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Carpal tunnel syndrome is the most common compressive neuropathy in the upper extremity, affecting as many as one in 20 people in the United States. Initial non-operative treatment with wrist splints can be very effective, with surgery reserved for patients with persistent or advanced symptoms.

The orthopedic team at HSS at NewYork-Presbyterian ³ûÖ­ÊÓƵ is highly experienced in the diagnosis and treatment of carpal tunnel syndrome, offering non-invasive diagnostic options as well as minimally invasive endoscopic carpal tunnel surgery to relieve symptoms.

Symptoms and Causes

Carpal tunnel syndrome is caused by compression of the median nerve at the level of the wrist. In its earliest stages, it may cause intermittent symptoms during certain activities or wake up the patient at nighttime. Patients report feeling like they need to shake their hand or drop it off the edge of the bed to alleviate symptoms. Paresthesias are present in the distribution of the median nerve, which classically include the thumb, index finger, middle finger, and the radial half of the ring finger. As the condition progresses, patients may report constant hand numbness, tingling, pain, and weakness. In cases with long-standing nerve compression, patients may have visible atrophy of the thenar muscles in the hand.

Occupations associated with repetitive exposure to vibration, such as operating a jackhammer, are a known risk factor. Texting or computer use may not directly cause carpal tunnel syndrome, but can aggravate symptoms. Carpal tunnel syndrome may also be present in association with wrist trauma or in the setting of pregnancy.

Making the Diagnosis

The symptoms of carpal tunnel syndrome may mimic those of other conditions, including:

• Cervical radiculopathy
• Peripheral polyneuropathy, such as that associated with diabetes
• Other peripheral compressive neuropathies, such as cubital tunnel syndrome or radial tunnel syndrome

The diagnosis of carpal tunnel syndrome can be made by taking a careful history and performing a physical examination that includes provocative maneuvers. Electrodiagnostic studies, including nerve conduction studies and electromyography (EMG), were previously considered as standard components of the diagnostic pathway for carpal tunnel syndrome, but are now ordered only in cases with intermediate pre-test probability or atypical presentation.

At HSS at New York-Presbyterian ³ûÖ­ÊÓƵ, doctors employ in-office ultrasound to evaluate the median nerve non-invasively during the initial consultation. High-resolution ultrasound evaluation can identify enlargement or swelling of the median nerve in the carpal tunnel and thickening of the flexor retinaculum, which are characteristic changes seen in carpal tunnel syndrome. Additionally, an ultrasound-guided carpal tunnel corticosteroid injection can be performed to not only relieve symptoms, but also to serve a diagnostic role in atypical cases.

When to Refer Your Patient to a Hand Surgeon

Non-operative treatments for carpal tunnel syndrome typically include:

• Activity modification, such as avoiding prolonged flexion or extension of the wrist and limiting repetitive wrist motions
• Anti-inflammatory medications
• Wearing a splint at night to maintain the wrist in a neutral position
• Therapy
• Corticosteroid injections

Primary care physicians often make the initial diagnosis of carpal tunnel syndrome and can initiate non-operative treatments, such as wrist splinting and anti-inflammatory medications. If symptoms persist despite splinting and lifestyle modifications or become more severe, referral to a hand surgeon is recommended.

Carpal Tunnel Surgery

When non-surgical therapies are not sufficiently effective to relieve the symptoms of carpal tunnel syndrome, surgery may be indicated. Patients who fail to benefit from initial non-surgical treatments and those with severe symptoms, such as constant numbness in the fingers or muscle atrophy, may benefit from surgery to achieve symptom relief and prevent progression.

During carpal tunnel surgery, the surgeon relieves compression of the median nerve by releasing the transverse carpal ligament in the wrist. It is performed as an outpatient procedure under local anesthesia or light sedation. There are two approaches, both of which are equally effective:

• During open carpal tunnel release, the surgeon makes a 2-3 cm incision in the palm directly over the carpal tunnel and cuts the transverse carpal ligament.
• With endoscopic carpal tunnel release, the surgeon makes an incision in the wrist less than a centimeter in size. Utilizing a camera and specialized endoscopic instruments, the surgeon releases the transverse carpal ligament. The endoscopic approach results in a smaller scar, less pain, and a quicker return to normal activities. The physicians at HSS at New York-Presbyterian ³ûÖ­ÊÓƵ have the training and access to specialized instrumentation to perform endoscopic carpal tunnel release.

After surgery, many patients report immediate improvement in their symptoms, such as nighttime pain, tingling, and numbness. It may take longer for more severe symptoms to resolve. Most patients can return to light activities or desk work within one week; those with more physically demanding jobs may need more time to return to their full activities. Carpal tunnel surgery typically achieves permanent relief of symptoms, and most patients do not require another operation.

Intra-operative image showing the transverse carpal ligament in the wrist before it is released during endoscopic carpal tunnel release.

Referring a Patient

Do you have a patient with persistent symptoms of carpal tunnel syndrome? Contact us at 212-746-4500 to refer a patient to HSS at NYP ³ûÖ­ÊÓƵ for a comprehensive diagnostic workup and treatment