Carpal Tunnel Syndrome JAAOS 2007 PDF

Carpal Tunnel Syndrome
C. Sabin Cranford, MD
Jason Y. Ho, MD
David M. Kalainov, MD
Brian J. Hartigan, MD
Abstract
Carpal tunnel syndrome is the most common compressive
neuropathy of the upper extremity. As a result of median nerve
compression, the patient reports pain, weakness, and paresthesias
in the hand and digits. The etiology of this condition is
multifactorial; anatomic, systemic, and occupational factors have
all been implicated. The diagnosis is based on the patient history
and physical examination and is confirmed by electrodiagnostic
testing. Treatment methods range from observation and splinting,
to cortisone injection and splinting, to surgical intervention. Both
nonsurgical and surgical management provide symptom relief in
most patients. The results of open and endoscopic surgery
essentially are equivalent at 3 months; the superiority of one
technique over the other has yet to be established.
Dr. Cranford is Orthopaedic Resident,

Northwestern Memorial Hospital,
Chicago, IL. Dr. Ho is Orthopaedic
Resident, Northwestern Memorial
Hospital. Dr. Kalainov is Attending
Surgeon, Northwestern Memorial
Hospital. Dr. Hartigan is Attending
Surgeon, Northwestern Memorial
Hospital.
None of the following authors or the
department with which they are affiliated
has received anything of value from or
owns stock in a commercial company or
institution related directly or indirectly to
the subject of this article: Dr. Cranford,
Dr. Ho, Dr. Kalainov, and Dr. Hartigan.
Reprint requests: Dr. Hartigan,
Northwestern Memorial Hospital, Suite
450, 676 N St. Clair Street, Suite 450,
Chicago, IL 60611.
J Am Acad Orthop Surg 2007;15:537548
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.
Volume 15, Number 9, September 2007
ymptoms of median nerve compression at the wrist were first

described in patients with distal
radius fractures by Sir James Paget
in 1854.1 The term carpal tunnel
syndrome (CTS) was coined by
Moersch2 8 decades later, and wide
recognition of the condition was
achieved in the 1950s because of the
work of Phalen.3 Today, CTS is well
recognized by health care workers
and the population at large because
of its significant health consequences and economic impact. In the
United States, region-specific incidences of 0.99 and 3.46 cases of CTS
per 100,000 person-years have been
reported.4 Approximately 500,000
surgical procedures are performed
each year, and the economic impact
of this condition is estimated to exceed $2 billion annually.5
Anatomy and
Pathophysiology
The carpal tunnel is bordered dorsally by the concave arch of the carpus and volarly by the transverse car-
pal ligament (TCL), with a variable

depth of 10 to 13 mm.6 Ten structures from the volar forearm pass
through the carpal tunnelnine
flexor tendons and the median nerve
(Figure 1). The median nerve is the
most superficial structure within the
canal, entering the space in the midline or just radial to the midline.
The median nerve may divide in
the forearm or split within the carpal
tunnel. Both conditions are associated with a persistent median artery.
The thenar motor branch of the median nerve usually originates in an
extraligamentous position distal to
the TCL. Less commonly, the motor
branch projects from beneath the
TCL (subligamentous) or perforates
through the TCL (transligamentous).7
The median nerve is susceptible
to compression within the carpal canal because of the unyielding fibroosseous borders.8 Normal pressure
within the carpal tunnel measures
2.5 mm Hg.9 A decrease in epineural
blood flow and edematous changes
occur when the pressure reaches 20
to 30 mm Hg. At pressures >30 mm
537
Anatomic
Anomalies such as a persistent
median artery, infection, ganglion
cyst, or tumor can occupy space
within the carpal canal and increase
interstitial fluid pressure.15 Trauma
may result in canal volume restriction from edema, hemorrhage, distortion of anatomy, and/or scar formation.11 The end-pathway in all
cases is similar: compression of the
median nerve.
Figure 1
pathogenesis of CTS is outlined in

Table 1.
Systemic
CTS can be associated with a
number of medical conditions, including obesity, drug toxicity, alcoholism, diabetes, hypothyroidism,
rheumatoid arthritis, primary amyloidosis, and renal failure.12,15 Rheumatoid arthritis and renal failure
may lead to an increase in pressure
within the carpal tunnel secondary
to pannus formation and amyloid
deposition, respectively. Drug toxicity, diabetes, and alcoholism may
have direct injurious effects on the
median nerve.
CTS can occur during pregnancy,
with a reported incidence of 20% to
45%.16 Symptoms typically develop
during the third trimester, vary in
severity, and abate postpartum with
nonsurgical management. The etiology of gestational CTS remains uncertain, but symptom onset is conceivably related to fluid retention.
Idiopathic
Most cases of CTS do not have an
identifiable etiology. Women are
more commonly affected than men,
and incidence increases with age.12,13
The histologic appearance of tenosynovial tissue in idiopathic cases
involves edema and fibrous hypertrophy, with minimal findings of inflammation. In a recent study of nine
patients with idiopathic CTS, a pressure guidewire system measured the
greatest compression of the median
nerve at a distance of 10 mm distal
to the distal wrist crease. This point
coincides with the thickest part of
the TCL.14
Exertional
In the workplace, CTS has been
attributed to repetitive use of the
wrist and digits, to repeated impact
on the palm, and to the operation of
vibratory tools.17-19 Extremes of wrist
flexion and extension have been
shown experimentally to elevate
pressure within the carpal tunnel.9
Finger flexion also increases the
interstitial canal pressure as the
lumbrical muscles are drawn proximally.20 Task-related factors are variable and inconsistent, however, and
the mechanisms by which they
may contribute to CTS are poorly
defined.19 A direct relationship be-
Carpal tunnel enclosing the median nerve and nine flexor tendons (the flexor pollicis
longus tendon, four flexor digitorum profundus tendon slips, and four flexor
digitorum superficialis tendon slips). (Reproduced with permission from DArcy C,
McGee S: Does this patient have carpal tunnel syndrome? JAMA 2000;283:
3110-3117.)
Hg, nerve conduction diminishes.10

A continued rise or a prolonged elevation in pressure may lead to a
complete median nerve block.9,10
Etiology
Acute CTS is caused by a rapid and
sustained increase in pressure within the carpal tunnel. The onset of
symptoms is sudden and may
prompt a decision for urgent surgical
decompression. Precipitating factors
producing acute CTS include wrist
trauma, infection, high-pressure injection, and hemorrhage.11 Chronic
CTS is a much more frequent condition, with the pathogenesis divided
into four categories: idiopathic, anatomic, systemic, and exertional. The
538
Journal of the American Academy of Orthopaedic Surgeons
C. Sabin Cranford, MD, et al
Table 1
Pathogenesis of Carpal Tunnel Syndrome
Idiopathic
Anatomic
Trauma
Posttraumatic swelling/hemorrhage/scar
Posttraumatic arthritis
Carpal dislocation
Distal radius malunion
High-pressure injection injury
Small carpal canal
Basal joint arthritis
Anomalous structures
Muscles
Palmaris profundus
Anomalous slip of the flexor pollicis longus
Proximal origin of a lumbrical
Reversed palmaris longus
Vascular
Persistent/thrombosed median artery
Masses/tumors
Ganglion
Lipoma
Fibroma/lipofibroma
Synovial sarcoma
Neuroma/neurofibroma/neurilemoma
Hemangioma
Systemic
Disorders affecting fluid balance
Pregnancy
Renal failure
Thyroid disease
Congestive heart failure
Obesity
Myxedema
Acromegaly
Inflammatory conditions
Rheumatoid arthritis
Lupus
Gout/pseudogout
Scleroderma
Dermatomyositis
Amyloidosis
Hemorrhagic disorders
Leukemia
Hemophilia
Anticoagulation
Neuropathic
Diabetes
Thyroid disease
Vitamin/nutritional deficiency
Vitamin toxicity
Alcoholism
Myeloma
Medication (lithium, blocker, ergot)
Infection
Constitutional factors
Advancing age
Female sex
Exertional (occupational)
Vibratory exposure
tween repetitive work activity (eg,

keyboarding) and CTS has never
been objectively demonstrated.
Diagnosis
The history and physical examination are key in making the diagnosis
of CTS. Patients with CTS report
nocturnal pain, numbness, and tingling in the thumb and one or more
radial fingers. Daytime paresthesias
are often elicited with activities involving prolonged wrist flexion and/
or extension. Shaking and wringing
of the hands may alleviate symptoms. Bilateral CTS is common,
with the condition most noticeable
in only one hand.21 An atypical presentation of CTS involves paresthesias in the radial digits but with pain
radiating proximally along the median nerve to the elbow and sometimes to the shoulder. Occasionally,
a dysesthesia can exist in the ulnar
nerve distribution that does not rule
out CTS. With chronic median
nerve compression, symptoms include a gritty or numb sensation in
the fingers, grip and pinch weakness,
and diminished finger dexterity with
a history of dropping objects. A selfcompleted Katz and Stirrat22 hand
symptom diagram can be useful in
making the correct diagnosis (Figure
2).
A thorough physical examination
including the cervical spine and entire upper extremities is warranted.
The soft tissues are assessed for skin
and muscle atrophy. Cold intolerance, dryness, and unusual textures
in the radial digits signify disruption

of the sympathetic fibers carried by
the median nerve. Active motion
measurements of the cervical spine
and all major joints in both upper extremities are obtained. Manual muscle strength testing is performed,
and grip and pinch measurements
are recorded. Spurlings maneuver is
helpful in excluding a cervical radiculopathy, particularly of the sixth
cervical nerve root, which can mimic symptoms of CTS. Percussion of
all major peripheral nerves may
point to an unsuspected area of
nerve entrapment. Deep tendon reflexes in both upper extremities are
measured, and assessment of blood
flow to each hand is completed.
Wrights hyperabduction maneuver, Adsons test, and the costocla539
Figure 2
Katz and Stirrat hand diagram. A, Classic pattern. Symptoms affect at least two of digits 1, 2, or 3. The classic pattern permits
symptoms in the fourth and fifth digits, wrist pain, and radiation of pain proximal to the wrist, but it does not allow symptoms on
the palm or dorsum of the hand. B, Probable pattern. Same symptom pattern as classic, except palmar symptoms are allowed
unless confined solely to the ulnar aspect. In the possible pattern (not shown), symptoms involve only one of digits 1, 2, or 3.
C, Unlikely pattern. No symptoms are present in digits 1, 2, or 3. (Reproduced with permission from Golding D, Rose D,
Selvarajah K: Clinical tests for carpal tunnel syndrome: An evaluation. Br J Rheumatol 1986;25:388-390.)
Table 2
Clinical Tests for Carpal Tunnel Syndrome
Test
Maneuver
Positive Results
Tinels sign
Percussion over the median Electrical shock sensation in

nerve at the wrist and
the median nerve
palm
distribution
Phalens test
Wrist flexed by gravity for

60 seconds
Numbness/tingling in the
median nerve distribution
Durkans
median nerve
compression
test
Manual pressure over the

median nerve at the
carpal tunnel for 30
seconds
Reverse Phalens Wrist and fingers actively

test
extended for 2 minutes
Tourniquet test
Hand elevation
test
Arm tourniquet inflated

above systolic pressure for median nerve distribution
60 seconds
Hand elevated above head Numbness/tingling in the
for 60 seconds
Wrist flexion
and carpal
compression
test
Elbow extended, forearm

supinated, and wrist
flexed; clinician applies
direct pressure over the
median nerve at the
carpal tunnel
Closed fist sign
Tight fist for 60 seconds
540
vicular test are occasionally useful

in diagnosing a thoracic outlet syndrome that can mimic CTS. Wrights
maneuver is conducted by abducting
and externally rotating the patients
arm and having the patient inhale
deeply. Adsons test is performed by
having the patient extend the neck,
turn the face toward the affected
side, and inhale deeply. The costoclavicular test is performed by having the patient move the shoulders
downward and backward with the
chest protruding. A positive response
for each test involves reproduction of
the patients pain symptoms, often
combined with a decrease in the radial pulse. With thoracic outlet syndrome, arm heaviness is reported
during Wrights hyperabduction maneuver and Adsons test.
Sensory testing alternatives for
CTS include innervation density
measurements using static or moving 2-point discrimination and
threshold sensory measurements
using Semmes-Weinstein monofilaments or vibrometry. Threshold sensory tests are more sensitive than innervation density measurements in
detecting early CTS.23,24 In the office

setting, most hand surgeons obtain
only static 2-point discrimination
and/or Semmes-Weinstein monofilament measurements.
Several provocative tests to diagnose CTS have been described (Table
2). Tinels sign is elicited by gently
tapping on the median nerve at the
carpal tunnel. A positive response is
noted if the patient describes an
electrical shock sensation in the median nerve distribution. Phalens test
is performed by placing the patients
elbow on an examination table and
allowing the wrist to flex for 60 seconds. If the patient reports paresthesias in the median nerve distribution, this test is considered positive.
Durkans median nerve compression
test involves direct compression of
the median nerve at the carpal tunnel for 30 seconds.25 This test is considered positive if the patient reports
numbness and/or tingling in one or
more of the radial digits.
Durkan25 reported a sensitivity of
87% and a specificity of 90% for the
median nerve compression test in detecting CTS, with even greater sensitivity (89%) and specificity (96%)
using a calibrated pressure device.
The sensitivities and specificities of
Tinels sign and Phalens test are lower.26 Szabo et al27 determined a probability of 0.86 in correctly diagnosing
CTS in the presence of a positive median nerve compression test, a positive hand diagram, night pain, and
abnormal Semmes-Weinstein monofilament testing.
Diagnostic Studies
Electrodiagnostic Testing
An electrodiagnostic study includes measurements of nerve conduction alone or in combination with
electromyography (EMG). Nerve conduction measurements are obtained
by electrically stimulating a nerve at
one point with data collection at a
separate point along the course of the
nerve. EMG involves insertion of a
needle into a muscle innervated by
the nerve under study and subsequent recording of electrical activity.

With stimulation of the median
nerve proximal to the carpal tunnel,
the distal motor latency may be measured greater than 4.5 ms. When
stimulating from distal to proximal,
the distal sensory latency may be
measured greater than 3.5 ms.28
In chronic and severe cases, EMG
demonstrates increased insertional
activity, fibrillation potentials, positive sharp waves, and/or fasciculation of the abductor pollicis brevis
muscle.
Electrodiagnostic testing is helpful in confirming the diagnosis of
CTS and in excluding other pathology (eg, cervical radiculopathy).29-31
Additionally, test results can provide
a baseline for comparison with future studies during the course of
treatment. Although uncommon,
CTS may occur in the absence of an
abnormal electrodiagnostic study,
and positive findings may be obtained in individuals without clinical symptoms of CTS.32
Imaging Studies
Baseline radiographs of the wrist
are frequently obtained during the
initial office evaluation and can be
useful in detecting unsuspected
wrist pathology. However, the importance of routine radiographic imaging of the wrist is uncertain given
the reported low yield of abnormal
findings.33 Both ultrasound and magnetic resonance imaging have been
reported as effective diagnostic tools
for CTS.34,35 The cross-sectional area
of the median nerve and the space
available for the nerve in the carpal
tunnel are measured and comparisons made to normal values. The diagnosis of CTS is primarily clinical,
however, and ancillary imaging
studies are usually not required for
this purpose.
Serologic Studies
No blood tests specifically support the diagnosis of CTS. However,
diabetes and hypothyroidism are
common diseases in the population

at large, and assessments of fasting
blood glucose and thyroid function
may be helpful in the general management of each patient. Several
medical conditions can lead to
symptoms that mimic CTS. Examples include pernicious anemia with
vitamin B12 depletion, folate deficiency, vasculitis, and fibromyalgia.
Referral to an internist, neurologist,
and/or a rheumatologist may be
helpful in situations in which the diagnosis of CTS is uncertain or when
a concomitant medical condition is
suspected.
Treatment
Management decisions rely on several factors, including the etiology
and chronicity of CTS, symptom severity, and individual patient choices. Nonsurgical treatment measures
are appropriate in the initial management of most idiopathic cases of
CTS. Splinting and corticosteroid injections may be prescribed, and they
have proven benefits.36-38 Surgical
treatment is indicated in acute cases
of CTS from trauma or infection, in
chronic cases with denervation of
the abductor pollicis brevis muscle
or a pronounced sensory loss, and in
cases unresponsive to conservative
management.
Nonsurgical
Splinting
Immobilization of the wrist at

night and intermittently during the
day has been shown to diminish reports of CTS.36,38 Pressure in the carpal tunnel is lowest with the wrist in
2 9 of extension and 2 6 of ulnar deviation.9,39,40 Prefabricated
splints typically align the wrist in
20 to 30 of extension. However,
CTS may be more effectively addressed with the wrist immobilized
in a neutral position.39
Oral Medications
Several medications have been

advocated in the treatment of CTS,
541
including diuretics, nonsteroidal

anti-inflammatory drugs (NSAIDs),
oral corticosteroids, and vitamin B6
(pyridoxine). Diuretics, NSAIDs,
and oral corticosteroids are thought
to decrease interstitial fluid pressure within the carpal canal. Vitamin B6 is a cofactor in neuronal
protein synthesis. Supplementation
with vitamin B6 may avert cofactor
deficiency associated with alterations in peripheral nerve metabolism.41
Celiker et al42 compared the effectiveness of NSAIDs and splinting
with corticosteroid injections in
treating CTS. They found that both
methods of treatment led to statistically significant improvement in
symptoms at 2 months. Chang et
al43 compared the use of NSAIDs, diuretics, oral corticosteroids, and placebo in four groups of patients with
mild to moderate CTS. In contrast
with the findings of Celiker et al,42
these authors detected no significant
symptom improvements with the
use of NSAIDs (or diuretics). However, oral corticosteroids were shown
to be effective at short-term (4
weeks) follow-up.
The initial enthusiasm for vitamin B6 supplementation has waned.
A review by Aufiero et al41 cited several studies supporting and disproving the efficacy of vitamin B6 for
treatment of CTS. Only two studies
cited by the authors were randomized and blinded in design, and both
studies detected no improvement in
CTS symptoms with administration
of vitamin B6.
Corticosteroid Injections
A corticosteroid injection can be

useful not only in nonsurgical management but also in confirming the
diagnosis of CTS as well as in predicting the results of surgery. Edgell
et al44 reported a significant (P < 0.05)
difference in the surgical success
rates between patients who obtained
some relief following an injection
(87%) and patients who experienced
no change in their symptoms (54%).
542
Gelberman et al37 found that a

single corticosteroid injection improved CTS symptoms in 76% of patients after 6 weeks. However, only
22% remained symptom-free at 1
year. An injection was determined to
be most effective in patients with
mild CTS symptoms, symptoms
present for <1 year, normal sensibility testing, and only minor electrodiagnostic study abnormalities.
Careful technique is required
when administering a carpal tunnel
corticosteroid injection to avoid injury to the median nerve and adjacent flexor tendons. Regrettably, little information is available to guide
the choice of corticosteroid preparation. A transient elevation in blood
glucose can be anticipated in patients with diabetes; thus, a less soluble corticosteroid preparation may
be considered (eg, triamcinolone
acetonide). Diabetic patients should
be instructed to monitor their serum
glucose levels closely for the first
few days because there have been
case reports of hyperglycemia following local corticosteroid injection.45
To our knowledge, there are no
absolute contraindications to administration of a cortisone injection
during the third trimester of an
uncomplicated pregnancy or in a
healthy breast-feeding woman with
a healthy infant. However, lidocaine
and corticosteroids are category B
and C drugs, respectively; therefore,
a discussion with the mothers obstetrician and/or childs pediatrician
might be prudent to obtain up-todate information and reduce the potential concerns of all involved.46
Other Modalities
Ultrasound therapy, ergonomic

modifications, nerve and tendon
gliding exercises, laser therapy, and
iontophoresis have been advocated
as adjunct and/or alternative treatment measures for CTS. In a
randomized study comparing ultrasound treatment with sham ultrasound treatment, ultrasound ther-
apy led to significantly (P < 0.05)

improved symptoms at 2 weeks, 7
weeks, and 6 months.47 However, another study demonstrated no appreciable benefit at 2 weeks from this
form of treatment.48 Ergonomic
changes at home and in the work
place can be considered for general
patient comfort and satisfaction.
Many recommended measures, however, including specially designed
desk chairs and computer keyboards,
have not been scientifically proved
to prevent or ameliorate symptoms
of CTS.49
Theoretically, nerve and tendon
gliding exercises enhance venous
blood flow and decrease pressure
within the carpal tunnel. Rozmaryn
et al50 evaluated 240 patients with
CTS, half of whom were instructed
to perform nerve and tendon gliding
exercises. In the group of patients
who did not perform these exercises,
71% eventually underwent carpal
tunnel release surgery, whereas in
the group of patients who did perform these exercises, 43% underwent surgery. Akalin et al51 conducted a prospective, randomized trial
comparing splint usage alone with
splint usage and nerve and tendon
gliding exercises. In contrast with
the findings of Rozmaryn et al,50
soft-tissue gliding exercises were
found to provide no significant benefit.
Laser therapy and iontophoresis
for treatment of CTS remain controversial. Few published data are available in the English-language literature to determine the efficacy of
either treatment modality.52,53
Surgical
Release of the TCL may be performed in an open or endoscopic
manner and under general, intravenous regional, or local infiltration
anesthesia.54
Open Carpal Tunnel Release
Open surgical release is the most

common method of carpal tunnel
decompression. The length of the
skin incision varies but typically is

<4 cm. The palmar fascia and TCL
are incised longitudinally to expose
the median nerve. The release is extended to the superficial palmar arterial arch distally and for a limited
distance proximally beneath the
wrist flexion creases. Care is taken
to avoid injury to the motor branch
and palmar cutaneous branches of
the median nerve.
Internal neurolysis, epineurotomy, and tenosynovectomy are rarely
indicated in primary open carpal
tunnel release surgery.55-57 In addition, routine reconstruction of the
TCL has not been found to be necessary to prevent bowstringing of the
flexor tendons.58
Endoscopic Carpal Tunnel
Release
Endoscopic techniques were introduced to address problems occasionally encountered with open carpal tunnel release surgeryscar
tenderness, pillar pain, and protracted time away from work. Popular approaches include the single
portal technique reported by Agee et
al59 and the dual portal technique
devised by Chow.60 In the Agee single-portal endoscopic technique, a
small transverse skin incision is
made at the ulnar border of the
palamaris longus tendon, that is,
midway between the flexor carpi radialis and flexor carpi ulnaris tendons, proximal to the wrist flexion
creases. A distally based flap of forearm fascia is elevated to expose the
proximal end of the carpal canal.
With the wrist held in slight extension, the endoscopic blade assembly
is inserted into the canal, making
sure that the blade is aligned with
the axis of the ring finger. The distal
edge of the transverse carpal ligament is identified, and the ligament
is sectioned distally to proximally.
The dual portal technique requires a
proximal incision and a distal incision deep to the TCL (Figure 3). Recognized learning curves are associated with each technique as well as
known surgical contraindications,

including wrist stiffness, proliferative synovitis, and tumorous infiltration into the canal.61
Limited Open Carpal Tunnel
Release
Limited-incision carpal tunnel release techniques similar to endoscopic surgery were developed to decrease palmar discomfort and hasten
the return to activities.62,63 A variety
of instruments has been designed for
these purposes. The surgical approach involves a small skin incision in the palm followed by release
of the distal end of the TCL under direct visualization. The proximal
TCL is incised in a distal-to-proximal direction using a cutting guide
(Figure 4). Attention to anatomic detail is necessary in directing the
blade because injury to the median
nerve has been reported.64 Open carpal tunnel release is recommended
over relatively blind release procedures (Figure 5).
Outcomes/Comparative
Studies
Nonsurgical Versus
Surgical Management
A recent prospective, randomized
trial comparing the efficacy of surgical decompression to local corticosteroid injection for the treatment of
CTS has challenged the notion that
surgery is more effective than nonsurgical management.65 The authors
concluded that local injection was
superior to surgery in the short term
but that surgery led to better functional improvements at 1 year. Hui
et al66 performed a similar randomized trial comparing surgery and
corticosteroid injections. Contrary
to the findings of Ly-Pen et al,65 the
surgically treated patients had greater symptomatic and neurophysiologic improvement at 5 months
compared with patients treated with
injection.
Open Versus Endoscopic

Carpal Tunnel Release
Endoscopic surgery has been
found to shorten recovery time compared with open carpal tunnel decompression, with a 2- to 3-week
earlier return to work.67-69 Nevertheless, studies have demonstrated no
substantial differences in final outcome between endoscopic and open
carpal tunnel release surgery. A recent randomized double-blind study
evaluated open and endoscopic techniques in 25 patients with bilateral
CTS.70 One hand in each patient was
treated by open carpal tunnel release
surgery; the other hand was treated
endoscopically. The outcome measurements at 3 months demonstrated no significant differences between treatment groups. However,
overall satisfaction was lower in the
endoscopic patients secondary to a
5% rate of revision surgery.
Bilateral Carpal Tunnel
Release
The potential benefits of simultaneous carpal tunnel release surgery
include decreased time away from
work and more efficient use of surgical resources.71 Retrospective studies
have shown that the costs associated
with simultaneous carpal tunnel releases are decreased and that the disability following simultaneous decompressions is no greater than with
sequential carpal tunnel decompression.72,73 These results must be interpreted with caution, however, because there are no prospective,
randomized studies comparing simultaneous with staged carpal tunnel release surgery.
Rehabilitation and
Complications
Wrist immobilization after carpal
tunnel surgery has not been shown
to confer any benefit in reference to
pain relief or surgical outcome.74-76
Active-motion exercises of the wrist
and fingers are encouraged postoperatively in nearly all patients.
543
Figure 3
Chow two-portal endoscopic technique. A, Entry portal. B, Exit portal. C, The endoscope and blade assembly are passed from
the proximal incision through the distal incision, deep to the transverse carpal ligament (TCL). D, The distal edge of the TCL
is released using a probe knife. E, A second cut is made in the midsection of the TCL with a triangular knife. F, The first and
second cuts are connected with a retrograde knife. G, The endoscope is repositioned beneath the TCL through the distal portal.
H, A probe knife is inserted to release the proximal edge of the TCL. I, A retrograde knife is inserted into the midsection of the
TCL and drawn proximally to complete the release. (Panels A, B, D, E, F, H, and I are adapted with permission from Chow JCY:
Endoscopic carpal tunnel release: Two portal technique. Hand Clin 1994;10:637-646.)
544
Figure 4
Figure 5
Incision through
transverse
carpal ligament
Hook of
Hamate
Pisiform
Limited incision technique. A, The

carpal tunnel tome is an example of
an instrument designed for a limited
incision technique. B, Through a 1.0- to
1.5-cm palmar incision, the distal edge
of the transverse carpal ligament (TCL)
is exposed and divided under direct
visualization. The wrist is held in slight
extension and the tome is positioned
into the defect with the blunt surface
deep to the TCL. Using a gentle
pushing motion, division of the TCL is
completed in a distal-to-proximal
direction (arrow). C, The angle
demonstrates that the wrist is held in
slight extension, approximately 30.
(Panel A is reproduced, and panels B
and C are adapted, with permission
from Lee WPA, Strickland JW: Safe
carpal tunnel release via a limited
palmar incision. Plast Reconstr Surg
1998;101:418-424.)
Complications have been reported with all techniques of carpal

tunnel release surgery, including but
not limited to injuries to the motor branch and palmar cutaneous
branches of the median nerve, hypertrophic scar formation, pillar
pain, laceration of the superficial
palmar arterial arch, incomplete release of the TCL, tendon adhesions,
infection, wound hematoma, finger
Flexor carpi
ulnaris
Ulnar nerve
and artery
Skin and
aponeurosis
reflected
Radius
Flexor carpi radialis
Median nerve
Flexor digitorum
superficialis
Open carpal tunnel release. The transverse carpal ligament is divided in a distal to
proximal direction near the hook of the hamate. A Carroll or Lorenz elevator may be
placed beneath the transverse carpal ligament to protect the median nerve.
(Adapted with permission from Stern SH [ed]: Key Techniques in Orthopaedic
Surgery. New York, NY: Thieme, 2001, p 84.)
stiffness, and recurrence.77 The most

common complication with open
carpal tunnel release surgery is pillar
pain, followed by laceration of the
palmar cutaneous branch of the median nerve. Pillar pain occurs in approximately 25% of surgical cases,
with symptom resolution reported
in most patients by 3 months.78 Incomplete release of the TCL with
persistent or recurrent CTS symptoms is the most frequent complication attributed to endoscopic carpal
tunnel release surgery.67-69
Recurrent CTS develops in 7% to
20% of surgical cases.79 The problem
is difficult to address, and revision
surgery is less successful than pri-
mary carpal tunnel release surgery.80 Several revision techniques

have been described, including neurolysis of the median nerve with fat
transfer, muscle transfer, and vein
wrapping.81-83 Factors that can help
to predict an unfavorable outcome
before primary carpal tunnel release
surgery include poor scores on
patient-reported measures of upper
extremity function and mental
health status, pending legal action,
and excessive alcohol intake.84
Summary
CTS is a common problem with significant economic impact. Several
545
risk factors are associated with disease development, but the primary
etiology in most cases remains unknown. A thorough history and
physical examination are key in
making the diagnosis; electrodiagnostic testing can be useful as a confirmatory study. Nonsurgical treatment (eg, splinting, oral medications,
corticosteroid injections) and surgical treatment (eg, open carpal tunnel
release, endoscopic carpal tunnel release, limited open carpal tunnel release) are both beneficial in providing
symptom relief in most patients.
The results of open and endoscopic
surgery are essentially equivalent after 3 months, and the superiority of
one technique over the other has yet
to be definitively established. Additional basic science and clinical outcome studies are needed to resolve
the many uncertainties and controversies surrounding CTS.
References
7.
8.
9.
10.
11.
12.
13.
14.
Evidence-based Medicine: The following are level I/II randomized

studies: references 36, 38, 42, 47, 52,
59, 65, 66, 68-70, 72, 75, and 76.
Citation numbers printed in bold
type indicate references published
within the past 5 years.
15.
16.
1.
2.
3.
4.
5.
6.
Paget J: Lectures on Surgical Pathology. Philadelphia, PA: Lindsay and

Blakiston, 1854.
Moersch FP: Median thenar neuritis.
Proc Staff Meet Mayo Clinic 1938;13:
220-222.
Phalen GS: Spontaneous compression
of the median nerve at the wrist.
JAMA 1951;145:1128-1132.
Nordstrom DL, DeStefano F, Vierkant
RA, Layde PM: Incidence of diagnosed
carpal tunnel syndrome in a general
population. Epidemiology 1998;9:
342-345.
Palmer DH, Hanrahan LP: Social and
economic costs of carpal tunnel surgery. Instr Course Lect 1995;44:167172.
Robbins H: Anatomical study of the
median nerve in the carpal tunnel and
etiologies of the carpal-tunnel syndrome. J Bone Joint Surg Am 1963;
45:953-966.
546
17.
18.
19.
20.
21.
Davlin LB, Aulicino PL, Bergfeld TL:

Anatomical variations of the median
nerve at the wrist. Orthop Rev 1992;
21:955-959.
Cobb TK, Bond JR, Cooney WP, Metcalf BJ: Assessment of the ratio of carpal contents to carpal tunnel volume
in patients with carpal tunnel syndrome: A preliminary report. J Hand
Surg [Am] 1997;22:635-639.
Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH:
The carpal tunnel syndrome: A study
of carpal tunnel pressures. J Bone
Joint Surg Am 1981;63:380-383.
Rydevik B, Lundborg G, Bagge U: Effects of graded compression on intraneural blood flow: An in vivo study on
rabbit tibial nerve. J Hand Surg [Am]
1981;6:3-12.
Szabo RM: Acute carpal tunnel syndrome. Hand Clin 1998;14:419-429.
Stevens JC, Beard CM, OFallon WM,
Kurland LT: Conditions associated
with carpal tunnel syndrome. Mayo
Clin Proc 1992;67:541-548.
Mondelli M, Aprile I, Ballerini M, et
al: Sex differences in carpal tunnel
syndrome: Comparison of surgical
and non-surgical populations. Eur J
Neurol 2005;12:976-983.
Ikeda K, Katsuro T, Naoki O: Segmental carpal canal pressure in patients
with carpal tunnel syndrome. Presented at the 60th Annual Meeting of
the American Society for Surgery of
the Hand, San Antonio, TX, September 22-24, 2005.
Michelsen H, Posner MA: Medical
history of carpal tunnel syndrome.
Hand Clin 2002;18:257-268.
Ekman-Ordeberg G, Slgeback S, Ordeberg G: Carpal tunnel syndrome in
pregnancy: A prospective study. Acta
Obstet Gynecol Scand 1987;66:233235.
Braun RM, Davidson K, Doehr S: Provocative testing in the diagnosis of
dynamic carpal tunnel syndrome.
J Hand Surg [Am] 1989;14:195-197.
Stromberg T, Dhlin LB, Lundborg G:
Hand problems in 100 vibrationexposed symptomatic male workers.
J Hand Surg [Br] 1996;21:315-319.
Dias JJ, Burke FD, Wildin CJ, HerasPalou C, Bradley MJ: Carpal tunnel
syndrome and work. J Hand Surg [Br]
2004;29:329-333.
Keir PJ, Bach JM, Rempel DM: Fingertip loading and carpal tunnel pressure:
Differences between pinching and a
pressing task. J Orthop Res 1998;16:
112-115.
Padua L, Padua R, Nazzaro M, Tonali
P: Incidence of bilateral symptoms in
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
carpal tunnel syndrome. J Hand Surg

[Br] 1998;23:603-606.
Katz JN, Stirrat CR: A self-administered
hand diagram for the diagnosis of carpal tunnel syndrome. J Hand Surg
[Am] 1990;15:360-363.
Gelberman RH, Szabo RM, Williamson RV, Dimick MP: Sensibility testing in peripheral-nerve compression
syndromes: An experimental study in
humans. J Bone Joint Surg Am 1983;
65:632-638.
Szabo RM, Gelberman RH, Williamson RV, Dellon AL, Yaru NC, Dimick
MP: Vibratory sensory testing in
acute peripheral nerve compression.
J Hand Surg [Am] 1984;9:104-109.
Durkan JA: A new diagnostic test for
carpal tunnel syndrome. J Bone Joint
Surg Am 1991;73:535-538.
Palumbo CF, Szabo RM: Examination
of patients for carpal tunnel syndrome: Sensibility, provocative, and
motor testing. Hand Clin 2002;18:
269-277.
Szabo RM, Slater RR, Farver TB, Stanton DB, Sharman WK: The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg [Am] 1999;24:
704-714.
Kimura J: The carpal tunnel syndrome: Localization of conduction abnormalities within the distal segment
of the median nerve. Brain 1979;102:
619-635.
Jablecki CK, Andary MT, So YT,
Wilkins DE, Williams FH: Literature
review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with
carpal tunnel syndrome: AAEM Quality Assurance Committee. Muscle
Nerve 1993;16:1392-1414.
Buch-Jaeger N, Foucher G: Correlation of clinical signs with nerve conduction tests in the diagnosis of carpal
tunnel syndrome. J Hand Surg [Br]
1994;19:720-724.
Padua L, Padua R, Lo Monaco M,
Aprile I, Tonali P: Multi-perspective
assessment of carpal tunnel syndrome: A multicenter study. Italian
CTS Study Group. Neurology 1999;
53:1654-1659.
Grundberg AB: Carpal tunnel decompression in spite of normal electromyography. J Hand Surg [Am]
1983;8:348-349.
Bindra RR, Evanoff BA, Chough LY,
Cole RJ, Chow JC, Gelberman RH:
The use of routine wrist radiography
in the evaluation of patients with carpal tunnel syndrome. J Hand Surg
[Am] 1997;22:115-119.
Altinok T, Baysal O, Karakas HM, et
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
al: Ultrasonographic assessment of

mild and moderate idiopathic carpal
tunnel syndrome. Clin Radiol 2004;
59:916-925.
Bordalo-Rodrigues M, Amin P, Rosenberg ZS: MR imaging of common entrapment neuropathies at the wrist.
Magn Reson Imaging Clin N Am
2004;12:265-279.
Manente G, Torrieri F, Di Blasio F,
Staniscia T, Romano F, Uncini A: An
innovative hand brace for carpal tunnel syndrome: A randomized controlled trial. Muscle Nerve 2001;24:
1020-1025.
Gelberman RH, Aronson D, Weisman
MH: Carpal tunnel syndrome: Results
of a prospective trial of steroid injection and splinting. J Bone Joint Surg
Am 1980;62:1181-1184.
Gerritsen AA, de Vet HC, Scholten RJ,
Bertelsmann FW, de Krom MC, Bouter LM: Splinting vs surgery in the
treatment of carpal tunnel syndrome:
A randomized controlled trial. JAMA
2002;288:1245-1251.
Burke DT, Burke MM, Stewart GW,
Cambr A: Splinting for carpal tunnel
syndrome: In search of the optimal angle. Arch Phys Med Rehabil 1994;75:
1241-1249.
Weiss ND, Gordon L, Bloom T, So Y,
Rempel DM: Position of the wrist associated with the lowest carpaltunnel pressure: Implications for
splint design. J Bone Joint Surg Am
1995;77:1695-1699.
Aufiero E, Stitik TP, Foye PM, Chen B:
Pyridoxine hydrochloride treatment
of carpal tunnel syndrome: A review.
Nutr Rev 2004;62:96-104.
Celiker R, Arslan S, Inanici F: Corticosteroid injection vs. nonsteroidal
antiinflammatory drug and splinting
in carpal tunnel syndrome. Am J
Phys Med Rehabil 2002;81:182-186.
Chang MH, Chiang HT, Lee SS, Ger
LP, Lo YK: Oral drug of choice in
carpal tunnel syndrome. Neurology
1998;51:390-393.
Edgell SE, McCabe SJ, Breidenbach
WC, LaJoie AS, Abell TD: Predicting
the outcome of carpal tunnel release.
J Hand Surg [Am] 2003;28:255-261.
Wang AA, Hutchinson DT: The effect
of corticosteroid injection for trigger
finger on blood glucose level in diabetic patients. J Hand Surg [Am] 2006;
31:979-981.
Koren G, Pastuszak A, Ito S: Drugs in
pregnancy. N Engl J Med 1998;338:
1128-1137.
Ebenbichler GR, Resch KL, Nicolakis
P, et al: Ultrasound treatment for
treating the carpal tunnel syndrome:
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
Randomized sham controlled trial.

BMJ 1998;316:731-735.
Oztas O, Turan B, Bora I, Karakaya
MK: Ultrasound therapy effect in carpal tunnel syndrome. Arch Phys Med
Rehabil 1998;79:1540-1544.
Lincoln AE, Vernick JS, Ogaitis S,
Smith GS, Mitchell CS, Agnew J: Interventions for the primary prevention of work-related carpal tunnel
syndrome. Am J Prev Med 2000;18(4
suppl):37-50.
Rozmaryn LM, Dovelle S, Rothman
ER, Gorman K, Olvey KM, Bartko JJ:
Nerve and tendon gliding exercises
and the conservative management of
carpal tunnel syndrome. J Hand Ther
1998;11:171-179.
Akalin E, El O, Peker O, et al: Treatment of carpal tunnel syndrome with
nerve and tendon gliding exercises.
Am J Phys Med Rehabil 2002;81:108113.
Irvine J, Chong SL, Amirjani N, Chan
KM: Double-blind randomized controlled trial of low-level laser therapy
in carpal tunnel syndrome. Muscle
Nerve 2004;30:182-187.
Banta CA: A prospective, nonrandomized study of iontophoresis, wrist
splinting, and antiinflammatory medication in the treatment of early-mild
carpal tunnel syndrome. J Occup
Med 1994;36:166-168.
Tomaino MM, Ulizio D, Vogt MT:
Carpal tunnel release under intravenous regional or local infiltration anaesthesia. J Hand Surg [Br] 2001;26:
67-68.
Gelberman RH, Pfeffer GB, Galbraith
RT, Szabo RM, Rydevik B, Dimick M:
Results of treatment of severe carpaltunnel syndrome without internal
neurolysis of the median nerve.
J Bone Joint Surg Am 1987;69:896903.
Leinberry CF, Hammond NL, Siegfried JW: The role of epineurotomy in
the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am
1997;79:555-557.
Shum C, Parisien M, Strauch RJ,
Rosenwasser MP: The role of flexor
tenosynovectomy in the operative
treatment of carpal tunnel syndrome.
J Bone Joint Surg Am 2002;84:221225.
Netscher D, Mosharrafa A, Lee M, et
al: Transverse carpal ligament: its effect on flexor tendon excursion, morphologic changes of the carpal canal,
and on pinch and grip strengths after
open carpal tunnel release. Plast
Reconstr Surg 1997;100:636-642.
Agee JM, McCarroll HR, Tortosa RD,
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
Berry DA, Szabo RM, Peimer CA: Endoscopic release of the carpal tunnel:
A randomized prospective multicenter study. J Hand Surg [Am] 1992;
17:987-995.
Chow JC: Endoscopic release of the
carpal ligament: A new technique for
carpal tunnel syndrome. Arthroscopy
1989;5:19-24.
Nagle DJ: Endoscopic carpal tunnel
release. Hand Clin 2002;18:307-313.
Bromley GS: Minimal-incision open
carpal tunnel decompression. J Hand
Surg [Am] 1994;19:119-120.
Lee WP, Plancher KD, Strickland JW:
Carpal tunnel release with a small
palmar incision. Hand Clin 1996;12:
271-284.
Chapman CB, Ristic S, Rosenwasser
MP: Complete median nerve transection as a complication of carpal tunnel
release with a carpal tunnel tome.
Am J Orthop 2001;30:652-653.
Ly-Pen D, Andru JL, de Blas G,
Snchez-Olaso A, Milln I: Surgical decompression versus local steroid injection in carpal tunnel syndrome: A oneyear, prospective, randomized, open,
controlled clinical trial. Arthritis
Rheum 2005;52:612-619.
Hui AC, Wong S, Leung CH, et al: A
randomized controlled trial of surgery
vs steroid injection for carpal tunnel
syndrome. Neurology 2005;64:20742078.
Thoma A, Veltri K, Haines T, Duku E:
A systematic review of reviews comparing the effectiveness of endoscopic
and open carpal tunnel decompression. Plast Reconstr Surg 2004;113:
1184-1191.
Brown RA, Gelberman RH, Seiler JG,
et al: Carpal tunnel release: A prospective, randomized assessment of open
and endoscopic methods. J Bone
Joint Surg Am 1993;75:1265-1275.
Trumble TE, Diao E, Abrams RA,
Gilbert-Anderson MM: Single-portal
endoscopic carpal tunnel release compared with open release: A prospective, randomized trial. J Bone Joint
Surg Am 2002;84:1107-1115.
Macdermid JC, Richards RS, Roth JH,
Ross DC, King GJ: Endoscopic versus
open carpal tunnel release: A randomized trial. J Hand Surg [Am] 2003;28:
475-480.
Wang AA, Hutchinson DT, Vanderhooft JE: Bilateral simultaneous open
carpal tunnel release: A prospective
study of postoperative activities of
daily living and patient satisfaction.
J Hand Surg [Am] 2003;28:845-848.
Fehringer EV, Tiedeman JJ, Dobler K,
McCarthy JA: Bilateral endoscopic
547
73.
74.
75.
76.
carpal tunnel releases: Simultaneous

versus staged operative intervention.
Arthroscopy 2002;18:316-321.
Weber RA, Boyer KM: Consecutive
versus simultaneous bilateral carpal
tunnel release. Ann Plast Surg 2005;
54:15-19.
Bhatia R, Field J, Grote J, Huma H:
Does splintage help pain after carpal
tunnel release? J Hand Surg [Br]
2000;25:150.
Finsen V, Andersen K, Russwurm H:
No advantage from splinting the wrist
after open carpal tunnel release: A
randomized study of 82 wrists. Acta
Orthop Scand 1999;70:288-292.
Cook AC, Szabo RM, Birkholz SW,
King EF: Early mobilization following
carpal tunnel release. A prospective
548
77.
78.
79.
80.
81.
randomized study. J Hand Surg [Br]

1995;20:228-230.
Braun RM, Rechnic M, Fowler E:
Complications related to carpal tunnel release. Hand Clin 2002;18:347357.
Ludlow KS, Merla JL, Cox JA, Hurst
LN: Pillar pain as a postoperative
complication of carpal tunnel release:
A review of the literature. J Hand
Ther 1997;10:277-282.
Tung TH, Mackinnon SE: Secondary
carpal tunnel surgery. Plast Reconstr
Surg 2001;107:1830-1843.
Botte MJ, von Schroeder HP, Abrams
RA, Gellman H: Recurrent carpal tunnel syndrome. Hand Clin 1996;12:
731-743.
De Smet L, Vandeputte G: Pedicled fat
flap coverage of the median nerve after failed carpal tunnel decompression. J Hand Surg [Br] 2002;27:350353.
82. Koncilia H, Kuzbari R, Worseg A,
Tschabitscher M, Holle J: The lumbrical muscle flap: Anatomic study and
clinical application. J Hand Surg
[Am] 1998;23:111-119.
83. Varitimidis SE, Riano F, Vardakas DG,
Sotereanos DG: Recurrent compressive
neuropathy of the median nerve at the
wrist: Treatment with autogenous
saphenous vein wrapping. J Hand
Surg [Br] 2000;25:271-275.
84. Katz JN, Losina E, Amick BC, Fossel
AH, Bessette L, Keller RB: Predictors
of outcomes of carpal tunnel release.
Arthritis Rheum 2001;44:1184-1193.

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Carpal Tunnel Syndrome

Dr. Cranford is Orthopaedic Resident,

Volume 15, Number 9, September 2007

ymptoms of median nerve compression at the wrist were first

pal ligament (TCL), with a variable