Everyone knows Carpal Tunnel Syndrome and computer use go (no pun intended) hand-in-hand, right? Actually, No. Contrary to what many people think, that belief has been shown to be false.
“The popular thought is that computer use confers a risk of carpal tunnel syndrome. We were expecting to find an increased risk, and when we didn’t, we were surprised,” Mayo Clinic neurologist Clarke Stevens, tells WebMD. “There is insufficient epidemiological evidence that computer work causes CTS,” according to a European study; and a 1-year study published by the National Center for Biotechnology, which followed 7,000 members of a trade union with questionnaires and clinical interviews, concluded that “computer use does not pose a severe occupational hazard for developing symptoms of CTS.”
What, then, is CTS and what are the major risk factors? Indian River County physicians Dr. Chris Talley and Dr. Anthony Ware diagnose and treat CTS patients. They have had similar experiences with their CTS patients, and share many observations, conclusions and current treatment preferences, in general agreement with orthopedic surgeons across the nation.
Talley, a Vero Beach orthopedic surgeon, is board certified, fellowship trained, and holds a medical degree from the University of Virginia School of Medicine in Charlottesville. Board-certified and fellowship-trained orthopedic surgeon Ware received his medical degree from the University of Massachusetts Medical School. He sees patients in Sebastian, Vero Beach and Melbourne.
The carpal tunnel is a narrow passageway on the palm side of the wrist made up of bones and ligaments. The median nerve, which controls the sensation and movement of the thumb, first two fingers and bottom half of the forefinger, runs through this tunnel. When this nerve is pinched or compressed, the result is the weakness, numbness, tingling and/or pain in the hand called carpal tunnel syndrome. The associated pain typically occurs at the base of the palm and inner wrist.
Talley explains that 10 structures have to pass through the “tunnel” – the median nerve and nine flexor tendons. The space within the tunnel can vary based on individual anatomy. Current studies indicate that women are up to three times more likely than men to suffer from CTS, and their often smaller wrist size could be a contributing factor.
Treatment of carpal tunnel syndrome, says Ware, represents “the most common, orthopedic upper body nerve compression procedures” performed in the U.S. Some conditions creating a higher risk factor for CTS include diabetes, thyroid problems, repetitive use, trauma and pregnancy,” he adds.
Talley notes that pregnancy, along with kidney disease, congestive heart disease, thyroid issues and kidney failure, can cause CTS through fluid retention (edema), which increases pressure on the median nerve.
“One of the common denominators related to activity,” Talley continued, “Is being exposed to vibration” over an extended period of time. “An extreme example would be operating a jack hammer.” Any occupation requiring long-term flexing or extending of the wrist joint can also trigger the problem.
Both physicians emphasize that more often than not – “in the vast majority of cases,” Talley says – the cause of CTS in any given patient is idiopathic or, as Ware puts it, “We just don‘t know.”
Ware’s initial assessment for the condition includes a two-point discrimination test to determine if the median nerve is compromised. This is done with the patient’s eyes closed, by touching a fingertip with two points, using calipers or a re-shaped paperclip, with the tips at least 5 millimeters apart, to see whether the patient can differentiate between one and two points. If the patient cannot feel the difference between one and two points, the nerve has likely been compromised. Bending, flexing and tapping the affected area also help determine location and intensity of pain and resistance.
Following the diagnosis, prior to any surgical procedure, a nerve conduction study should always be done, the doctors say. This will determine the speed and strength of the nerve signal, thus localizing the area of compression in order to ensure the problem is, in fact, in the carpal tunnel and not the orbital tunnel, which involves the elbow rather than the wrist area. Talley has seen patients seeking second opinions, who have had CTS surgery that did not relieve the symptoms. Further testing found the issue wasn’t CTS after all, but a pinched nerve in another location, radiating to the hand.
Based on initial assessment results, treatment is chosen. Typically, unless a patient’s pain is extreme, non-invasive procedure options are offered. A wrist splint is often recommended, says Talley, explaining that stabilizing the wrist in a neutral alignment, especially at night, can prevent the wrist hyper-flexion or extension that often occurs during sleep. Hyper-flexion can irritate the compressed nerve further, causing pain intense enough to awaken the patient.
Other conservative treatments, says Ware, include cortisone injections, or use of other anti-inflammatory drugs such as Motrin, to relieve swelling. Talley also mentions “a short course of oral steroids, hand therapy treatment, ultrasound, activity modification and avoidance of provocative activities.” These methods can be tried and given a chance to work, Talley says, “but, often, it does come down to surgery.”
Alternative treatment options for CTS such as cold laser and magnet treatments are questionable, Talley says, “There are no studies that can support those treatments as effective.”
Except for the mildest CTS, or for CTS caused by such limited-time events as pregnancy, most physicians agree these non-invasive treatments “usually don’t work – but we give the option to try,” says Ware. He also notes that CTS is not always reversible, especially in patients who have suffered for years without treatment, resulting in permanent damage. If caught and treated early, CTS is usually reversible.
For the majority of patients, one of three open CT release procedures will be successful:
The traditional fully-open release surgery involves an incision across the wrist, long enough to release the Median Nerve along the entire affected area. This is achieved by cutting the ligament, thus relieving the pressure.
The partial open surgery requires an incision in the palm only, not across the wrist. Recovery time is usually shorter than with the traditional full open surgery.
The third procedure is endoscopic surgery, which requires the smallest incision. The surgeon does not observe the surgical site directly, but employs a camera placed within the wrist, through which the procedure can be viewed. Although this procedure has the shortest healing time and less bleeding, it is comes with a higher rate of incomplete release and greater risk of injury to ligaments.
“You need a very good visualization,” says Ware. “If you don’t have a clear visual, well, it’s risky. When I do an endoscopic procedure, I’m always prepared to switch to a bail-out, open procedure.” Ware may choose the endoscopic procedure if a patient has “heavy use of the hand,” and needs to return to work as soon as possible.
Talley agrees. “My personal favorite is limited open. There is a small – about 2 centimeter – incision, and you’re looking directly at the ligament. Endoscopic is nice, but it carries a risk of cutting a tendon. I really have not seen the advantage of endoscopic vs. traditional. In my experience limited open is pretty much the same as far as recovery time frame, and studies that have looked [at the results], a couple months after surgery, show virtually no difference in the final outcome.”
Following surgery, with the pressure released, a patient who had symptoms for a relatively short period of time should find those symptoms go away quickly. If, however, the nerve has been compressed for a longer period of time, the pain will usually disappear quickly; numbness may remain for a few weeks or even months, but will eventually subside in most cases.
