Transcription:
How to Deal with Carpal Tunnel Syndrome

Michael Carrese (Host):  It’s one of the most common nerve disorders affecting millions of Americans and costing billions every year in lost wages and productivity. I’m talking about carpal tunnel syndrome and we’ll be learning all about it today from Dr. Theresa Wyrick, an Orthopedic Hand Surgeon with University of Arkansas for Medical Sciences. This is UAMS Health Talk. I’m Michael Carrese. Dr. Wyrick, thanks for joining us. And I suppose it makes sense to start by asking you to explain what carpal tunnel syndrome is and why is it so common?

Theresa Wyrick, MD (Guest):  Sure. Carpal tunnel syndrome is basically a pinched nerve at the wrist. So, basically you have a series of three nerves that supply sensation and movement for the hand and for the fingers. One of those nerves is called the median nerve and that’s the one that becomes pinched or compressed in carpal tunnel syndrome.

The anatomy is such that on the palm side of the wrist, there truly is a tunnel. So, if you think about driving your car through a tunnel where it has a floor, two sides and a roof; that is the same kind of tunnel structure that exists in your wrist. And inside that tunnel; is the median nerve which we will talk about more and also the nine tendons that flex or bend the fingers and the thumb.

So, it’s basically an enclosed space and there’s not really room for anything extra.

Host:  Yeah it sound pretty crowded if you have nine tendons and the nerve in there.

Dr. Wyrick:  Right, right. It is. It can get crowded. So, the floor of the tunnel and the sides of the tunnel are a rigid structure which are the carpal bones or the bones in the wrist. So, they don’t really have any give in them. On the roof of the tunnel, you have the ligament type structure and so what happens is within this enclosed tunnel where the nerve sits or lives, if that ligament which is the roof becomes thickened; then it narrows the space in the tunnel and that then puts pressure on the nerve and the nerve is sensitive to that pressure and it makes the nerve not work.

So, it would be much like if you were sitting on your foot and your foot goes to sleep. That pressure related phenomenon that makes your foot tingle and burn and sting and not work right and then wake up; that’s the same sort of phenomenon that happens in your fingers whenever you have that compression or pinched nerves in the setting of carpal tunnel syndrome. So, that’s the most common symptom that you will see.

Host:  And what kind of motion will produce all of that?

Dr. Wyrick:  Well, it can happen at rest, but it seems like it puts more pressure on the nerve if you are doing a lot of movement. So, we think that repetitive task, repetitive movement of the fingers can increase the pressure in the tunnel. We also think that holding the wrist in maximally flexed or even a maximally extended position puts more pressure on the wrist mechanically and puts more pressure on the nerve and that can make the nerve not work.

Sometimes, we’ll see patients who complain of worsening symptoms if their gripping for a period of time such as gripping a steering wheel where they have to constantly shift hands because one hand is going number when they are driving long distances. Holding a phone up to your ear, holding up a newspaper or a book or a magazine. Sometimes, for women using a hair dryer or brushing their hair, putting on eye makeup. Anything that sort of requires a sustained pinch or grip over time, can also cause symptoms.

Host:  And do you find patients coming in thinking any kind of wrist pain is carpal tunnel? Can it be misdiagnosed or misunderstood?

Dr. Wyrick:  Sure. I think a lot of people don’t actually know that carpal tunnel syndrome is going to produce nerve like symptoms. So, a lot of people know the term carpal tunnel syndrome but may not know exactly what it is. And so, they are also somewhat worried about it or fearful of it because they may have heard stories of people who have lots of trouble with carpal tunnel syndrome and it can be quite debilitating and so, they worry that any symptom they might have in their hands might be carpal tunnel syndrome.

And certainly, carpal tunnel syndrome is a really common hand and wrist complaint that I see in my practice. But it is certainly not the cause of all wrist and hand complaints. And so, sometimes people kind of worry that it’s carpal tunnel syndrome and it may be, and it may not be. So, it certainly does require a thorough history and evaluation to figure out if that’s what’s going on or it it’s something else.

Host:  So, talk about that process of evaluation. What do you do when you have a patient with you that has this concern?

Dr. Wyrick:  Most importantly we ask a thorough history as to when the symptoms are occurring, what exactly are the symptoms. In carpal tunnel syndrome they’ll have sensation of pins and needles, numbness in the fingers, classically the numbness involves the thumb, pointer and middle fingers because that’s the median nerve which is the one that’s compressed. Those are the fingers that it supplies sensation in. and then we’ll also ask when does it bother you and so people say when they have carpal tunnel syndrome; people will say some of those things like we talked about like gripping a steering wheel or holding a phone. It also seems to be something that wakes people up from sleep at night. That’s a really common complaint.

So, they’ll wake up in the middle of the night or early morning hours with the hand being numb and tingly and asleep and so that’s a really debilitating symptom because if they can’t get good rest at night; then that makes everything else not tolerable. So, a lot of times, people are really miserable because they are not resting well at night. Because carpal tunnel syndrome will often flare up at night.

We’ll ask about what the symptoms are exactly and see if that fits with a possible diagnosis of carpal tunnel syndrome. Although it is a nerve problem, we usually will get x-rays to look at the bones and see if there is anything abnormal from the standpoint of the bones that may suggest that they are a part of the problem that’s causing pressure on the nerves or whether there might be something else that might be causing their symptoms. So, that would be a routine part of the evaluation.

And then when we do our physical exam, we are checking for grip strength, we’re checking for movement, we’re checking sensation. So, we’ll do all of those things on exam. We’ll also screen for things that can mimic carpal tunnel syndrome like a pinched nerve at the elbow which is called cubital tunnel syndrome and then also a pinched nerve in the neck which is called cervical radiculopathy. So, those are things that can mimic carpal tunnel syndrome, so we want to make sure that we have the right diagnosis and we have localized the right area of compression of the nerve. The nerve sort of comes off the spinal cord and acts like a water hose if you will delivering the nerve signal all the way down the arm to all the muscles and eventually to the fingers to give sensation.

And so, the idea is that if there is compression anywhere along that nerve or that water hose if you will; it can cause symptoms downstream and so we want to make sure that we’ve examined upstream and downstream fully to make sure that we’ve localized the problem correctly.

And then lastly, there is a test which is called a nerve conduction test or an electromyogram and that’s usually done by a neurologist or a physical medicine doctor and it’s a test the involves looking at how well the nerves in the arm are conducting their signals. And so, basically, it involves stickers that are placed on the arm and some needles to examine the health of the muscle. But that really give us objective data on how well the nerves are doing their job. If there is slowing of the signal or compression and exactly where the problem is in the nerve, if it’s in the neck or at the elbow or it’s at the wrist and is consistent with carpal tunnel syndrome.

Host:  You’re listening to Dr. Theresa Wyrick. She’s an Orthopedic Hand Surgeon with the University of Arkansas for Medical Sciences. We’re talking about carpal tunnel syndrome. So, you’ve done all that evaluation and diagnosis, what is typically the next step for most patients in terms of treating this?

Dr. Wyrick:  When we have the right diagnosis and we’ve confirmed that it’s carpal tunnel syndrome, if from the standpoint of the objective electrodiagnostic testing it shows that there are signs of nerve damage or the compression is severe and it is categorized as severe carpal tunnel syndrome; then we worry about permanent nerve damage and so in that case, we often would recommend not trying a course of conservative treatment but going ahead and considering surgery which would be a carpal tunnel release. Because if you have signs of nerve damage then the nonsurgical treatment is not going to help, and we also worry about permanent loss of sensation or function.

So, in those patients, we want to go ahead and recommend surgery, take the pressure off the nerve surgically so that we can give the nerve the opportunity to recover. Outside of those people who have severe carpal tunnel syndrome, if it happens to be mild or moderate on the objective electrodiagnostic testing; then we might try a course of nonsurgical treatment and so that would include using a wrist brace which would support the wrist in a neutral position. Usually we would tell the patient to sleep in it at night because many times that’s the time when they are having a lot of trouble and a lot of symptoms and so that can be very helpful.

We also try and recommend limiting repetitive motion activities. So, for instance, if you type a lot; that can be an aggravating factor for carpal tunnel syndrome so we would recommend that you take frequent breaks, rest your hands, try and type for a while but then do some other task that you might have to do like telephone work or something like that so that you are resting the hands. And those are kind of the nonsurgical treatments that we think probably work the best.

Host:  And there’s also a lot of knowledge now about how you have your hands positioned when you are sitting and typing and doing different activities too, right?

Dr. Wyrick:  Right. We know that having to do long term repetitive desk work and computer work can be difficult not only from the standpoint of carpal tunnel syndrome but just from the standpoint of overuse tendonitis, neck pain, shoulder pain, all of those sorts of things and so it is important to really evaluate your workstation if you are someone who has to sit at a desk frequently and make sure that you are in a comfortable position. Usually we would tell people that you want to sit with both feet flat on the floor, try and have a good back support in your chair, usually have some sort of wrist or gel pad that can help you so that you keep your wrists in a more neutral position when you are typing.

And then also again, just trying to take frequent breaks to make sure that you are resting your muscles and you are stretching if you need to.

Dr. Wyrick:  So, as we wrap up here Dr. Wyrick, what do you wish people understood more about carpal tunnel syndrome?

Dr. Wyrick:  Well we do talk about trying to do things to prevent it but ultimately, it’s a really common diagnosis. We actually think that everyone will develop carpal tunnel syndrome at some point in their life and will deal with it. I think that what you also should know is that it’s very treatable. Surgical treatment for carpal tunnel syndrome is very successful and can prevent long-term nerve damage and loss of function. It’s also very little down time from the standpoint of doing the surgery, we can do it which just some numbing medicine and a little bit of sedation and some cases just with some numbing medicine done at an outpatient surgery procedure sort of setting. So, it doesn’t require general anesthesia. It’s a very low risk procedure. After surgery, you can start using the hand right away for light things. You can drive the following day. You can get your hands wet and wash them and do hygiene and activities within about 48 hours and the sutures would come out at about 12 days.

So, it’s a very quick recovery and very little down time and it’s a really gratifying thing. I think it’s probably one of the most gratifying surgeries that I do because it’s technically very straightforward. The patients are very happy that we’ve restored quality of life and also importantly, return to a good night sleep and so when they come back to see me after their carpal tunnel release and they are sleeping through the night and they no longer have problems with burning and tingling in the hands, they are very happy, and they are very grateful.

And so, I like making people happy and this is one of the surgeries that makes people the happiest. So, it makes my job easy and enjoyable.

Host:  Oh I’m sure it’s very satisfying. Well I’m afraid we’re going to have to leave it there. But I want to thank our guest Dr. Theresa Wyrick who is an Orthopedic Hand Surgeon with the University of Arkansas for Medical Sciences. For more information on Dr. Wyrick and carpal tunnel treatment, you can go to www.uamshealth.com. If you found this podcast helpful, please share it on your social channels or check our full podcast library for additional topics that may interest you. This has been UAMS Health Talk. Thanks for listening.