Carpal Tunnel Syndrome

Compiled by:
Vindhita Ratiputri (1102014273)
z
Advisory Lecturer:
dr. Donny H. Hamid, Sp.S

Clinical Rotation in Department of Neurology

Pasar Rebo Province General Hospital, Jakarta
19 November 2018 – 22 Desember 2018
Faculty of Medicine, YARSI University
 ANATOMY
z
Anatomy of Brachial
Plexus z
Distribution of Median
Nerve z

In the forearm
Anterior interosseous nerve:
Supplies the deep muscles in
the anterior forearm.

Palmar cutaneous nerve: The

skin of the lateral palm
Distribution of Median
Nerve z
Motor function
In the forearm
In the hand
 Superficial layers: Pronator
 The recurrent branch: Thenar
teres, flexor carpi radialis and muscles – muscles associated with
palmaris longus movements of the thumb.
 Intermediate layer: Flexor  The palmar digital branch: The
digitorum superficialis. lateral two lumbricals – these
muscles perform flexion at the
Deep layer: Flexor pollicis longus, metacarpophalangeal joints and
pronator quadratus, and the lateral half extension at the interphalangeal
of the flexor digitorum profundus (the joints of the index and middle fingers
medial half of the muscle is innervated
by the ulnar nerve).
Distribution of Median
Nerve z

 Palmar cutaneous branch: Lateral aspect of the palm.

This nerve does not pass through the carpal tunnel
 Palmar digital cutaneous branch: The palmar surface
and fingertips of the lateral three and half digits
Anatomy of Carpal
Tunnel z
Anatomy of Carpal
Tunnel z
z
DEFINITION

Compression
Carpal of the
Tunnel median
Syndrome nerve within
(CTS) the carpal
tunnel

May or may not

The symptoms be accompanied
occur in the by objective
median nerve changes in
distribution sensation and
strength
 z EPIDEMIOLOGY

Unilateral in 42% of
cases (29% right,
Women > men
13% left) and 58%
• The highest prevalence
bilateral
in women aged > 55
In the United years, usually between
40-60 years
States:
• Around 1-3 cases per
1,000 people each year
with a prevalence of
around 50 cases in
1,000 in the general
population
 z ETIOLOGY
• Pregnancy, hypothyroidism,
Hormonal disorders
acromegaly

Metabolic disease • Diabetes, obesity, amyloidosis

• Arterial hypertension, Raynaud’s

Vascular disease
disease

Work
z
PATHOPHYSIOLOGY
z
The mechanical compression theory

Normal pressure in
Excessive clamping
the carpal tunnel is
of the median nerve
2 – 10 mmHg

The pressure that exceeds

Extension: ↑ 10 x the systolic pressure caused
a focal demyelinization at the
Flexion: ↑ 8 x location of the nerve that
was compressed
 z
The microvascular disorders theory

Decrease in Decrease in the

Decrease in the
nutrients and ability to deliver
flow and supply
oxygen to the impulses to the
of blood nerve nerve

The nerve Scar and fibrous

becomes tissue are
damaged formed
 z
The vibration theory

Continuous Epineural Microvascular

swelling of the disorders of the
vibration median nerve median nerve
z CLINICAL
PRESENTATION
 z

Precipitating factors
Numbness and tingling Pain

Autonomic disorders

Decrease
in strength
of the
fingers

• Changes in temperature in the

distribution of the median nerve Muscle
weakness when
Move the wrist after • Skin color disturbances in the
abduction and
wake up during sleep distribution of the median nerve opposition to
• Skin becomes dry the thumb
z DIAGNOSIS
Anamnesis

 This is include symptoms that are felt

by the patient, when they occur, things
that trigger and things that alleviate
these symptoms.
 The symptoms are in accordance with
the distribution of the median nerve in
the area of the wrist and fingers.
 z
DIAGNOSIS
Physical examination

Atrophy of the
thenar muscle Luthy's sign Weakness of
(Bottle's sign) abductor pollicis
brevis muscle
• (+) = The skin • The first finger is aligned with
folds can’t touch the second finger, then the
the surface of the patient is asked to do an
object tightly abduction movement while
the examiner gives the finger
the resistance
 z
DIAGNOSIS
Specific neurological examination

Tinel’s test Phalen’s test

 Tap over the volar surface of the wrist
 = Parasthesia in the thumb, index,
middle finger and the medial side of the
ring finger
 Flex the wrist and keep it that position
for 60 seconds
 = Pain or parasthesia in the
distribution of the median nerve
 z
DIAGNOSIS
Specific neurological examination
The carpal Hand elevation test
compression test

 Press the median nerve on the wrist for  Raise the hand and hold it for 60
60 seconds seconds
 = Pain, tingling, and discomfort in  = Discomfort in the median
the area innervated by the median nerve nerve area
z
DIAGNOSTIC
EVALUATION
 z
Nerve Conduction Studies (NCS)

Diagnostic criteria for CTS

Prolonged motor and sensory latencies of the median nerve, and reduced
sensory and motor conduction velocities

Standard method of diagnosis

Compare the latency and amplitude of a median nerve segment across the
carpal tunnel to another nerve segment that does not go through the carpal
tunnel, such as the radial or ulnar nerve
 Bland’s Neurophysiological Grading Scale for CTS
z

Grade Neurophysiological findings

Grade 0 (Negative) Normal motor and sensory conduction studies

Grade 1 (Minimal) CTS demonstrable only with most with most sensitive tests

Sensory nerve conduction velocity slow on finger/wrist measurement

Grade 2 (Mild)
Normal terminal motor latency

Sensory potential preserved

Grade 3 (Moderate)
Motor slowing: DML to ABP < 6.5ms

Sensory potential absent

Grade 4 (Severe)
Motor potential preserved; DML to APB < 6.5 ms

Sensory potentials absent

Grade 5 (Extreme)
DML to APB > 6.5 ms

Sensory and motor potentials effectively unrecordable

Grade 6 (Very Extreme)
Surface motor potential from APB < 0.2 mV amplitude
DML: distal motor latency ; APB: abductor pollicis brevis
z
Electromyography (EMG)

Evidence of pathologic changes in the

muscles innervated by median nerve
• Abductor pollicis brevis muscle

To exclude other conditions and to

assess severity of CTS
 z
• Thickening of the median nerve, flattening of the
nerve within the tunnel and bowing of the flexor
retinaculum
Ultrasound

• Swelling of the median nerve and increased signal

intensity on T2-weighted images indicating
accumulation of the axonal transportation, myelin sheath
MRI degeneration or oedema
z

TREATMENT
Non-surgical
Treatment z

Nonsteroidal anti-
Rest the wrist inflammatory drugs
(NSAIDs)

Vitamin B6
(Pyridoxine)
• Pyridoxine 100-300 mg /
day for 3 months
Non-surgical
Treatment z

Wrist splints

 Mild to moderate CTS patient

 It is used in the neutral position

of wrist.
 It can be used continuously or
only at night for 2 – 3 weeks.
Non-surgical
Treatment
Steroid injection
z
Steroid injection
Dexamethasone 1-4 mg/ml, or
Hydrocortisone 10-25 mg, or
Methylprednisolone 20-40 mg
Injection administration
Needle no. 23 G or 25 G
1 cm to the proximal fold of the
wrist medial to the palmaris longus Can be repeated
muscular tendon with forming a 30
in 7 to 10 days for
angle
a total of three or
four injections
Non-surgical
Treatment
z

Nerve gliding
 To restore mobilization of our
peripheral nerves.
 These exercises are based on
the principle that tissue from
the peripheral nervous system
is designed for movement, and
that nerve tension and gliding
may have an effect on
neurophysiology through
changes in blood vessel flow
and axoplasmic

Repeat the above exercise 3 – 5 times. Do the movements slowly

 Surgical This involves severing a ligament around the wrist
Treatment z to reduce pressure on the median nerve

Open release surgery Endoscopic surgery

One or two incisions (about ½ inch each)

Making an incision up to 2
inches in the wrist and then cutting
the carpal ligament to enlarge the
carpal tunnel.
in the wrist and palm, inserts a camera attached
to a tube, observes the nerve, ligament, and
tendons on a monitor, and cuts the carpal
ligament (the tissue that holds joints together)
with a small knife that is inserted through the
tube.
 z
PROGNOSIS

 The prognosis is usually good. There are several factors that can cause a
bad prognosis, such as mental status and alcohol use.
 Bilateral symptoms and positive Phalen maneuvers are poor indicators of
prognosis.
 Research shows that 34% of idiopathic CTS patients experience perfect
resolution in 6 months.
 If the surgery has been done but there is no improvement, then consider
these following possibilities:
1. Error making a diagnosis, maybe a trap / pressure on the median nerve
located in a more proximal place.
2. Total damage to the median nerve has occurred.
3. New CTS occurs as a result of surgical complications such as due to
edema, adhesions, infections, hematoma or hypertrophic scarring.
 z REFFERENCES
Aroori, S. and Spence, RAJ. (2008). Carpal tunnel syndrome. The Ulster Medical Society, p6–17
Bland JDP. A Neurophysiological Grading Scale for Carpal Tunnel Syndrome. (2000). Muscle Nerve.; 23:
1280-83.
Ibrahim, I., Khan, WS., Goddard, N. and Smitham, P. (2012). Carpal Tunnel Syndrome: A Review of the
Recent Literature. The Open Orthopaedics Journal. Vol. 6, p71-72.
Kishner, S. (2015). Brachial Plexus Anatomy. Available:
https://emedicine.medscape.com/article/1877731-overview#a2. Last accessed 10th Dec 2018.
Maggi, SP., Lowe, JB. and Mackinnon, SE. (2003). Pathophysiology of nerve injury. Clinics In Plastic Surgery.
30: p109-126
Murphy, KA. and Morrisonponce, DK. (2018). Anatomy, Shoulder and Upper Limb, Median Nerve. Available:
https://www.ncbi.nlm.nih.gov/books/NBK448084/. Last accessed 10th Dec 2018.
Sucher, BM. and Schreiber, AL. (2014). Carpal Tunnel Syndrome Diagnosis. Physcal Medicine Rehabilitation
Clinics of North America. 25: p229-247
Padua L, Caraci D, Pazzaglia C. (2016). Carpal tunnel syndrome: clinical features, diagnosis, and
management. The Lancet. 15: p1273–84.