treatment

Surgical intervention is indicated when there is a failure of medical treatment, severe symptoms (constant numbness), or advanced forms (muscle wasting). The procedure involves releasing the transverse carpal ligament to increase the size of the tunnel and decrease pressure on the nerve.

Dr Alexandre Kilinc favors the ENDOSCOPIC minimally invasive technique. This modern approach uses a tiny camera (endoscope) inserted through a very small incision in the wrist crease to view the inside of the carpal tunnel and cut the ligament.

This surgery is performed as a day procedure under WALANT (Wide Awake Local Anesthesia No Tourniquet). This means the patient is awake, only the hand is numbed, and no painful tourniquet is applied to the arm.

Advantages of the endoscopic approach:

• A smaller, less painful incision (usually less than 1.5 cm).
• Faster functional recovery and return to work.
• Less scar tissue in the palm, reducing post-operative discomfort.

7. Recovery

Post-operative recovery varies by patient, but following an endoscopic release, the timeline is generally accelerated:

• Immediate relief: Night-time symptoms usually disappear within the first few days.
• Mobilization: Immediate, gentle finger mobilization is encouraged right after surgery to prevent stiffness and tendon adhesions.
• Symptom resolution: Long-standing tingling and numbness may take 2 to 4 months to resolve fully as the nerve slowly regenerates.
• Pillar pain: Some patients experience temporary pain at the base of the palm (pillar pain), which slowly fades over a few weeks.
• Return to activity: Return to light activities is possible within 1-2 weeks. Full recovery, including heavy lifting, may take several weeks.

Rare complications include Complex Regional Pain Syndrome (CRPS) or inadvertent nerve injury, but these risks are extremely low in the hands of an experienced surgeon.

8. When to See a Doctor

You should schedule an appointment with a hand specialist if you experience:

• Persistent tingling or numbness in your thumb, index, and middle fingers.
• Frequent night-time awakenings due to hand pain or numbness.
• Noticeable loss of grip strength or fine motor control.
• Visible muscle wasting at the base of your thumb.
• Symptoms that increasingly affect your daily activities or work performance.

Do not wait until the numbness becomes constant or the muscle atrophies, as this indicates severe nerve damage that may not fully reverse even with surgery. Book a consultation with Dr. Kilinc.

Frequently Asked Questions