managment

1. Dr. Muhammad Mamun Ur Rashid
MBBS, DA, FCPS(Anesthesiology)
Consultant, Pain clinic
Dhaka medical college hospital,Dhaka.
Carpal tannel syndrome

2. Introduction
 Carpal tunnel is the most common focal
compression neuropathy.It results from
compression of the median nerve at the wrist.
This syndrome affects 3% of adult Americans and
is about three times more common in women
than in men.

3. Prevalence
 It is extremely common in diabetic patients with
neuropathy, where its prevalence increases to
almost 40%..
 Other medical causes include acromegaly,
rheumatoid arthritis, renal failure,hypothyroidism,
and amyloidosis.

4. Pathophysiology
 The cause of carpal tunnel syndrome has been
linked to work-related repetitive wrist activity,
although the validity of this relationship continues
to be challenged.

5. Clinical Features
 Classic symptoms of carpal tunnel syndrome are
pain,numbness, and paresthesias in the
distribution of the median nerve, although
numbness of the entire hand may be a more
common initial clinical complain.
 Symptoms usually are worse at night and as the
compression becomes more severe can awaken
patients from sleep on a nightly basis.

6. Clinical Features
 These patients often exhibit a tendency to flick
their wrist as if they were shaking a thermometer
in an attempt to relieve the painful paresthesias
(“flick sign”).

7. Examinations
 Tinel's sign: The patient is asked to place the
palm upward and the examiner brings the
affected hand into full dorsiflexed position to
compress the carpal tunnel with flexor
retinaculum. The examiner then percusses the
median nerve using the broad side of a hammer.
The sign is positive if the patient perceives the
paresthesia in thumb, index and middle fingers.

8. Examinations
 Phalen's test: The patient is asked to allow the
wrist to hang downward in a fully but not forced
palmar flexed position for a minimum of 30
seconds. The Phalen's test is positive if the
patient's symptoms are reproduced .

9. Investigation
 NCV: Diminished sensation in a median
distribution and weak thumb abduction are far
more strongly correlated with abnormal NCV
studies. Regarding NCV studies, although they
are recognized as a diagnostic gold standard for
carpal tunnel syndrome, 25%of patients with
positive clinical histories and examinations for
carpal tunnel syndrome can have normal NCV
studies.

10. Investigation
 These studies essentially assess demyelinization
and axonal loss by determining conduction
velocities, distal latencies, and response
amplitude.The largest diameter axons of the
motor or sensory nerve disproportionately
contribute to these measurements.The
conduction velocity of a nerve is the conduction
velocity of the fastest fibers .

11. Investigation
 If in some patients with carpal tunnel syndrome
the smaller diameter axons in the median nerve
were preferentially compressed, but the larger
diameter axons were spared, it is understandable
that clinically they may complain of significant
entrapment, but have normal median sensory and
motor nerve conduction results. In the end, carpal
tunnel syndrome remains a clinical diagnosis.

12. Investigation
 Carpal tunnel syndrome remains a clinical
diagnosis that is frequently supported by
electrodiagnostic studies. Despite reported
advances in ultrasound and MRI evaluation of the
carpal tunnel, these modalities remain unproven
adjuncts to the clinical examination.
 Although many asymptomatic individuals can
have abnormal NCV suggestive of median
neuropathy at the wrist. Equally important to note
is that surgery may be effective in patients with
clinical symptoms who have normal NCV studies.

13. Treatment
 Although carpal tunnel surgery is effective, it is
performed too often and often prematurely. the
decision regarding surgery should be based on
significant symptoms that do not respond to
conservative measures, including splinting and
local combined injections of a corticosteroid and
anesthetic into the carpal tunnel.
 If these patients are followed,many improve with
or without treatment.

14.  Persistent wrist pain, nocturnal awakening
associated with the flick sign,and thenar muscle
weakness or atrophy are the best indicators of
the need for surgery.