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Threading the needle

Surgery can ease pain from tiny carpal tunnel

August 18, 2012
dsp By MaryAnn Kromer - Staff Writer (mkromer@advertiser-tribune.com) , The Advertiser-Tribune

The term "carpal tunnel" may sound like an amusement ride, but people who have this condition know it is anything but fun. Many people who use their hands on the job develop carpal tunnel syndrome, a condition that can causes burning pain, numbness or tingling, and weakness in the hand.

An injury or frequent, repetitious movements of the wrist and hand can irritate the median nerve, which transmits impulses to the palm, thumb, index and middle fingers. The nerve and nine tendons pass through the wrist below the transverse carpal ligament through a narrow "tunnel" of tissue and bone. Swelling in this canal squeezes the nerve and impairs sensation in the hand.

Dr. Steven Copeland has been practicing in the Tiffin area for seven years. A 1999 graduate of the University of Chicago, he treats carpal tunnel patients in the office of Ohio Orthopedics and Sports Medicine. The company has offices in Findlay and in the Mercy Office Building adjacent to Mercy Tiffin Hospital.

Article Photos

PHOTO BY MARYANN KROMER
Dr. Steven Copeland points to the spot where he would insert endoscopic tools to perform carpal tunnel surgery.

"It's something I've seen pretty steadily since I've been in practice. ... Prevention is tough because so many people we're seeing do repetitive activities - factory work, jobs that require repetitive use of the hands. It becomes a bit challenging to avoid those things, if that's what your job is. So it's a tough condition to prevent."

A few employers rotate employees to different stations during their shifts. Other job sites may schedule breaks in which workers are given time to rest their hands and do exercises to extend the fingers, wrists and shoulders and alleviate strain. Copeland is not aware of any local companies with that policy.

"I have not heard of one person in this area that ever mentioned that's something that they did. That doesn't mean it's not happening," he said.

Fact Box

To prevent strain on the arms and hands at the computer

Elbows should be level with or slightly higher than the keyboard.

Raise the chair high enough to keep the elbows level.

The keyboard should be relatively flat to prevent stretching the wrists.

A cushion or pad under the wrist can keep it in the proper position.

Supporting the forearm from elbow to mouse hand reduces strain on the entire arm.

Courtesy of www.chiropractic-help.com

More about carpal tunnel

The National Institute of Neurological Disorders and Stroke has compiled information about carpal tunnel syndrome on the National Institute of Health website, http://www.ninds.nih.gov/

disorders/carpal_tunnel/carpal_tunnel.htm

The first symptoms of carpal tunnel typically develop at night when the patient sleeps with flexed wrists. The person's dominant hand usually is the first to be affected. As the condition progresses, the symptoms also occur during the day, causing difficulties in making a fist or grasping small objects. If carpal tunnel is not treated, the muscles at the base of the thumb can deteriorate, and the person may not be able to sense heat and cold in the affected hand.

People who use vibrating hand tools or who work on assembly lines doing activities such as sewing, packing, lifting, cutting and cleaning, often suffer from carpal tunnel. Computer use with bent wrists also can cause irritation. These motions have not been proven to cause the condition, but they can contribute to the symptoms.

Known causes include trauma to the wrist or hand; rheumatoid arthritis; alcoholism; obesity; multiple sclerosis; pituitary or thyroid disorders; diabetes; fluid retention; especially small nerve canals; and tumors or cysts in the canal.

To diagnose the condition, the physician first checks the neck, shoulders, arms and hands.

Lab tests and X-rays can reveal fractures, arthritis, diabetes and other diseases. These are treated first to see if symptoms improve.

Ultrasound and MRI can show if the person's anatomy is the problem.

If carpal tunnel is diagnosed in its early stages, the patient may be able to get relief from conservative treatments. Resting the affected hand for two weeks is the first step. A wrist splint can be worn to reduce flexing and twisting. Cold packs can be useful for swelling, and over-the-counter pain relievers can be tried. Supplements of vitamin B6 have been reported to help some patients. Yoga can reduce pain and strengthen one's grip. More aggressive treatments include injections of corticosteroids or lidocaine.

If conservative measures are not effective, outpatient surgery can be performed. The surgeon cuts the transverse ligament to enlarge the nerve canal and relieve pressure. There are some risks, such as infection, nerve damage, stiffness and pain at the incision site, but most clients have good results.

To prevent carpal tunnel syndrome, employers can allow workers to rotate jobs, take rest breaks or require them to do exercises during the work shift. Sometimes, the design of tools and work stations can be adjusted to protect workers' hands.

Individuals can help themselves with good posture, proper wrist positions, stretching exercises and splints to wear on the job.

When a person comes to the office with symptoms of carpal tunnel syndrome, Copeland does a series of physical tests to check the patient's range of motion, tenderness, swelling, discoloration and other factors.

The physical tests can help pinpoint the cause of symptoms and rule out posture issues and other conditions that could cause the same symptoms.

"One of the very common things is night pain ... that wakes them up. That is a sign to be checked by a doctor," Copeland said.

Sometimes lab tests are needed if multiple sclerosis, arthritis, diabetes or other diseases are suspected. X-rays or magnetic resonance imaging can reveal fractures or an abnormally small carpal tunnel. An electromyography study or nerve conduction study, typically is done by a neurologist or a physical medicine and rehabilitation doctor to confirm the diagnosis.

"Usually, when someone comes in with numbness and tingling in their fingers, you can get a good sense if it's carpal tunnel or if it is coming from a different nerve in the forearm or the neck. Or there are central nervous system conditions that can cause numbness and tingling," Copeland said.

If carpal tunnel is detected in the early stages, rest and exercises may give significant relief.

Over-the-counter anti-inflammatory drugs, such as aspirin and ibuprofen, can be helpful, as long as the patient can tolerate them.

Copeland said pain medications do not have much effect on nerve pain, so he does not prescribe them for carpal tunnel. Wrist splints, especially when worn at night, help many patients.

Some references suggest applying ice for swelling or heat to improve circulation. Copeland disagrees with those tactics.

"For treatment for carpal tunnel, I do not recommend cold or heat. I have not found either one of those to give people much benefit," he said.

Corticosteroid injections can give short-term relief. Copeland said he uses ultrasound guidance to place the injection for the most effective results.

Hydro-dissection with ultrasound guidance is a newer procedure to inject medication between the ligament and the nerve. Copeland said "the jury is still out" on its value.

Most carpal tunnel patients are encouraged to try non-surgical treatments first and save surgery as a last resort. Once the condition becomes severe, Copeland recommends surgery right away. People who wait too long for the surgery may not get full recovery of sensation and strength in the affected hands.

"With the surgery, essentially, you take the pressure off the nerve. You don't go in there and fix the nerve. The body has to recover," he explained.

The surgery entails cutting the transverse carpal ligament to relieve pressure on the nerve. In the past, surgeons did open surgery with a two-inch incision made in the palm. About 20 years ago, an endoscopic procedure was developed. A tube carrying a tiny camera and blade is inserted through a small lateral cut. The camera guides the surgeon to the ligament and the blade makes the cut. Both kinds of surgery give good results, but "Your thumb, index, and middle fingers are your fine motor fingers of your hand, so you really need those," Boes said.

Most patients choose endoscopic surgery.

"The advantage of endoscopic is less pain and people get better faster," Copeland said. "It's an outpatient surgery. It takes about 10 minutes to do and you're in and out the same day."

Patients for either technique receive a sedative to remain semi-conscious and the skin is numbed at the incision site.

Copeland said he occasionally does use the open procedure for patients who did not get relief from a prior surgery. They tend to have better results with open surgery. Scar tissue eventually fills in the gap in the ligament.

People who plan to return to a job of repetitive movement or heavy lifting usually must wait six weeks after surgery to resume work.

Those with lighter use of their hands are advised to take off at least a week before going back to work.

"I tell people the day of surgery that when they come back to see me their goal is to be able to make a full fist. Starting the day of surgery, they are doing their own therapy working on motion," Copeland said.

About half of his patients recover without physical therapy after the surgery. Those who cannot make a fist two weeks after surgery are referred for rehabilitation.

For those who need to get back on the job, physical therapy can help a person regain strength flexibility and sensation more quickly.

People who use a computer at work are less likely to suffer from carpal tunnel, but it can occur. Ergonomics can be employed to prevent and relieve symptoms of carpal tunnel.

"The main thing would be the level of the keyboard. I tell people it's one of those things you have to experiment with. If your hands are going numb when you're typing on the keyboard, a lot of times it's coming from the ulnar nerve (in the elbow) and not the median nerve. In general, their keyboard is too high. They can raise their seat, lower their keyboard or keep the keyboard on their lap."

Wrist cushions also may be helpful, but Copeland said it is better not to rest the wrist on a hard surface. The hand and forearm should form a straight line with the fingers curving downward to do most of the typing motions.

His advice is to consult a doctor if one suspects carpal tunnel to get the symptoms under control.

 
 

 

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