Diagnosis and Treatment of Carpal Tunnel Syndrome Case Study

Introduction
Carpal tunnel syndrome (CTS) is the most common compressive neuropathy affecting the hand.  The symptoms are caused by pressure applied to the median nerve in the carpal tunnel, presumably by the transverse carpal ligament, but the precise etiology for the development of this pressure is unknown in most cases. CTS is an important and costly cause of disability in the United States.  The association between CTS symptoms and workplace exposures is variably reported although the most common association is with jobs in the manufacturing sector.  The cost per injured worker has been estimated to be approximately $30,000.

The symptoms of CTS may be described in a variety of ways and the presenting complaints may include “numbness”, “tingling”, “pins and needles” or “pain”. The key consideration for the diagnostician is the recognition that the cardinal symptom of CTS is a sensory disturbance in the median nerve distribution however it may be described by the patients.

The diagnosis of CTS is primarily clinical in nature and depends on the recording of a set of symptoms and the observation of a few important physical examination findings.  Electrodiagnostic tests may have an important diagnostic role in some circumstances. Effective non-operative treatment for CTS is available and surgical release of the transverse carpal ligament is almost always successful.  Surgical treatment is usually reserved for cases in which non-operative treatment has failed although surgical treatment may be the first recommendation where there is clinical evidence of actual denervation in the hand, usually the result of longstanding and severe median nerve compression.

History and physical examination
A 60 year old female presents with a complaints of “tingling” affecting the thumb, index and middle fingers of the right hand.  This symptom began spontaneously about four months previously and was not associated with any injury or change in her activities. She first noted this symptom at night when it disrupted her sleep, sporadically at the outset but in recent weeks on almost a nightly basis. She is employed as a legal secretary. Her right hand is dominant.
 
The physical examination of the right hand does not reveal abnormalities on inspection; in particular the bulk of the intrinsic musculature of the hand, including the thenar eminence, is normal.  There is no tenderness to palpation in the hand.  The neurologic examination shows that the strength of the abductor pollicis brevis muscle is normal and is rated as grade V.  Two point discrimination in the distribution of the median nerve is normal. The Phalen test is positive.  The Tinel sign is positive – light tapping over the median nerve at the level of the carpal tunnel causes paraesthesiae radiating into the index and middle fingers.
 
 Management
On the basis of the history and physical examination a diagnosis of CTS is made and the patient is advised to undergo a steroid injection into the carpal canal and in addition, to begin splinting the hand in wrist brace preventing wrist flexion during sleep. Within two weeks the symptoms of tingling have been fully addressed.  The patient has continued with her usual work activities and gradually reduces her splint use over the next four weeks.
 
She returns for further follow-up about one year later. In the interim she states that the sensory symptom gradually returned about six months after splinting was fully discontinued.  She resumed nighttime splinting but the symptoms have persisted despite this treatment.  She intermittently experiences the symptoms during the day as well but she finds that daytime splinting is not practical because it disrupts her work activities to an unacceptable degree. The physical examination has not changed since the initial assessment. Because surgical release of the carpal tunnel is now a treatment option she is advised to undergo electrodiagnostic tests of her median nerve function.  These are performed within several weeks and confirm median nerve dysfunction at the level of the carpal tunnel. She is advised to undergo an open carpal tunnel release.
 
Outcome
As a result of the surgical release of the transverse carpal ligament the patient experiences an immediate resolution of the sensory symptoms. Although she is troubled by mild wound tenderness for the next six weeks she is able to return to all of her work activities with three weeks of the surgical procedure and without any formal program of post-operative rehabilitation. The wound tenderness has resolved by the time she is seen for a final follow-up three months after the surgical procedure.  The sensory symptoms remain fully resolved at that time.