"Carpal Tunnel" will be seen in this column often because of the extent of the emphasis on it today. What follows would be a very conservative and thorough medical investigation as to the diagnosis of carpal tunnel. This will allow better discussion of alternative treatment regimens with company medical personnel, in order to initiate preventative concepts.
Not every patient with carpal tunnel syndrome (CTS) needs surgery. Total disability with rest of the hands, or a change in occupational duties with less repetitious motion will help. Various splints of the wrist joint are used during work in the hope of reducing symptoms. Wearing a night splint to prevent flexion, etc., often helps. Right-handed people with only left CTS should be asked to remove their wrist watch.
Proper medication to reduce water retention or diabetes may also relieve symptoms. If the CTS is mild or of short duration, conservative treatment is highly recommended.
Steroid injection into the carpal tunnel may give dramatic but transient relief. This is accomplished by an injection through a #25 gauge needle into the carpal tunnel, medial to the median nerve. This seldom causes permanent relief.
Relief can usually be achieved by not working or by changing jobs temporarily. But, symptoms usually reoccur after the employee returns to his former work. This is the basis of the argument for not delaying surgery in well-established cases. The benefits of total or partial disability are transient and eventually add only to the total cost until the cause is corrected.
Recently, the carpal tunnel syndrome has been associated with pyridoxine (B6) deficiency. Proponents of this recommend 200 mg daily for six weeks. In cases of proven deficiency (50 percent of CTS cases) the symptomatic relief is definite. The basis of its action is not known, but the Institute for Biomedical Research, University of Texas, is currently working with a large series and is soliciting industrial participation. This treatment is not widely used and not yet scientifically proven.
The operation is a simple one. Some have been done as an outpatient using local anesthesia. But the majority of procedures are done with general or, more commonly, intravenous regional block anesthesia. The latter is accomplished by fixing a needle into a vein near the wrist, elevating and wrapping an elastic bandage about the hand and forearm to collapse the vascular spaces, and inflating a blood pressure cuff on the arm to 280 mm Hg. The elastic is removed and 50 cc of .5% Xylocaine is injected into the vein and capillary bed. Anesthesia is excellent until shortly after release of the cuff pressure.
Through a longitudinal incision in the proximal palm, following the skin lines, the dense transverse carpal ligament is divided. The underlying median nerve is protected. It is exceedingly important to incise all the fibers of the ligament and also to avoid injury to branches of the median nerve. The occasionally abundant, thickened synovia may require excision. The skin is closed and the hand and wrist are wrapped with a splint and a compression dressing and elevated. The blood pressure cuff is deflated and removed. If the disease is bilateral the second hand is operated upon after the first is functional (two to three weeks).
The operation is usually followed by immediate relief of pain, and the numbness disappears in the vast majority of the cases. After healing and return of function, the employee may return to the previous work.
Complications of Surgery
- Incomplete division of the transverse carpal ligament.
- Injuries to the palmar cutaneous branch of the median nerve.
- Sympathetic dystrophy.
- Hypertrophic scar.
- Palmar hematoma.
- Bowstring of flexor tendons.
- Adhesion of flexor tendons.
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