Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

This is probably the most common hand condition that we see in our clinics, yet still remains controversial. At present the Scottish Government is auditing the management of this condition in all hospitals in Scotland. This means just like the Scottish Hip Fracture Audit, which improved time to theatre and management of hip fractures, hopefully the long delays in diagnosis and management will be resolved.

One of the biggest problems is waiting times for Nerve Conduction Studies. Throughout Scotland this does vary, with some trust coping much better than others. One of Greater Glasgow and Clyde’s biggest problems is that the majority of NCS are performed at the Southern General, and obviously the department is under great pressure. Hopefully this is where the extra funding will go.

However, one of the controversial topics is whether all patients with carpal tunnel syndrome (CTS) require NCS. In patients who give a good history (night pain, tingling/numbness while gripping), and has strong clinical findings such as a positive Tinnel’s test, positive Phalen’s test, altered 2-point discrimination over the median nerve distribution and muscle wasting of the thenar eminence, NCS are probably not required. It tends to be in patients who have mixed signs and a poor history, or a history of systemic disease such as diabetes, where they are of most benefit. However it is possible for them to have false negative results. One other test or treatment which can aid our diagnosis is response to steroid injection. A good response or resolution of symptoms is very helpful.

Current Surgical Practice:

The choices of surgery for CTS include:

• Open decompression
  A 4 cm incision at the base of the palm, not crossing the wrist crease
• Extended open decompression
  As above but extending proximally across the wrist crease. This is usually used in difficult cases or revisions.
• Mini open / mid palmar technique
  A 2 cm in the mid palm, in which dissection is performed proximally down the carpal tunnel. This technique was developed to avoid an incision over the base of the palm, as it it can be quite sensitive. It was also thought that pillar pain (pain on pressing palm, e.g. When rising from a seat) would be less. Overall the complications are higher and the resultant benefits are variable. Very few surgeons perform or undertake this procedure.
• Endoscopic
  This technique has comparable results to the standard open technique, although some surgeons would argue patients recover faster over the first 2 months. The disadvantage is it takes more time to learn, requires more expensive equipment and usually takes more time to perform. There are few surgeons undertaking this procedure. The wound is 1 -2 cm within the palm.

Complications:

• Infection: < 1%
• Nerve Injury < 1%
• CRPS: Variable figures published but can be as high as 25% (mean 5%)
• Recurrence up to 10% in patients lifetime, but few require further operation.