Carpal tunnel syndrome

When talking about a tunnel syndrome or wrist syndrome, refer to the carpal tunnel syndrome - a pathological contraction or nerve compression, which is responsible for the sensitivity of the palmar surface of the hand.

This disease is considered a threshold and requires compulsory treatment. Otherwise, irreversible changes in the affected nerve may occur, which in time will lead to a complete loss of palm sensitivity and some degenerative disorders.

[1], [2], [3], [4], [5], [6]

Epidemiology

As we have already said, carpal tunnel syndrome is considered a fairly common pathology. Most of the patients are women, and the incidence of men is about 10%.

The disease can begin regardless of age. Nevertheless, the majority of cases occur during the period of extinction of hormonal activity, that is, after 45 years. Among the total number of patients you can meet patients under 30 years. But, as a rule, they are 15 times smaller than older people.

[7], [8], [9], [10]

Causes of the carpal tunnel syndrome

The carpal tunnel syndrome begins to develop when there are provocative circumstances in which there is a decrease in its diameter or swelling - anything that leads to a squeezing of the nerve. For immediate reasons, you can include:

• injury to the wrist joint, followed by swelling or bruising;
• violation of the integrity of the wrist bone;
• inflammatory process in the radiocarpal joint;
• neoplasms protruding into the carpal canal;
• inflammatory process in tendons of muscular flexors;
• other causes of edema of soft tissues of the upper extremities (diabetes, hypothyroidism, etc.).

The most common reason is considered to be tenosynovitis of the flexor musculature of the wrist, which may be a consequence of physical overstrain of the hand.

[11], [12], [13]

Risk factors

Analyzing the above causes of the syndrome, you can identify the relevant risk factors:

• cardiovascular diseases;
• diseases of tendons and ligaments;
• cysts of tendon sheaths;
• calcification;
• arthritis and pseudoarthrosis;
• infectious diseases.

Among the systemic pathologies that can cause the development of the syndrome of the carpal canal, you can call diseases of the endocrine system, autoimmune diseases, polyneuropathies.

[14], [15], [16]

Pathogenesis

The median nerve is formed from the fibers of the 4 spines of the nerves of the spinal cord, which participate in a peculiar net of the brachial plexus. It extends downwards along the arm and innervates the main carpal musculature, including the muscles responsible for flexing the wrist joint and the motor capacity of the large, index and middle fingers. The compression of the median nerve leads to a worsening of blood circulation in it, or even its blockade. Ischemia of nerve fibers develops.

At the initial stage only the superficial nerve parts suffer. However, over time, the situation is aggravated and affects more deeply located tissues. As a consequence - there are cicatrical changes, which provokes pain and paresthesia of the hand and fingers.

[17], [18], [19], [20], [21],

Symptoms of the carpal tunnel syndrome

The first signs of the syndrome of the carpal canal appear as a loss of sensitivity of the fingers on the arm, often in the morning. Toward the middle of the day, sensitivity is restored.

Somewhat later, numbness spreads to all fingers, except for the little finger. In addition, there is soreness, "creepy" and a feeling of heat at the fingertips.

Pain is observed throughout the finger, not just in the joint region.

Sometimes these symptoms capture the entire hand, or even reach the elbow fold.

Unpleasant sensations can cause considerable discomfort, especially at night. As a result, insomnia can develop.

If during an attack to do an easy gymnastics of the upper extremities, then the condition temporarily improves as a result of restoration of the disturbed blood circulation.

With the progression of the syndrome of the carpal canal, more and more new symptoms appear. Patients note weakness in the hand and some impairment of coordination, they can drop objects, losing the ability to hold them with their fingers.

Every third patient with tunnel syndrome has a change in the shade of the skin: as a rule, the skin on the affected hand has a pale appearance.

In severe cases, with severe nerve congestion, numbness can seize the entire arm to the elbow, and even to the shoulder joint or neck. This condition often leads to diagnostic errors, as doctors take it for signs of cervical osteochondrosis.

[22], [23], [24]

Forms

There are several stages of development of the tunnel syndrome:

1. Pain stage, when the only sign of clamping the median nerve is pain.
2. The stage of numbness, which is characterized by the appearance of pain and numbness in the fingers.
3. The stage of motor disorders, when movements in the hand become limited and uncoordinated.
4. The stage of increasing weakness, which develops against the background of soreness, impaired sensitivity and limited movement.
5. The stage of hypotrophy, which often represents irreversible changes in tissues.

In addition, various types of carpal tunnel pathology are also defined:

• neuropathy of the radial nerve;
• syndrome of the carpal and cubital canals.

This classification is adopted for a more accurate description of the disease when diagnosed, which makes it as detailed as possible.

[25], [26]

Complications and consequences

The syndrome of the carpal canal can not be attributed to pathologies that are life-threatening to the patient. But a slow, painful process can gradually lead to a significant limitation of mobility of the affected limb. Therefore, the implementation of competent treatment is considered not only desirable, but also necessary for further full-fledged activity. Only after successful qualified therapy the syndrome forecast can be called favorable.

[27], [28], [29], [30], [31]

Diagnostics of the carpal tunnel syndrome

Collecting patient complaints, examining and probing the problem areas of the hand. The doctor discovers the lowered sensitivity of the first 3-4 fingers on the palm side. When the process is started, muscle weakness and atrophic changes in the muscle responsible for the removal of the thumb are detected.

Special testing:

• Tinnel test - simultaneously with tapping in the projection zone of the median nerve, a feeling of tingling in the fingers appears;
• Falen's test - if you bend the wrists in the wrist and raise your hands up, you can feel numbness in your fingers for one minute;
• Test vest - if the area of the forearm wear a pneumomange and pump it, the patient will feel in the fingers of the pain and signs of numbness.

Instrumental diagnostics:

• Electro neuromyography is used to visualize the partial blockade of impulse conduction through the median nerve in the carpal canal;
• X-ray method - helps to eliminate diseases of the bone system;
• the method of ultrasonic diagnostics (ultrasonography) - may indicate a thickening of Lig. Retinaculum and impairment of nerve mobility;
• method of magnetic resonance imaging - allows to detect flattening of the median nerve, which indicates its compression.

Laboratory diagnostics with carpal tunnel syndrome is practically not used, only in case of exclusion of other diseases. Such tests as UAC, OAM may indicate the presence of an inflammatory process.

[32], [33]

Differential diagnosis

Differential diagnosis is performed with compression neuropathy of other nerve endings, with osteochondrosis of the cervical region (radicular syndrome C6-C7), with transient cerebral circulation disorder, etc.

Treatment of the carpal tunnel syndrome

Patients with uncomplicated course of carpal tunnel syndrome may be prescribed drug therapy, which consists in using anti-inflammatory drugs simultaneously with fixation (immobilization) of the affected hand.

If such treatment turned out to be ineffective, then the only option could be an operation. Its essence - the dissection of the transverse wrist ligament, involved in the formation of the carpal canal. In complicated situations resort to excision of modified scar tissue adjacent to the nerve, as well as partial excision of tendon sheaths.

• Drugs that are used to treat carpal tunnel syndrome:

Corticosteroid preparations
	Disperspan	Kenalog
Dosage and route of administration	Enter into the lesion from 0.25 to 2 ml of the drug.	Enter the inside of the joint, 10-40 mg at a time.
Precautionary measures	Before the introduction of the drug, consider a possible allergy to betamethasone.	Do not use in pregnancy, diabetes, with a tendency to form blood clots and bleeding.
Side effects	Edema, allergic reaction.	Local allergic reactions.

Nonsteroidal anti-inflammatory drugs
	Ibuprofen	Acetylsalicylic acid
Dosage and route of administration	Take inside 400-800 mg three times a day.	Use inside after eating a 0.5-1 g to three to four times a day.
Precautionary measures	Do not use with stomach ulcer, colitis, hemopoiesis disorders, with a tendency to allergies.	The drug is contraindicated in case of stomach ulcer, predisposition to allergy, during pregnancy. Do not take long.
Side effects	Pain in the stomach, indigestion, headache.	Pain in the abdomen, nausea and vomiting, drowsiness, increased sweating.

To restore peripheral circulation, vascular agents such as Trental, Xanthinol, Nicotinic acid, in combination with anti-inflammatory and diuretic drugs that remove edema (Diacarb, Triampur) can be prescribed. In case of loss of sensitivity of the palms, drugs based on carbamazepine such as Tegretol are used, in the amount of 200 mg up to 3 times a day.

Early stages of the disease can be successfully treated with the introduction of novocaine into the carpal canal.

• Physiotherapeutic treatment helps to speed up the relief of the condition, eliminate soreness, numbness. Often the use of such procedures:
  • UHF - exposure to the affected area of ultra-high frequencies, which contributes to increased blood circulation;
  • CMT is an amplipulse therapy.

In addition, it is recommended to use the muscle, articular and radicular technologies of manual therapy, therapeutic physical training (we'll talk about it later), reflexotherapy.

• Treatment of carpal canal syndrome at home is possible only at an early stage of the disease. In this case, it is necessary to take anti-inflammatory drugs, and also to fix the brush for the night with a special bandage - a langette, which prevents flexion of the wrist joint. In addition, doctors advise to reduce the motor activity of the limb, especially as regards enhanced grasping movements, bending and tilting the wrist.

If the listed actions did not work, or the problem reappeared, then do not hesitate to go to the doctor.

Alternative treatment of carpal tunnel syndrome

Before embarking on an alternative treatment for the syndrome, you must carefully weigh the pros and cons. If the treatment does not have the expected effective effect, then the disease can be started, and then cure it becomes more difficult.

• The first recipe. Fill with boiling water (preferably in a thermos) 1 tbsp. L. Laurel leaf powder and 3 tbsp. L. Fenugreek. After 2 hours, the infusion is filtered and we take 100 ml 3-4 times a day.
• The second recipe. Fill 0.5 liter container with dried St. John's wort warm sunflower oil, put in a cool place for three or four weeks. After that, let the oil drain through the cheesecloth, mix the ginger powder (1 tablespoon). We got an ointment, which should be used to massage the limb and wrist.
• The third recipe. We brew in the thermos an equal number of turns, rhizomes of burdock, hop cones, birch leaves, elderberry and verbena. We insist 2-3 hours and take 100-150 ml 4 times a day.
• The fourth recipe. We dilute the white clay with warm drinking water to a mushy density. We put on a cloth or gauze, folded in several layers, and apply to the affected area. Keep the compress until the clay dries completely.

A compress based on goat milk also helps. A piece of cotton fabric or gauze is moistened in fresh goat milk and applied for 2-3 minutes to the affected area. The procedure is repeated several times a day, until the state is relieved.

[34], [35]

Operative treatment of carpal tunnel syndrome

Operative treatment is one of the most effective in tunnel syndrome. It is not used until there is a hope for a drug-solving problem. The operation is appointed only in the following cases:

• with persistent relapses of the disease;
• with neglected, or so-called "old" disease;
• with atrophic changes in muscles;
• with a significant blockade of the impulse (according to the results of electro neuromyography).

The operation is a dissection of the carpal ligament and, in some cases, excision of scar tissue (neurolisis).

Surgical intervention can be performed in an open or endoscopic way. And the one and the other option has one goal - the elimination of compression of the median nerve.

Endoscopic surgery is considered more sparing, since this method implies minimal damage to the outer tissues. Accordingly, and the scar after the operation will be almost invisible.

The advantages of open surgery are absolute access to the examination of the operation area. The doctor can carefully consider the problem and eliminate it.

As a rule, the operation is considered standard, without any complications, and lasts for 30-50 minutes. Hospitalization is not required: the patient is given a local anesthetic, and after the intervention, a plaster is applied (for about 2 weeks). The operated patient on the same day can go home, where he will independently take the doctor's prescribed treatment.

Rehabilitation after surgery

The effectiveness of the operation largely depends on the qualification of the surgeon, from the prescription of the pathological process. But also important is the post-operative care for the damaged limb. Therefore, after surgical intervention, it is necessary to adhere to such rules:

• carefully follow all the doctor's instructions;
• regularly visit a doctor for examination.

Immediately after the operation, a gypsum dressing is applied to the limb, or a special bandage is used, which allows the fingers to move, but at the same time reliably fixes the wrist joint. Approximately in 12-14 days the patient comes to remove the stitches.

Night and morning pain in the limbs should disappear within a few days after the operation. A small numbness is temporarily left: it may take a little longer to fully restore the innervation.

After the removal of the joints, the patient can already perform simple hand movements, but significant physical exertion will be prohibited for at least three months.

On the site of the incision there is a small scar: as a rule, it is hardly noticeable and does not cause inconvenience to the person.

Gymnastics with carpal tunnel syndrome

Carpal tunnel syndrome shows exercise therapy. The purpose of such gymnastics is to restore the function and mobility of the joint, to strengthen atrophied muscles.

Often medical gymnastics is combined with electrostimulation, when the patient is subjected to synchronous muscle irritation, which is performed simultaneously with their contraction.

At the first stage of treatment it is recommended to carry out such exercises:

1. Hand put on the surface of the table. Do intensive flexion and extension movements with all your fingers, and every single finger.
2. The hand rests against the surface of the table. Fix proximally located phalanx with a healthy arm, and then make intensive flexion and extension of interphalangeal joints.
3. The elbows rest on the surface of the table, the brushes are placed together, placing them up. Fold and raise their fingers, helping with a healthy hand.
4. They take the pads of the fingers to various points on the same palm.
5. They grasp fingers of various sizes from small to large.
6. Using your fingers, rotate on the table a small ball, one and the other.

Exercise is slow, with repetitions of 5 to 8 times.

In addition, they practice such exercises in a warm pool. In this case, the whole limb should be in the water up to the shoulder.

The second recovery phase consists of the following classes:

• the execution of clicks with fingers on different subjects in weight and texture (soft pads, wood, balls, etc.);
• stretching the rubber band with your fingers;
• throwing and catching a small ball;
• toss balls of different sizes.

An additional effect is the dressing of the brush at night, as well as general relief of the work process, until the function of the limb is fully restored.

Prevention

Prevention of carpal tunnel syndrome consists in moderate physical exertion, which would help to relax the hand. It is also important to consolidate and introduce some motor skills into the habit:

• keep posture;
• avoid sudden movements;
• learn to relax.

To prevent carpal syndrome should carefully plan and equip the workplace. It should be equipped in such a way that you can periodically relax your wrist and wrist joint.

The seat should be comfortable, with an anatomical backrest and handrails positioned so that the arm rested on the elbow joint, but not on the wrist.

Approximately every 45-60 minutes it is desirable to get up from the workplace, warm up, do gymnastic exercises for the hands and brushes.

If you adhere to these simple rules, it is possible to prevent the appearance of carpal tunnel syndrome.

[36], [37]