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Carpal   Tunnel   Syndrome (Is there a need for an operation ?)

V. V. Tolkachov, V. S. Tolkachov (Point of view)

The most common illness affecting the hands, which can lead to partial or full disability, is the Carpal Tunnel Syndrome (CTS). Over 75 million people suffer from CTS, mainly in the industrialized countries (Karjalainen A., Niederlaender E. 2004). The peak time during which this illness surfaces in people is between the ages of 35-60. Also, in the affected group, there are people of the working age (Popelyansky Ya.Yu. 2003). This problem occurs 3-5 times more often in women than in men (Berzins Y. E. 2003). The cause of CTS is currently unknown.

Most of the researchers believe that the primary cause of CTS is long working hours with monotonous movement of the hands. This kind of work causes prolonged mechanical trauma on the wrist joint and the carpal tunnel. On the basis of this research, Liu et al. concluded that the carpal tunnel syndrome occurred in 1/6 surveyed people who worked on a computer.

In today’s world, working on a computer is considered to be one of the basic factors which can lead to the development of CTS. The information field is full of accusations against the keyboard and mouse and have conducted extensive research in this direction. After that, an unofficial name appeared “Syndrome of the Computer Mouse” or “Mouse’s disease”. With this analogy, smartphones can be included as a risk factor. The newly queued name for CTS is “Smartphone Syndrome”.

It seems unconvincing since the authors had only focused on the localized problem with the carpal tunnel. For example, how is it possible to explain the fact, based on the dominating “mouse theory”, the other hand can be affected when it had not had the chance to hold the “mouse” by its “tail”?

According to Hanrahan, in the US, every year there are between 400,000 – 500,000 operations for CTS. The economic costs for this exceed $2 billion. Other sources indicate that for the carpal tunnel syndrome, the fees incurred for one operation in the US are approx. $30,000.

The problem with treating the patients in this category is far from being resolved. Since, despite the use of modern technology, the number of unsatisfactory results and relapse in the late post-operative period is 10-20% and sometimes more.

The major complications, following surgical procedure on the wrist with the purpose of decompressing the carpal canal, are: the formation of scar contractures, damage to the median nerve, wound infection (Mackinnon SE. 1991).

From the shown data, we can see that there is an unclear prognosis with regard to the recovery of disturbed functions of the upper limbs. Oftentimes, the illness can lead to problems with household adaptation, incompetence at work, and sometimes disability. Therefore, it is important to continue developing effective methods for early detection of CTS and sound treatment.

Carpal tunnel syndrome has many synonyms: entrapment neuropathy, ischemic neuropathy, traps syndrome, trapped neuropathy, and tunnel neuropathy.

Definition (common version): CTS is regarded as one of the types of compression neuropathies. This is based on a local pinching of the median nerve at the point where it passes through the narrow anatomical tunnel under the transverse carpal ligament. The disease manifests complex pain, sensory, motor, autonomic and trophic disorders.


Carpal tunnel (anatomic and physiological features)

Carpal tunnel (carpalis capri.) is a narrow tunnel on the palm side with the size of 2cm in diameter. It consists of bones, muscles, and tendons of the wrist. Through the tunnel, the tendons, which allow you to bend your fingers and wrist, blood vessels, and the median nerve, pass freely.

The top of the channel is covered by a large ligament (transverse carpal ligament) or flexor (Latin: Retinaculum flexorum). It is stretched between the radius and ulna, and appears as a strip of strong connective tissue.

The purpose of the ligament is derived from its name (Retinaculum flexorum ) i.e. it serves to contain and protect the contents of the carpal tunnel: tendons, muscles used to bend the fingers and hand, blood vessels, and the median nerve. Outside of that, the ligament keeps the small bones in the wrist together for normal functionality of the hand and is a connective location for muscles which allow for the movements of the thumb and little finger. When the ligament is cut, these functions are either partially or fully lost.

The median nerve (anatomical and physiological features)

The median nerve (Latin: Nervus medianus), comes from the fibers of the lower cervical and first thoracic (C5 – T1) spinal roots and is formed by the merging of the lateral and median cords of the brachial plexus. Brachial plexus is located, just as in the sphincter, between then anterior and middle scalene muscles, and one rib below. On the forearm, the nerve emerges between the superficial and deep flexor muscles of the fingers and gives them their branches. Then, through the opening of the carpal tunnel, it joins with the palmar surface of the hand along with the tendons of the flexor muscles. The channel nerve is the most superficial, directly under the transverse carpal ligament. After that, it is divided into branches and supplies the large area of the index, the middle, and the pinkie fingers.

The median nerve is mixed. It consists of sensory, motor, and sympathetic fibers. The latter regulates the tone of the walls of the blood and lymph vessels in the wrist.

To function properly, the nerve should be free to slip in the surrounding tissues and structures. During the movement of the extremities, the nerve is able to glide longitudinally within the few millimetres, which protects it from hyperextension (Kalmin O. V., 1988; Sunderland S., 1990; Lundbord G., 1996).

Normally, the median nerve is not exposed to the compression of the carpal tunnel and the wrist movements do not disturb its function.

The most commonly reported complaints and clinical manifestations of the CTS: the weakness of the hand, numbness in the fingers, and presence of paresthesias (tingling or pins and needles). Pain also accompanies the condition. It can be periodic, constant, aching, burning, and shooting. Painful symptoms are usually worse at night. The patient is forced to out of bed a few times to knead their hands, which can bring temporary relief. Increased pain can be provoked by any physical activity. As the condition progresses the wrist becomes harder to control, there’s loss of motor function. The patient experiences difficulty in carrying out even the simplest daily tasks. There is a possibility of vascular disorders, which appear as paleness or marble skin tone and swelling of the hand. In advanced cases, the patient develops a muscle atrophy of the thumb (thenar) and the wrist appears like a “monkey’s hand”. Chronic pain, prolonged and frequent interruptions of sleep leads to depletion of the nervous system and development of neurotic disorders.

Our experience indicates that treatment should begin with the repositioning of the vertebrae in the problem area. When conducting manual therapy, it is important to take into the account the structural features of the spine at the level of lower-cervical and upper-thoracic (C6-T4) sections. The mobility of the vertebrae at this level is significantly limited due to the presence of fixed joints between the transverse processes of the vertebrae and rib arcs. That is why the manipulation technique the doctor possesses is very important.

We have developed a technique of manual therapy that eliminates the intervertebral blocks at a designated level to restore the physiological position of the vertebrae and improve the condition of the surrounding tissues as well as eliminate tension in your neck and shoulder area.

Patient N had an operation to cut the carpal ligament on the right wrist with the purpose of decompression of the median nerve (visible postoperative scar). In the pictures we can see the residual effects, a year after the operation: presence of edema, more pronounced on the other hand, signs of vascular dystrophy as we can see the marbling of the skin. When testing the patient’s strength, right arm (operated) is weaker than the left. Due to the presence of carpal tunnel syndrome in the left hand, the patient is queued for a similar operation. Currently, the patient is being treated at out centre, according to our methodology. Goal: removal of residual effects after undergoing surgery on her right hand, removal of pain, and recovery of functionality of the left hand (without surgery).

Edematous degenerative disorders of the soft tissue in the right hand a year after undergoing surgery.