Nerves - Conditions
Carpal Tunnel Syndrome
Cubital Tunnel Syndrome
Carpal Tunnel Syndrome
This is a relatively common condition sometimes caused by repetitive injury to the wrist such as using a heavy vibrating tool, lengthy use of a computer keyboard, etc. Pregnancy may precipitate symptoms only to resolve upon childbirth.
Initial treatment may consist of using splints or cortisone injections. Definitive care is surgical and almost always performed as outpatient.
The abnormality lies in the ligament across the wrist which becomes hypertrophied (enlarged). This presses on the median verve which causes a "tingling" or numbness in the hand. It can cause a burning sensation and eventually even paralysis of a portion of the thumb.
Patients frequently find themselves waking up in the middle of the night having to wring their hands or shake their hands because of the "numbness". Sometimes the hand will fall asleep while driving a car. It is frequently bilateral (noted in both hands), one usually more than the other.
An EMG/NCV may be performed as outpatient. This assists in the diagnosis or confirmation of the condition. Generally this small electrical test is all that is needed to assist in confirmation of the above condition.
Surgery is comfortable, performed with local anesthesia and sedation, and fairly quick. The prognosis is almost always excellent unless the condition is extremely severe, associated with another condition such as diabetes, or in the very old.
When the diagnosis is bilateral carpal tunnel syndrome, the patient has the option of surgery on one or both hands simultaneously. Frequently the decision is made based upon the patient's type of employment.
Sometimes both hands are required in certain occupations, and then the patient may choose to have bilateral carpal tunnel release since that usually allows him to return to work sooner. (For light duty, it may be two or three weeks, for heavy duty up to six weeks). If only one side was done at a time, return to heavy work would still take about four to six weeks per side, so twice as long.
While driving is not recommended for the first 7 to 10 days after the incision (usually because of the dressing), light duty such as answering phone, using the opposite hand for writing or keyboard use is allowed the following day.
The operation is performed usually making a small incision in the palm along a palm crease and then using various instruments, and working beneath the skin the carpal ligament is severed longitudinally. Alternative endoscopic techniques can also be utilized, but they may require more than one small incision, take longer, and have the same success rate. Therefore, an open incision is usually preferred by most surgeons. Afterwards, a dressing is wrapped around the palm between the fingers and up a short distance on the wrist. The patient can use his fingers afterwards for movement but is encouraged to keep the dressing clean and especially dry. Fine sutures are usually left in 8 to 12 days and removed in the doctor's office.
Surgery and the recovery periods is almost always quite comfortable, but moderate pain medications are usually given at the time of surgery especially for the first day or two. After surgery, if the patient uses the hand to vigorously too soon, there may sometimes be tenderness about the thumb and wrist area.
The treatment for this condition remains effective in most cases, and there seldom is a need for re-operation or further surgery.
Cubital Tunnel Syndrome
This is a condition sometimes precipitated by injury about the elbow or continuous pressure in the soft tissue point just beyond the elbow which is referred to as cubital tunnel. This tunnel contains the ulnar nerve which as both motor and sensory components.
The sensory component is responsible for the majority of symptoms, causing pain and a tingling sensation about the elbow, radiating down the forearm and into the fourth and fifth digits (assuming the thumb is #1). If left untreated and the condition progresses, it can result in a “claw hand” where the muscles “wither” between the bones in the hand so that the palm appears claw-like in appearance. This implies injury to the motor portion of the nerve.
Initial management consists of avoiding those activities that aggravate the condition such as keeping the soft part of your forearm (just beyond the elbow) off the edge of a desk or car door or hard arms in a chair. More aggressive management would be surgical decompression which is usually performed with the patient under general anesthesia. And incision is made starting above the elbow and going below the ligament which is now hypertrophied (enlarged) about the nerve. When displaced anteriorly, the nerve is frequently wrapped in a small fatty blanket obtained from the patient's own tissues. After surgery, a dressing is placed, and the patient's elbow sometimes kept at 90 degrees in the dressing for about 2 to 3 days and slowly allowed to extend thereafter. Sutures are left in approximately 8 to 12 days.
Surgery can take 45 minutes to even more than an hour, but the post-operative course is usually comfortable with discomfort controlled with moderate pain medications.