Carpal Tunnel Syndrome

 Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, accounting for 90% of all neuropathies. In my experience as a physiatrist in Rome I always try to find the best therapeutic strategy based on scientific evidence and my experience in agreement with the patient. 

The carpal tunnel is a non-extensible osteofibrous canal, delimited above by the transverse carpal ligament and below by the carpal bones. Inside there are the median nerve, the tendons of the superficial and deep flexor muscles of the fingers and the tendon of the long flexor of the thumb. CTS can be divided into mild (intermittent symptoms) and moderate (constant symptoms over time). Severe CTS is characterized by the presence of sensory symptoms in addition to an atrophy of the thenar eminence of the hand.

Since the carpal tunnel is an inextensible element, anything that takes up space inside it will cause an increase in pressure and suffering of the median nerve which represents the most sensitive element. Among the main causes are cysts and arthrogenic ganglia as well as flexor tenosynovitis.

Among the intrinsic risk factors linked to CTS are obesity, age and female sex. Other intrinsic risk factors are diabetes mellitus, osteoarthritis, estrogen replacement therapy, hypothyroidism, short and broad hands and short stature. 

The symptoms are characterized by pain, tingling, numbness and reduced functionality of the wrist and palmar surface of the first 3 fingers of the hand. CTS has a gradual onset, usually nocturnal with increasingly greater involvement up to the involvement of the muscles with difficulty in grasping and fine movements.

The diagnosis of CTS is clinical and is made on the basis of signs, symptoms and specific provocation and sensitivity tests. Electromyography and ultrasound of the wrist may also be helpful in confirming the diagnosis.

Conservative management is the first approach when symptoms are mild or moderate, or when surgery is contraindicated. However, when symptoms are severe, surgery is the first line of treatment. Multimodal manual therapy may be as effective as long-term surgery in mild and moderate CTS. Among the interventional procedures there is neurolysis of the median nerve which consists in injecting medicinal substances (often saline solution and cortisone) by ultrasound-guided around the nerve in order to reduce the inflammation of the nerve and the neighboring tendon components, break the adhesions and promote mobility and flow of the nerve. Surgery is still preferable in the most serious cases.