Carpal Tunnel Syndrome

D Leung, Hospital for Special Surgery, New York, NY, USA

r 2014 Elsevier Inc. All rights reserved.

Median neuropathy at the carpal tunnel, or carpal tunnel can increase the pressure within the space. This increased
syndrome (CTS), is the most common peripheral nerve pressure can then lead to compression or ischemia of the
entrapment syndrome. It can be confused clinically with bra- median nerve.
chial plexopathy, cervical radiculopathy, or thoracic outlet Phalen, an orthopedic surgeon who popularized the diag-
syndrome. nosis and treatment of CTS with a series of publications
starting in the 1950s, postulated that increased pressure in the
carpal tunnel occurs with persistent wrist flexion or extension
Anatomy during sleep. This increased pressure, in turn, leads to nerve
ischemia, resulting in paresthesias in the nerve distribution.
The median nerve originates from fibers of C6–T1 nerve roots. The question of whether CTS can be a result of occupation-
It receives contribution from both the lateral and medial cords related hand or wrist overuse remains controversial. Some
of the brachial plexus. From the lateral cord, fibers from C6 authors have reported occupation and heavy manual labor as
and C7 roots innervate and convey sensation from the thenar a risk factor for CTS, but others have disputed the association.
eminence, thumb, index finger, middle finger, and ring finger. Studies of nerve conduction in hands of workers show no
These fibers also supply the motor innervation of proximal consistent association between prevalence of CTS and the type
forearm muscles in the median nerve territory. The C8–T1 of occupational activity or duration of employment. A longi-
fibers from the medial cord supply the motor fibers of the tudinal prospective study had 166 workers followed over 17
distal muscles in forearm as well as the intrinsic hand muscles. years. At the eleventh year evaluation, older age, female gen-
After forming from the lateral and medial cords, the me- der, being overweight, cigarette smoking, and job-related vi-
dian nerve runs down the arm and does not give off any motor brational exposure conferred greater risk for development of
or sensory branch until it is in the forearm. After supplying CTS. By the seventeenth year evaluation, only being over-
muscles in the forearm, the palmar cutaneous sensory branch weight and female gender continued to have a positive cor-
arises just proximal to the wrist and carpal tunnel to supply relation with the condition. One study of medical workers
sensation over the thenar eminence. The last branch of the who are frequent keyboard/computer users showed no dif-
median nerve then proceeds to enter the carpal tunnel in the ference in frequency of CTS when compared with the general
wrist. The carpal tunnel is formed by the carpal bones on population.
the floor and sides, and its roof is formed by the transverse
ligament. The contents of the carpal tunnel include nine flexor
tendons to the digits and thumb as well as the median nerve. Clinical Presentation
Once it transverses the carpal tunnel, the median nerve divides
into motor and sensory divisions in the palm. The motor Patients with CTS typically complain of nocturnal paresthesias
component supplies the first and second lumbricals as well as or burning pain in the territory supplied by the nerve. It is a
the muscles in the thenar eminence (opponens pollicis, ab- reliable symptom, although its cause is uncertain. Some pa-
ductor pollicis brevis, and superficial head of flexor pollicis tients may complain of stiffness in the hand as a presenting
brevis). The sensory branch supplies the thumb, index, mid- symptom rather than pain. The sensation of pain or dis-
dle, and lateral half of the ring finger. The index and middle comfort often spread to the forearm, elbow, and even to the
fingers receive two digital branches (one median and one shoulder and neck area. Sometimes, the pain may be localized
lateral), whereas the thumb and ring finger each have one to the shoulder and forearm instead of the hand and wrist.
branch. Most commonly, the area of discomfort involves the thumb,
index and middle finger, and the radial half of the ring finger.
Patients also complain of stiffness and weakness in the hands,
Pathogenesis especially with activity. Weakness and thenar atrophy are late
findings in CTS, although they may be presenting symptoms
CTS has been reported to have a population incidence of because the sensory loss is unnoticed by the patient.
0.1–0.3% annually among adults, with prevalence of 50 cases
per 1000 person per year, and a lifetime estimated risk of 10%,
with the condition affecting both hands in approximately half Physical Findings
of the patients. Many conditions are associated with CTS:
structural/anatomic (ganglion, lipoma, and neuroma), in- On physical examination, sensation can be normal in early
flammatory (rheumatoid arthritis, gout, tenosynovitis, and stages of CTS. When the condition is more advanced, hyp-
scleroderma), neuropathic/ischemic (diabetes, alcoholism, esthesia may occur in a median nerve distribution. Classically,
and amyloidosis), or shifts in fluid balance (pregnancy, the sensory deficit localizes to the radial aspects of the palm,
hypothyroidism, and obesity). In other words, any process splitting the ring finger. Because the region of the thenar
that can increase the volume within the carpal tunnel eminence is supplied by the palmar cutaneous sensory branch,

602 Encyclopedia of the Neurological Sciences, Volume 1 doi:10.1016/B978-0-12-385157-4.00652-7

 Carpal Tunnel Syndrome 603

which originates before the carpal tunnel, the sensory exam- latencies from the thumb, recording at the wrist; the median
ination is normal in this region. On motor examination, thumb and ulnar wrist-to-digit 4 sensory latencies; and the digit-to-
abduction and opposition are usually normal unless the con- palm and palm-to-wrist conduction study of the median
dition is severe, in which case thenar atrophy may be present. nerve, which can also differentiate between peripheral neur-
Other tests commonly performed in examination for CTS opathy and conduction block in CTS. Each of these com-
include the Tinel and Phalen tests. The Tinel sign is produced parison studies measures identical distances between
by tapping the median nerve over the volar skin crease. It is stimulating and recording electrodes for the median and
positive if it causes tingling or an electric shock sensation ex- compared nerve, which then ideally minimizes effects of other
tending into any or all of the digits innervated by the median variables known to affect conduction studies, such as age and
nerve. The test is neither sensitive nor specific. Tinel sign may temperature. These internal comparison studies can detect
be positive in approximately half of patients with CTS, but it milder cases of CTS by documenting focal slowing of the distal
may be also positive in up to half of the asymptomatic group. median nerve. These studies can also indicate the degree of
In the Phalen test, the patient holds the wrist passively secondary axonal injuries or loss based on motor and sensory
flexed for 30–60 s to determine whether this elicits pain and amplitudes, which has implications in the degree of injury and
numbness is due to CTS. Phalen found this test positive in prognosis, even with appropriate treatment. However, only the
80% of those he tested, with fewer false positives. The belief is digit-to-palm and palm-to-wrist sensory and motor nerve
that this maneuver further compresses the median nerve study document conduction block across the carpal tunnel,
against the proximal edge of the transverse carpal ligament which signifies demyelination and has a better prognosis than
and adjacent flexor tendons. axonal degeneration.
Another clinical maneuver that can elicit symptoms of CTS Using needle EMG to evaluate CTS can help differentiate
is direct compression of the median nerve for up to 30 s using this condition from others that may cause similar complaints,
both the thumbs or a mechanical device. The time it takes for such as high median neuropathy or cervical radiculopathy
the patient to develop pain, numbness, or paresthesias is (usually C6 or C7), which can cause hand pain and par-
noted, with the sensitivity and specificity of the test reported to esthesias. It can also assess the severity of CTS regarding any
be 87% and 90%, respectively. Clinicians have also found a acute or chronic denervation with axonal loss.
loss of two-point discrimination in the fingers in patient with If the median-innervated muscles of the thenar eminence
CTS. (opponens pollicis or abductor pollicis brevis) are abnormal,
but those innervated by proximal median nerve and ulnar
innervated C8–T1 muscles are normal, then the diagnosis of
Electrophysiological Testing distal median neuropathy/CTS is confirmed. In most situ-
ations, EMG study is normal unless the entrapment is severe,
Nerve conduction studies and electromyography (EMG) are with axonotmesis. Rarely there is denervation on EMG with
performed routinely for evaluation of CTS. The aim of the normal conduction studies; presumably this indicates primary
study is to document a focal lesion of the median nerve at the axonotmesis, supporting the notion that both EMG and nerve
wrist as the cause of the symptoms and to eliminate other conduction studies are equally important in CTS evaluation.
possible causes, such as peripheral neuropathy, proximal
median neuropathy, or cervical radiculopathy. In most cases of
CTS, demyelination of the nerve is present at the site of the Other Diagnostic Tests
compression, with secondary axonal loss in advanced cases.
On sensory conduction testing, findings include slow con- CTS is usually idiopathic, although there are many medical
duction velocity and low amplitudes of sensory nerve action conditions associated with it, such as diabetes, hypothyroid-
potentials. These sensory changes are often the first abnormality ism, rheumatoid arthritis, and amyloidosis. However, routine
documented in early CTS. As the condition worsens, motor use of screening tests, such as rheumatoid factor, thyroid
conduction studies may show prolonged distal latency, with function tests, and blood glucose, usually has a low yield, and
reduced or absent thenar compound motor action potentials in the decision whether to perform such tests should be based on
advanced or severe cases. If the largest and fastest fibers of the the individual patient’s medical history, presenting symptoms,
median nerve are blocked or have undergone Wallerian de- or other risk factors.
generation due to CTS, there can be slowed motor conduction Magnetic resonance imaging allows detailed views of
in the forearm segment. The minimum F-wave latency may also wrist anatomy. It is rarely used in routine clinical diagnosis of
be prolonged when compared to that of the ulnar nerve be- CTS, but it can be useful if CTS is suspected to be caused by a
cause the signal must also traverse the carpal tunnel. mass lesion, such as ganglia or tumors (neurofibroma and
Although decreased sensory and motor conduction schwannoma).
amplitudes and velocities, as well as prolonged motor distal In the past decade, ultrasonography has gained popularity
latencies, can diagnose many cases of CTS, these values can be in diagnosing entrapment neuropathies including CTS.
normal in early or mild stages. In these situations, special Ultrasound examination of the median nerve at the wrist has
studies may be required. Usually, further studies using internal been used to diagnose CTS, either alone or in conjunction
comparison to the ulnar or, less frequently, the radial nerve with electrodiagnostic studies, and correlates well with clinical
of the same hand are performed. These studies include com- symptoms. The median nerve is often noted to be enlarged
parison of the median (second lumbrical) and ulnar (inter- just proximal to site of entrapment. The criteria for diagnosis
ossei) distal motor latencies; the median and radial sensory usually involves measuring the cross-sectional area of the
604 Carpal Tunnel Syndrome

median nerve at the wrist, and a cut off exceeding 10 mm2 is orally or by direct injection into the carpal tunnel. Local
sensitive for diagnosis of CTS; however, the test is more spe- steroid injections provide better symptom relief than a short
cific when the cut off is greater than 12 mm2. course of oral steroids. A subgroup of patients in whom local
Although nerve enlargement has been reported as the most steroid injection are indicated includes the elderly and poor
common finding in nerve entrapment syndromes, other surgical candidates with complaints of pain. Steroid injections
findings reported include decrease in nerve echo texture, with may relieve pain within a few days and benefit may last from a
the nerve becoming more hypoechoic; changes in shape with few weeks to 6 months. Results from different authors indicate
the nerve more flattened or pinched; and enlargement of good to complete relief of symptoms in up to 81% of patients.
fascicle size and increased vascularity within the nerve with Disadvantages of steroid injections are that the effects are
Doppler studies. In CTS, there is also report of decrease in temporary and more than two or three injections are not ad-
median nerve mobility at the wrist. vised due to the danger of focal tendon damage and rupture.
Steroid injections can be useful in conditions in which CTS is
Differential Diagnosis expected to be of limited duration, such as during pregnancy.
If there is evidence of a mass lesion, thenar atrophy,
As mentioned earlier, other disorders have presented symp- denervation on EMG, or persistent or recurrent symptoms
toms similar to those of CTS. Peripheral causes include despite conservative therapies, then the definitive treatment is
proximal median neuropathy, brachial plexopathy, and cer- surgical decompression of the carpal tunnel by cutting the
vical radiculopathy. Compression of C6 and C7 cervical roots transverse carpal ligament. Both open carpal tunnel release
is the most common disorder mimicking CTS. Pain and par- (OCTR) and endoscopic carpal tunnel release (ECTR) have
esthesias in the arm and hand are common with C6 and C7 been used for treatment of CTS. ECTR and minimal OCTR are
radiculopathy. However, pain in the neck and shoulders is popular because they cause less postoperative discomfort and
much less common in CTS, and pain that is exacerbated by there is earlier return to functional activities. Both open and
neck movement or radiates to the chest wall or scapular in- endoscopic techniques have been shown to have similar long-
dicates cervical radiculopathy. Clinically, patients with cervical term results in relieving median nerve compression, as repre-
radiculopathy can have worsening symptoms during the day sented by subjective pain relief in the patients as well as
with arm use, whereas symptoms of CTS tend to exacerbate at functional status. Surgical complication rates of both OCTR
bedtime. On examination and during EMG studies, attention and ECTR are 1% when performed by experienced surgeons.
is paid to C6 and C7 innervated muscles to detect weakness or Complications include injuries to median, ulnar, and digital
denervation. There can also be diminished tendon reflex when nerves, arteries; or flexor tendons as well as incomplete release
compared to the unaffected side – the biceps reflex when C6 is due to incomplete ligation of the transverse carpal ligament.
involved and the triceps reflex if C7 root is affected. Complications appear to be more severe and more difficult to
Proximal median neuropathy around the elbow causes recognize in ECTR. Postoperative care in carpal tunnel release
paresthesias and numbness of the thenar eminence, and af- includes wrist splinting in a neutral position for several weeks.
fects the muscles in the forearm responsible for thumb flexion However, a prospective study found that patients who did not
(flexor pollicis longus), arm pronation (pronator teres and receive wrist splinting postoperatively had earlier functional
quadratus), and wrist flexion (flexor carpi radialis). Detection recovery than those splinted for 2 weeks, without an increase
of brachial plexopathy can be accomplished clinically if in complications. Both endoscopic and OCTR have been
sensory and motor deficits attributable to multiple nerves are shown to be safe and effective in treating CTS, without clear
present, with electrophysiological confirmation based on difference in outcome over the long-term follow-up.
nerve conduction testing and EMG findings. With treatment, the prognosis of CTS is excellent. Many
Rarely, symptoms from some central nervous system dis- patients present early in the disorder due to pain and par-
orders can be confused with those of CTS, including focal esthesias before any muscle atrophy or axonal loss has oc-
seizures and transient ischemic attacks. However, pain is curred. Patients whose main complaints are intermittent pain
usually not present in these conditions. and paresthesias without any fixed motor or sensory deficits
usually respond well to conservative treatment. Those with
persistent symptoms despite conservative management have
Treatment good symptom relief with surgery, with improvement in
85–90% of patients within days of operation. If persistent
In cases of acute CTS caused by fractures, hematoma, or sensory or motor deficits are present at the time of surgery,
compartment syndrome, appropriate surgical intervention or recovery will depend on whether the deficits are caused by
repair are necessary and may include carpal tunnel release to demyelination at the site of compression, leading to con-
protect the function of the median nerve. duction block, secondary axonal loss, or a combination of the
In idiopathic CTS, treatment can be either surgical or two. If the cause is conduction block, then remyelination after
nonsurgical. Patients with mild symptoms may be relieved by decompression is usually complete within a few weeks. If the
the use of a neutral wrist splint during sleep. Addition of a deficits are secondary to axonal loss, then recovery is expected
nonsteroidal antiinflammatory drug for 2 or 3 weeks can also to be slow over several months. In advanced cases in which
decrease pain in the wrist. Most of the symptom improvement thenar atrophy is prominent, motor and sensory recovery is
from splints occurs by 2 weeks. usually incomplete, although pain and paresthesias often
If symptoms recur or persist after a trial of splinting for a improve. In the past, elderly patients as well as patients with
few weeks, the next step in treatment may be steroids, either diabetes were considered to have poorer outcomes from carpal
 Carpal Tunnel Syndrome 605

tunnel release surgeries. However, recent prospective studies Bickel KD (2010) Carpal Tunnel Syndrome. Journal of Hand Surgery 35A:
have shown that elderly patients (470 years old) and diabetic 147–152.
Cartwright MS, White DL, Demar S, et al. (2011) Median nerve changes following
patients have similar symptom improvement and satisfaction
steroid injection for carpal tunnel syndrome. Muscle & Nerve 44: 25–29.
to matched controls. Therefore, patients with early CTS can be Marshall S, Tardif G, and Ashworth N (2007) Local corticosteroid injection for
managed with conservative treatment, but carpal tunnel re- carpal tunnel syndrome. Cochrane Database of Systematic Reviews 18:
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nonsurgical treatment. Mondelli M, Giannini F, and Giacchi M (2002) Carpal tunnel syndrome incidence in
a general population. Neurology 58: 289–294.
Nathan PA, Istvan JA, and Meadows KD (2005) A longitudinal study of predictors
of research-defined carpal tunnel syndrome in industrial workers: Findings at 17
See also: Brachial Plexopathies. Median Nerve and Neuropathy. years. Journal of Hand Surgery 30B: 593–598.
Phalen GS (1976) Reflections on 21 years experience with carpal tunnel syndrome.
Neuropathies, Entrapment. Neuropathies, Instrumental. Radiculopathy. Journal of the American Medical Association 212: 1365.
Sensation, Assessment of. Tarsal Tunnel Syndrome. Thoracic Outlet Preston DC (1999) Distal median neuropathies. Neurologic Clinics 17: 407–424.
Syndromes. Writer’s Cramp/Tremor Quality Standards Subcommittee of the American Academy of Neurology (1993)
Practice parameter for carpal tunnel syndrome. Neurology 43: 2406–2409.
Stevens JC, Sun S, Beard CM, et al. (1988) Carpal tunnel syndrome in Rochester,
Minnesota, 1961 to 1980. Mayo Clinic Proceedings 38: 134–138.
Further Reading Stevens JC, Witt JC, Smith BE, et al. (2001) The frequency of carpal tunnel
syndrome in computer users at a medical facility. Neurology 56: 1568–1570.
American Academy of Neurology, American Association of Electrodiagnostic Tapadia M, Mozaffar T, and Gupta R (2010) Compressive neuropathies of the upper
Medicine, and American Academy of Physical Medicine and Rehabilitation extremity: Update on pathophysiology, classification, and electrodiagnostic
(1993) Practice parameter for electrodiagnostic studies in carpal tunnel findings. Journal of Hand Surgery 35: 668–677.
syndrome. Neurology 43: 2404–2405. Vogelin E, Nuesch E, Juni P, et al. (2010) Sonographic follow-up of patients with
Atroshi I, Gummesson C, Johnsson R, et al. (1999) Prevalence of carpal tunnel carpal tunnel syndrome undergoing surgical or nonsurgical treatment:
syndrome in a general population. Journal of the American Medical Association Prospective cohort study. Journal of Hand Surgery 35A: 1401–1409.
282: 153–158. Weisler ER, Chloros GD, Cartwright MS, et al. (2006) The use of diagnostic
Atroshi I, Larsson GU, Ornstein E, et al. (2006) Outcomes of endoscopic surgery ultrasound in carpal tunnel syndrome. Journal of Hand Surgery 31A: 726–732.
compared with open surgery for carpal tunnel syndrome among employed Wong SM, Hui ACF, Tang A, et al. (2001) Local vs systemic corticosteroids in the
patients: Randomized controlled trial. British Medical Journal 332: 1473. treatment of carpal tunnel syndrome. Neurology 56: 1565–1567.