Although some occupations requiring repetitive hand use and/or exposure to vibration seem to increase the risk of carpal tunnel syndrome, the majority of individuals in such jobs do not get carpal tunnel syndrome, unless they are anatomically predisposed to it.

Diagnosing Carpal Tunnel
Physical exam findings in the patient who has carpal tunnel consist primarily of median nerve irritability, which is identified by sensitivity to tapping at the wrist level. An examiner can test for sensitivity to pressure by holding the wrist in a flexed position or placing direct pressure on it for a short period of time. Examination of the neck and proximal forearm to rule out other causes of nerve compression are also done as part of the examination.

In most cases, the patient’s history and a physical exam are enough for a diagnosis, but in some cases, it may be necessary to provide additional objective confirmation of nerve dysfunction. This can be done by doing an electromyogram (EMG), which is a nerve test to evaluate the electrical conductivity of the nerve. The EMG is not infallible and fails to diagnose about 10 percent of confirmed carpal tunnel syndrome cases. It may also produce a false positive.

Another way of obtaining objective information is to inject adrenal corticosteroids into the carpal canal to shrink swelling, thus diminishing pressure. A steroid injection will decrease pressure and invariably improve true carpal tunnel syndrome symptoms, unless permanent median nerve damage has occurred. The benefit is usually temporary, but temporary improvement confirms the carpal canal as the source of the symptoms.

Other tests such as X-rays and magnetic resonance imaging (MRI) scans might be useful to rule out other causes of wrist pain, but these tests cannot confirm a diagnosis.

Exploring treatments for Carpal Tunnel
Treatments to decrease swelling in the carpal canal include activity modification, stabilizing the wrist, physical therapy, use of antiinflammatory medication, and occasional injections of corticosteroids. These measures are effective in mild cases; but once symptoms begin occurring on a frequent or continuous basis, these treatments are rarely effective in providing any significant longterm or permanent relief.

For those patients with significant symptoms, the only permanent solution is carpal tunnel release, a surgery that will increase the size of the carpal tunnel. This procedure is performed frequently with a high success rate and a relatively low rate of repeat surgery.

Transverse carpal ligament surgery, a traditional method of relieving carpal tunnel syndrome, consisted of an open incision along the transverse carpal ligament and distal forearm fascia. Historically, this operation required a 2- to 3-inch incision beginning at the narrowest part of the wrist in the midline continuing out into the palm of the hand; and it was recommended to dissect around the tendons and nerves to remove inflammatory tissue and scarring. However, various studies have identified that in most cases dissection of the nerve and removal of synovial tissue is not necessary and is perhaps detrimental to recovery from carpal tunnel syndrome, because it may cause the formation of additional scar tissue.

After this type of surgery, “pillar pain” has been recognized as the most likely side effect. This pain is an ongoing tenderness in the palm of the hand usually associated with grasping, which is present in all patients for the first four to six weeks. In a few individuals individuals, however, it lasts for several months and even permanently. Unfortunately most of those at risk cannot be identified preoperatively; but it usually can be treated successfully with physical therapy.

Trying an alternative
The problems recognized above led to the development of the endoscopic technique, which has been widely practiced for at least 10 years. Endoscopic carpal tunnel surgery makes up about 20 percent of the carpal tunnel releases done today. The technique is demanding, and may increase the risk of nerve injury. Published studies offer conflicting results with respect to this issue. Risk of nerve injury is dependent on the surgeon’s experience with the technique. There are few contraindications to endoscopic carpal surgery, except perhaps previous carpal tunnel surgery.

On the positive side, although studies are conflicting, the consensus seems to be that individuals who undergo endoscopic carpal tunnel surgery are able to recover more rapidly and return to activities sooner than those undergoing traditional open carpal tunnel surgery. In most cases individuals undergoing endoscopic carpal tunnel surgery recovered two to three weeks faster than their counterparts who had traditional carpal tunnel surgery. Long-term results between the two techniques have not been shown to be any different.