Curing a Case of What Used to Be Mistaken Identity

Armen Hareyan's picture
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In the 1930s and 40s, many people suffering from numbness in their hands ended up having extensive surgery on the discs in their necks, in a futile attempt to release the pressure on a compressed nerve, until researchers demonstrated that the real problem lay elsewhere. Then, as Dr. Thomas Trumble, chief of the Hand and Upper Extremity Institute and professor of orthopaedics and sports medicine at the University of Washington, says, the real culprit was identified: carpal tunnel syndrome. That's the compression of the median nerve as it passes under a ligament between the wrist and palm of the hand.

"The carpal tunnel is the key gateway for the tendons and nerves to enter the hand," Trumble says. "It's a tight, enclosed space with bone on three sides and that ligament near the underside of the wrist. Carpal tunnel syndrome is caused by the ligament getting shorter, thicker and contracted through a combination of heavy use and age. As the ligament thickens, there's less room for the nerve; it gets compressed and circulation of blood to the nerve is reduced, causing the symptoms."

Those symptoms include numbness and occasionally pain and weakness, which can be at their worst when people go to sleep, because the hands curl into a position that blocks circulation to the nerve. While carpal tunnel syndrome is most common in the middle aged, it can be a problem at any age except childhood. In some aggressive cases, such as commercial fishermen or contact martial arts participants, stopping the activity that causes the symptoms relieves the problem. It's important, though, that suspected cases of carpal tunnel syndrome get a careful diagnosis.

"Aside from the clinical tests, which examine function and map how fast the nerve can transport signals, we also look at the hands, to see if there has been any muscle loss, which happens only in the most severe cases," Trumble states. "The hope is to diagnose and treat people before they have signs of permanent loss of sensation and muscle tissue."

The initial treatment often consists of wearing a brace or splint on the affected hand at night, along with regular doses of aspirin, ibuprofen or other over-the-counter pain medications. Another option is a steroidal injection, intended to break the cycle of irritation long enough to reduce pressure on the nerve. It often is only effective for three to nine months. If numbness and pain are still severe, the patient may want to consider surgery to release the pressure the ligament is placing on the nerve.

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There are two kinds of surgery available for carpal tunnel syndrome: open surgery, which uses an incision about two inches long to gain access to the ligament, and endoscopic surgery, which uses either one or two portals, about three-eighths of an inch long, to insert a fiber-optic camera and instruments to cut the ligament.

"I've done about 3,000 endoscopic carpal tunnel surgeries over the past 10 years," Trumble notes. "Recently, in a randomized study of both endoscopic and open surgery, patients were much more satisfied after the endoscopic surgery. They had less scar sensitivity and went back to work sooner than patients who had the open surgery."

Trumble advises people considering this surgery to look for a surgeon who is board-certified in hand surgery, since that means that he or she has sought education specifically related to hand surgery.

"Most physicians don't use a cast on patients after this surgery. People can drive within a day or two afterward and they can do light tasks, like keyboarding, within a week, but it's generally a month or so before they can do things like housework or cooking," Trumble adds. "It takes about three months to get peak hand strength back for things like opening jars."

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For more information on the diagnosis and treatment of carpal tunnel syndrome and other orthopaedic issues, click on www.orthop.washington.edu

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