Letter: ‘Proof’ about Carpal Tunnel Syndrome Published on Saturday, August 18, 2007 Dear Sir, I would like to respond to Ms Christina Dumal’s letter of August 2, 2007 in which she asked for “proof” of my statement that repetitive activities, such as using a computer keyboard, are not the cause of carpal tunnel syndrome. Her concern allows me to elaborate on certain points which were not addressed in the series, The Truth About Carpal Tunnel Syndrome (CTS) which recently appeared in your newspaper. No, we don’t yet know what causes carpal tunnel syndrome. We don’t know exactly what causes the diffuse tendon sheath thickening in the carpal canal that then compromises the median nerve. However, we do understand the pathophysiology and know that certain medical conditions predispose patients to developing CTS: rheumatoid arthritis, diabetes, thyroid conditions, even menopause. It is entirely possible that future research will determine that in certain patients, obesity, genetics (inherited traits such as the structure of the carpal tunnel canal) and even today’s often poor, high fat diet, or excessive alcohol and caffeine consumption may be contributing factors that produce metabolic changes leading to CTS. We already suspect a strong metabolic connection. I’d like to make the analogous comparison to our knowledge of cancer. We understand the histology, cell types and progression of the disease, but we don’t really know the cause—likely aberrant genes, perhaps triggered by undiscovered viruses or prions—and certainly not some simple activity. Ms. Dumal asked for proof that carpal tunnel syndrome is not “work related” and by that I assume she means caused by jobs that require repetitive motion activities. That proof can be found in findings of numerous scientific studies conducted during the past 15 years, many of which have been published in leading medical journals, including the Journal of the American Medical Association (JAMA). One of the leaders in CTS research is Dr. Peter Nathan of the Portland Hand Surgery and Rehabilitation Center in Portland, Oregon. His landmark 11- year study, involving of hundreds of subjects representing a very diverse range of ages, was one of the first definitive studies that found no relationship between repetitive activity and the compression of the median nerve within the carpal canal. That compression of the nerve is what causes the symptoms of CTS. Another often cited study conducted by Oregon State University’ medical department reinforced this finding, as Dr. Richard Kinston, working with Dr. Nathan confirmed: “In fact, the job studied requiring the most intense repetitive motions, keyboard data entry, actually had a significantly reduced risk for CTS in over 2600 subjects studied. Ongoing studies conducted at the Mayo Clinic in Rochester, MN continue to provide the proof Ms. Dumal seeks. Many of these published findings can be accessed online through university and public library systems, often at no charge. These and other epidemiological studies have demonstrated that so called” repetitive stress injury” has no relationship to compression neuropathies. There are other well-known researchers whose studies have shown that people with repetitive motion jobs don’t experience any more aches or pains in their hands than the population at large. Despite published scientific data that repetitive activity is not the cause of CTS, this mythical link seems impossible to correct. The media, and even members of the medical community, choose to ignore the evidence refuting this fallacy. If in fact, repetitive activities “caused CTS” then every computer user, video game player and typist would develop CTS. Much of the world’s professional work force would be disabled due to such widespread computer use. Not only is this obviously not the case, but many CTS sufferers I have treated have never used a computer or keyboard of any kind, or performed any repetitive activities whatsoever. Ms. Dumal asks why “recurrence is so high (for CTS) when one returns to the same job that involves what many researchers believe contributes to this syndrome, such as repetitive motion…” This is simply not true. Resuming prolonged repetitive activities can aggravate the symptoms of CTS once a patient experiences the onset of those symptoms—this is not a “recurrence of CTS.” Logically, how could you expect to do the same thing and have different results? An important component of conservative treatment advises the patient to change his work habits if the job requires such activities; take breaks from those activities frequently, rest, and stretch. With proper evaluation by a hand specialist and early treatment, the majority of patients experience relief from CTS symptoms. If a patient fails to respond to conservative treatment, then a simple surgical procedure called endoscopic carpal tunnel release, discussed at length in the series, has proved extremely effective in relieving CTS symptoms and those symptoms have a very, very low recurrence rate. I hope that if Ms. Dumall herself is suffering from CTS symptoms she will overcome her suspicion and fear and be evaluated by a hand specialist. I welcome any readers with concerns or questions to contact me through my website, https://www.drbadia.com/. It’s important to understand the medical facts about CTS and know that treatment is not only available to you, but also quite simple. Dr. Alejandro Badia Miami, FL
Bahamian patients often travel to Miami to undergo endoscopic release of the median nerve since in the Caribbean nations, the procedure is currently done via an open incision with is much more painful, takes longer to recover and may require rehabilitation. We have good relationships with therapists in Nassau, Freeport etc but fortunately, most patients with carpal tunnel release require no formal therapy and have complete relief of their painful numbness. Procedure is done with local anesthesia requires only a 3 day stay in Miami (Doral) and patients can use the hand immediately.
Diabetes is a systemic disease with wide ranging manifestations due to defects in insulin production or organ receptor sensitivity to this critical hormone. It has profound effects on the cells comprising the circulatory, nervous and connective tissue systems. This widespread involvement of systems is expressed in the hand, a complex organ of function comprising multiple tissue types.
The treatment requires recognizing the diverse expression of this disease in this wonderful tool that is both an organ of functioning expression as well as sensation. Typically, diabetes patients have symptoms that are due to these problems going unrecognized. Often times, they are not severe, and hence are not brought to the attention of the primary care physician or endocrinologist. In other cases, the symptoms are not recognized as being a manifestation of a very treatable problem. The hand surgeon should be involved at an early time when any of these symptoms present as the pathology can be arrested at an early stage and avoid more severe morbidity.
Numbness or tingling in the fingers is often ignored until it becomes persistent or painful. This if often interpreted as neuropathy and occurs commonly in the foot. However, the foot is much more commonly involved with neuropathy and leads to different and more severe problems with ulceration, since it is a weight-bearing organ. This tingling, or “paresthesias”, is more often due to nerve compression in the upper extremity. Most commonly, carpal tunnel syndrome is present, which is median nerve compression at the level of the wrist. It is actually due more to inflammation of the surrounding flexor tendons, rather than direct pathology of the nerve itself. The nerve can be more sensitive to compression if an element of neuropathy is present. Patients typically complain of numbness or tingling in the thumb or central fingers. This is often worse at night and can cause difficulty sleeping. Chronic and severe compression of the nerve leads to weakness of the thumb with subsequent difficulty in many daily tasks.
The diagnosis of carpal tunnel syndrome is usually made through a careful history and physical exam of the hand, and confirmed by nerve conduction studies, which measure the electrical conduction of the median nerve through the wrist. The treatment initially consists of sleeping with a night splint, which keeps the wrist in a neutral position, and high doses of vitamin B6. Anti-inflammatories may help as well, and in certain indications a cortisone injection in the wrist. However, the majority of cases with significant persistent symptoms will require a decompression of the carpal canal to take pressure off the median nerve. This has been traditionally done by an open incision, but can now be done endoscopically in a minor procedure with local anesthesia. Patients can use the hand immediately after the outpatient procedure, and only need to miss a minimum amount of work and can usually forego any therapy.
The cause of carpal tunnel syndrome is really a thickening and inflammation of the tendons that pass in the tunnel along with the delicate nerve. This same tendonitis deep in the wrist causes mechanical problems and pain farther along in the palm. Inflammation of these flexor tendons as they travel to the finger leads to pain in the palm of the hand with occasional “triggering” or catching of the tendon in the tunnel as the patient attempts to extend the finger after flexing. Occasionally, the problem is severe enough that the finger locks, and the opposite hand is used to forcibly extend the digit. This can be accompanied with considerable pain that often radiates up the arm, and difficulty in making a tight fist, particularly in the morning upon awakening. The treatment is quite simple, involving either reducing the tendon inflammation or opening the tunnel through which it passes. A Corticosteroid injection along the tendon sheath is very effective, unless the patient experiences locking where the mechanical problem is more profound and requires a mechanical solution. A trigger finger release is done by a small incision in the palm and opening the tight sheath containing the tendon allowing it to glide once again. In isolated cases of trigger finger, we can even do this percutaneously, without making an incision. This is also done under local anesthesia, and the dressing is removed the very next morning by the patient himself. Open release of the tendon pulley is usually done in conjunction with a carpal tunnel release, as they commonly occur together since they are different manifestations of the same pathology.
There is a misconception that cortisone injections are harmful to patients, particularly diabetics. This is not the case when limited to several injections spanned out over time and in low doses and different locations. This medication tends to stay in the local area injected and does not affect the patient systemically. Nevertheless, these pathologies often do not respond adequately to this treatment, and these minor procedures should be performed. This is commonly the scenario is other locations such as certain types of wrist tendonitis, like dequervain’s tenosynovitis, or bursitis of the shoulder, where an arthroscopic excision of bursa can be done to alleviate and usually cure the problem.
Technically called carpal tunnel release surgery, the surgery to treat carpal tunnel syndrome may be of the open or endoscopic type. There are a number of surgical instruments used to open and expose any body part, and they are common to all surgeries. However, carpal tunnel release surgery requires some specialized instruments, especially if performed endoscopically.
General Surgical Instruments for CTS Carpal Tunnel Syndrome
In order to open the skin and overlying tissues, which conceal internal body parts, sterile surgical instruments are required. They are similar to instruments used for most other surgeries, not only for carpal tunnel release surgery. Aside from ancillary support instruments such as monitors and magnifiers, dedicated surgical implements include cutting instruments, such as scissors and scalpels; grasping instruments, such as forceps and hooks; tissue exposure instruments, such as retractors and probes; blood control devices, such as hemostats and bipolar electrocautery; and tissue closure devices, such as needle drivers and clamps.
Open Release Surgery
Open release surgery involves cutting open the palm and wrist to expose the transverse carpal ligament. The result is a two-inch long incision and the advantage is complete exposure of the ligament and the surrounding structures. In this way the surgeon can cut, or release, the ligament with more confidence about not harming the adjacent tissues. In addition to the aforementioned general surgical instruments listed, other specialized implements are required including small retractors, a curved hemostat and blunt dissecting scissors.
Endoscopic Release Surgery
According to “Chapman’s Orthopaedic Surgery,” endoscopic release surgery requires the same instruments used for open release surgery. However, since this procedure involves making one or two small incisions—called portals—the procedure requires a wrist arthroscope, which is a tubular viewing apparatus.
In the single portal technique, the arthroscope and a blade assembly are inserted into the same incision and guided to the transverse carpal ligament. Sometimes, the arthroscope has a video camera attached for easier viewing on a television screen.
In the double portal technique, two incisions are made: one on the wrist and one on the palm. Each incision is used for inserting the arthroscope and blade assembly. Usually, a trocar-and-sheath assembly is required for effective insertion and removal of the instruments. The blade assembly is a special knife, which cuts upwards and with a reverse stroke.
It should be noted that it is not unusual for the endoscopic surgery procedure to be abandoned while in progress in favor of changing over to the open release technique. Sometimes visualizing the structures is problematic and the surgeon will opt for obtaining better exposure.
The Badia Hand to Shoulder Center in Doral, Miami, Florida has found a unique niche in the Florida orthopedic market. It is the only practice devoted to hands and upper extremities in the Sunshine State. “The specialty of hand surgery is very diverse because we’re basically every type of surgeon for the hand,” says Alejandro Badia, MD. “We’re the orthopedic surgeons, we’re the plastic surgeons, we’re the vascular surgeons, we’re the neurosurgeons of the hand.”
On the surface, such a specialized practice might not seem to make economic sense, particularly in light of the trend toward large group practices that can cover every orthopedic problem. But the Miami Hand Center’s success has disproved the conventional wisdom-Badia and his three colleagues perform between 80 and 100 surgeries and see 400 to 500 patients every week. By concentrating on a single specialty, the private Latino-owned clinic can be run much more efficiently from both an economic and patient point of view. There’s another payoff for the center’s four surgeons. “Personally, I was offered a position with a group up in the Fort Lauderdale area, but what I realized early on, particularly in my specialty, which is so diverse-there’s so many different types of cases-is that it would be best to join somebody else who does that specialty, not only to be able to ask somebody else questions, [but to] be able to share work with somebody else on the most interesting and challenging cases,” says Badia. “The group I was going to join had a spine guy, a sports medicine guy, a pediatric orthopedist, but if I got a difficult hand case I didn’t want to be the only person to know something about that. Just the other day I saw a case I’ve never seen before.” He adds that being in a specialty practice also gives him and his other colleagues an opportunity to learn from one another.
All Age Groups and Walks of Life Welcome
Though specialized in its practice, the clinic does not have a specialized patient demographic. Cases come from all age groups-from newborns to the elderly-and all walks of life. Though most of their patients go to outside groups for rehabilitation, the more complicated cases return to the clinic for specialized help. Badia is able to monitor the progress of these patients through a window looking onto the rehab section that he affectionately calls “the fishbowl.” “It allows us to monitor our patient’s progress while doing therapy,” says Badia. “That’s a big advantage because in hand surgery the therapy is really critical.” However, the rehabilitation services the clinic offers are limited-both by insurance approval issues and by the limited number of rehab therapists it employs-and is not a key part of the center’s income flow.
Its high volume and status as an emergency center made the Miami Hand Center an ideal choice to be a pilot site for a new digital radiography system. The system allows the doctors at the center to manipulate the images, making them lighter or darker, or zoom in on the damaged tissue-all in order to make a better diagnosis. The system also makes good business sense for the practice by freeing space for the storage of films and increasing the efficiency of cataloging the studies.
An Informal Hand Surgery Fellowship
Badia and his colleagues have not created a monopoly on their knowledge. At any time they have three to four hand surgeons working at the clinic as part of an informal hand surgery fellowship. These visiting physicians-most of whom are from Latin America-study at the Miami Hand Center from a few weeks to 3 to 6 months honing their skills. Badia says that these “fellows” serve an important purpose for the practice. “The fellowships are the key because it brings in new thoughts, and allows us to teach,” he says. In connection with the fellowship, Badia is in the process of setting up a cadaver laboratory to teach orthoscopy techniques-including wrist, base of the thumb, and carpal tunnel release.
No matter how techniques and technology may change the way the physicians at the Miami Hand Center manage their practice and provide service to their patients, one thing will not change: every day will bring unexpected and new challenges that they will have to solve.
People with diabetes are prone to carpal tunnel syndrome
People with diabetes know that their disease may cause foot problems and are constantly on the alert for “danger” symptoms. But virtually nobody knows that diabetes is also a common element in hand problems. Do you have numbness or tingling in your fingers? This may be a complication of diabetes. Frequently, hand problems associated with diabetes are not severe, and hence are not brought to the attention of the doctor.
Numbness or tingling in the fingers, often ignored until it becomes persistent or painful, may be caused by carpal tunnel syndrome, which is a nerve compression at the wrist. This is actually caused more by inflammation of the surrounding tendons – tendinitis – rather than a problem with the nerve itself. High blood sugar can cause tendinitis. Therefore, people with diabetes are prone to carpal tunnel syndrome.
Patients typically complain that their symptoms grow worse at night. Compression of the nerve also may lead to weakness of the thumb, which poses difficulty in many daily tasks.
The diagnosis of carpal tunnel syndrome
The diagnosis of carpal tunnel syndrome is usually made through a careful history and physical exam of the hand and wrist, and confirmed by studies that measure the electrical conduction of the median nerve through the wrist.
Treatment initially consists of sleeping with a wrist splint and high doses of vitamin B6. Anti-inflammatories may help as well, as might a corticosteroid injection in the wrist. These treatments, however, help the symptoms, but do not cure the problem. Those with significant or persistent symptoms will require a minor surgical procedure to decompress the carpal canal and take pressure off of the median nerve. A new technique allows this to be done endoscopically through a tiny incision with local anesthesia and mild sedation. Patients can use their hand immediately after the outpatient procedure, miss only a minimal amount of work, and usually don’t need any follow-up therapy.
Another tendinitis problem that people with diabetes are prone to is called trigger finger, and is where the tendon going to the finger catches in its sheath as the person tries to extend the finger after flexing. With this condition, it can be difficult to make a tight fist, particularly upon wakening. Occasionally, triggering is severe enough that the finger locks and must be pried open with the other hand, which can cause considerable pain that radiates up the arm.
The treatment of trigger finger is simple, ranging from a corticosteroid injection to a minor surgical procedure to release the tight sheath.
People with diabetes may also notice tendinitis in the shoulder or elbow. If you have any hand, elbow, or shoulder problems, discusses them with your doctor or diabetes educator.