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|NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS
|Year : 2018 | Volume
| Issue : 3 | Page : 674-675
Carpal tunnel syndrome: The lessons learnt and the points often overlooked in its management
Department of Neurosurgery, P D Hinduja Hospital, Veer Savarkar Marg, Mahim (W)Mumbai, Maharashtra, India
|Date of Web Publication||15-May-2018|
Dr. Ketan Desai
Department of Neurosurgery, P D Hinduja Hospital, Veer Savarkar Marg, Mahim (W) Mumbai - 400 016, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Desai K. Carpal tunnel syndrome: The lessons learnt and the points often overlooked in its management. Neurol India 2018;66:674-5
Carpal tunnel syndrome (CTS) classically presents with pain and weakness in the hand due to compression of the median nerve inside the carpal tunnel. Almost 80%-90% of entrapment neuropathies are due to CTS. The exact cause and pathogenesis of CTS is unclear, and hence, it is related to numerous risk factors like size of the carpal tunnel; pregnancy; occupations involving exposure of the hand and wrist to a high pressure, a high force, repetitive work and vibrating tools; and, systemic co-morbidities like obesity, thyroid dysfunction, diabetes mellitus, and rheumatoid arthritis. The clinical presentation shows varying manifestations like pain and paresthesias in the hand and digits, as well as motor weakness and wasting of the hand muscles. In 9% of cases of CTS, there is associated ulnar nerve involvement in Guyon's or cubital tunnel. The patient with mild symptoms of CTS can be managed with conservative treatment like wrist support and local injection of steroids. However, in moderate-to-severe cases, surgery is the best treatment option that provides cure. The basic principle of surgery is to expand the volume of the carpal tunnel by dividing the tough transverse carpal ligament (TCL) to release the pressure on the median nerve. The overall results of surgery are rewarding and patients shows a dramatic relief in pain as well as paresthesia, and the motor weakness also improves over time.
Sharief et al., in their article, have brought out and discussed some very important points related to CTS. The association of risk factors like occupations related to repetitive work involving the wrist and fingers, vibrating tools and co-morbidities like hypothyroidism, obesity, diabetes and rheumatic disease are known to be associated with CTS. We see an increased number of patients with these risk factors and co-morbidities. They have also highlighted a strong association of obesity and female gender with CTS and the literature review also supports these findings. I totally agree with the stated fact that this problem is very common and its progression can lead to severe sensory motor deficits. The pain and paresthesia are quite often very troublesome and disturbs the day-to-day activity of the patient. Generally, the problem is bilateral with one side being worse than the other. Unless the risk factors are simultaneous treated, it is likely that the CTS on the other, less severe, side may worsen and eventually need surgery. It is often seen that with progression of the problem, the sensory symptoms become less severe and motor deficits becomes prominent. Electromyography (EMG) classically shows denervation changes in severe cases, and in such a scenario, the outcome following surgery is guarded. I strongly feel that CTS is an underdiagnosed problem and often the symptomatology is confusing and is erroneously attributed to spinal pathologies. The key to diagnosis is the classical pain and paresthesia in outer three fingers, worsening of the pain following repetitive wrist movement, and wasting of the thenar muscles with sensory –motor loss in the distribution of median nerve in the hand. Nerve conduction test is diagnostic, and in a majority of patients, the electromyographic test is not required. The key to surgery is to thoroughly expose the median nerve in the carpal tunnel and perform an external neurolysis. The deep fascia of the forearm in the region of the wrist should also be divided along with the transverse carpal ligament, as it may sometimes also act as a compressing force.
The authors in the article in focus have not discussed the following points which merited mention and discussion:
- The incidence of bilateral carpal tunnel syndrome and the need for bilateral intervention have not been addressed
- What were the criteria that helped in deciding the need for surgical intervention?
- The incidence of acute presentation of CTS and the role of anti-inflammatory medications and steroids in the treatment and management of this problem have not been focused upon.
- The association of diabetes mellitus (51%) was more common than hypothyroidism (10%) in the study by Sharief et al. In contrast, the hypothyroid state is more commonly associated with CTS; and, with diabetes mellitus, the related peripheral neuropathy is more common.
Finally, I would conclude that Sharief et al., have analyzed some very important observations that have relevance in the diagnosis and the eventual outcome following surgery.
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