Carpal tunnel syndrome: treatment with folk remedies and drugs. Symptoms. Reviews. Carpal tunnel syndrome surgical treatment Carpal tunnel syndrome surgery

carpal tunnel syndrome(CTS [syn.: carpal tunnel syndrome, English carpal tunnel syndrome]) - a complex of sensory, motor, vegetative symptoms that occurs when the trunk (SN) is malnourished in the area of the carpal tunnel (PC) due to its compression and (or) overstretching, as well as violations of the longitudinal and transverse slip CH. According to Russian and foreign data, HF develops in 18–25% of cases of tunnel [in the GC] neuropathy [ !!! ], which is characterized by positive (spontaneous pain, allodynia, hyperalgesia, dysesthesia, paresthesia) and negative (hypesthesia, hypalgesia) symptoms in the zone of sensitive innervation of the median nerve. Untimely detection and treatment of CTS leads to an irreversible loss of hand function and a decrease in the quality of life, which determines the need for early diagnosis and treatment of CTS.

Anatomy

ZK - inelastic fibro-osseous tunnel formed by the bones of the wrist and the flexor retinaculum. Anteriorly, the ZK limits the tendon retinaculum of the flexor muscles (retinaculum flexorum [syn.: transverse ligament of the wrist]), stretched between the tubercle of the navicular bone and the tubercle of the large trapezoid bone from the lateral side, the hook of the hamate bone and the pisiform bone with the medial. Behind and from the sides, the canal is limited by the bones of the wrist and their ligaments. Eight carpal bones articulate, forming together an arc, facing a slight bulge back to the back, and a concavity to the palm. The concavity of the arch is more significant due to the bony protrusions towards the hand on the scaphoid on one side and the hook on the hamate on the other. The proximal part of the retinaculum flexorum is a direct continuation of the deep fascia of the forearm. Distally, the retinaculum flexorum passes into the proper fascia of the palm, which covers the muscles of the eminence of the thumb and little finger with a thin plate, and in the center of the palm it is represented by a dense palmar aponeurosis, which runs in the distal direction between the thenar and hypothenar muscles. The length of the carpal tunnel is on average 2.5 cm. The CH and nine tendons of the finger flexors pass through the carpal tunnel (4 - deep finger flexor tendons, 4 - superficial finger flexor tendons, 1 - tendon of the long flexor of the thumb), which pass to the palm, surrounded by synovial sheaths. The palmar sections of the synovial sheaths form two synovial bags: the radial (vagina tendinis m. flexorum pollicis longi), for the tendon of the long flexor of the thumb and the ulna (vagina synovialis communis mm. flexorum), common to the proximal sections of the eight tendons of the superficial and deep flexors of the fingers. Both of these synovial sheaths are located in the carpal tunnel, wrapped in a common fascial sheath. Between the walls of the SC and the common fascial sheath of the tendons, as well as between the common fascial sheath of the tendons, the synovial sheaths of the flexor tendons of the fingers and the SN, there is a subsynovial connective tissue through which the vessels pass. CH is the softest and ventrally located structure in the carpal tunnel. It is located directly under the transverse ligament of the wrist (retinaculum flexorum) and between the synovial sheaths of the flexor tendons of the fingers. SN at the wrist level consists on average of 94% of sensory and 6% of motor nerve fibers. The motor fibers of the SN in the SC area are predominantly combined into one nerve bundle, which is located in most cases on the radial side, and in 15–20% of people on the palmar side of the median nerve. Mackinnon S.E. and Dellon A.L. (1988) believe that if the motor bundle is located on the palmar side, it will be more prone to compression than in the dorsal position. However, the motor branch of HF has many anatomical variations that create a great deal of variability in the symptoms of carpal tunnel syndrome.

Before reading the rest of the post, I recommend reading the post: Innervation of the hand by the median nerve(to the website)

Etiology and pathogenesis

note! CTS is one of the most common peripheral nerve tunnel syndromes and the most common neurological disorder in the hands. The incidence of STS is 150:100,000 of the population, more often STS occurs in women (5-6 times more often than in men) of middle and old age.

Allocate professional and medical risk factors for the development of CTS. In particular, professional (exogenous) factors include a static setting of the hand in a state of excessive extension in the wrist joint, which is typical for people who work at a computer for a long time (the so-called “office syndrome” [those users who, when working, are at greater risk of with a keyboard, the hand is extended ≥ 20° or more in relation to the forearm]). CTS can be caused by prolonged repeated flexion and extension of the hand (eg, pianists, painters, jewelers). In addition, the risk of CZK is increased in people working in low temperature conditions (butchers, fishermen, workers in fresh-frozen food departments), with constant vibrational movements (carpenters, roadmen, etc.). It is also necessary to take into account the genetically determined narrowing of the SC and / or the inferiority of the nerve fibers of the heart failure.

There are four groups of medical risk factors: [ 1 ] factors that increase intratunnel tissue pressure and lead to a violation of the water balance in the body: pregnancy (about 50% of pregnant women have subjective manifestations of CTS), menopause, obesity, renal failure, hypothyroidism, congestive heart failure and taking oral contraceptives; [ 2 ] factors that change the anatomy of the carpal tunnel: the consequences of fractures of the bones of the wrist, isolated or in combination with post-traumatic arthritis, deforming osteoarthritis, disimmune diseases, incl. rheumatoid arthritis (note: in rheumatoid arthritis, HF compression occurs early, so every patient with CTS should exclude the development of rheumatoid arthritis); [ 3 ] volumetric formations of the median nerve: neurofibroma, ganglioma; [ 4 ] degenerative-dystrophic changes in the median nerve resulting from diabetes mellitus, alcoholism, hyper- or beriberi, contact with toxic substances. [ !!! ] Elderly patients are often characterized by a combination of the above factors: heart and kidney failure, diabetes, deforming osteoarthritis of the hands. Decreased motor activity in the elderly often contributes to the development of obesity, one of the risk factors for the development of HF compression neuropathy (Evidence A).

note! Despite the fact that there are several dozen local and general factors contributing to the development of the syndrome, the majority of researchers come to the conclusion that the primary cause of CTS provocation is chronic trauma to the wrist joint and its structures. All this contributes to the development of aseptic inflammation of the vascular-nerve bundle in a narrow channel, leading to local edema of fatty tissue. Edema, in turn, provokes even greater compression of the anatomical structures. Thus, a vicious circle is closed, which leads to the progression and chronicity of the process (Chronic or repeated compression of the CH causes local demyelination, and sometimes degeneration of the CH axons).

note! Possible double crush syndrome, first described by A.R. Upton and A.J. McComas (1973), which consists in SN compression in several sections of its length. According to the authors, in most patients with CTS, the nerve is affected not only at the level of the wrist, but also at the level of the cervical nerve roots (spinal nerves). Presumably, compression of the axon in one place makes it more sensitive to compression in another, located more distally. This phenomenon is explained by a violation of the axoplasmic current in both the afferent and efferent directions.

Clinic

In the initial stages of CTS, patients complain of morning numbness of the hand(s) [more pronounced than the first three fingers of the hand], daytime and nighttime paresthesias in these areas (relieved by shaking the hand]). Attention should be paid to the fact that in CZK sensory phenomena are predominantly localized in the first three (partly in the fourth) fingers of the hand, since the sign of the hand to the fingers (palm) receives sensitive innervation from the SN branch that runs outside the ZK. Against the background of sensitivity disorders, there are motor disorders of the type of sensitive apraxia, especially pronounced in the morning after waking up, in the form of disorders of fine purposeful movements, for example, it is difficult to unfasten and fasten buttons, lace up shoes, etc. Later, patients develop pain in the hand and I, II, III fingers, which at the beginning of the disease may be dull, aching in nature, and as the disease progresses, they intensify and acquire a burning character. Pain can occur at different times of the day, but more often it accompanies attacks of nocturnal paresthesias and intensifies with physical (including positional) load on the hands. Due to the fact that HF is a mixed nerve and combines sensory, motor and autonomic fibers, neurological examination in patients with compressive-ischemic HF neuropathy at the wrist level may reveal clinical manifestations corresponding to the defeat of certain fibers. Sensitivity disorders are manifested by hypalgesia, hyperpathia. A combination of hypo- and hyperalgesia is possible, when zones of increased perception of pain stimuli are found on some parts of the fingers, and zones of decreased perception of pain stimuli on others ( note: as with the other most common compression syndromes, the clinical picture may rapidly or slowly worsen or improve over time). Movement disorders in carpal tunnel syndrome are manifested in the form of a decrease in strength in the muscles innervated by the median nerve (the short abductor muscle of the first finger, the superficial head of the short flexor of the first finger), and atrophy of the muscles of the elevation of the first finger. Vegetative disorders are manifested in the form of acrocyanosis, changes in skin trophism, sweating disorders, sensations of coldness of the hand during attacks of paresthesia, etc. Of course, the clinical picture in each patient may have some differences, which, as a rule, are only variants of the main symptoms.

note! It is necessary to remember about the possibility of a patient having a Martin-Gruber anastomosis (AMH) - anastomosis from HF to the ulnar nerve [LN] (Martin-Gruber anastomosis, median-to-ulnar anastomosis in the forearm). In the case of the direction of the anastomosis from the FN to the SN, it is called the Marinacci anastomosis (ulnar-to-median anastomosis in the forearm).

AMG renders [ !!! ] a significant impact on the clinical picture of lesions of the peripheral nerves of the upper limb, making it difficult to make a correct diagnosis. In the case of a connection between SN and FN, the classical picture of a certain nerve lesion may become incomplete or, conversely, redundant. So, if heart failure is affected in the forearm distal to the place of AMH discharge, for example, with CTS, the symptoms may be incomplete - the strength of the muscles that are innervated by the fibers passing as part of the anastomosis does not suffer, in addition, in the case of the presence of sensory fibers in the composition of the connection, sensitivity disorders can not occur or be expressed insignificantly. In the case of damage to the FN distal to the site of AMH attachment, the clinic may become redundant, since, in addition to the FN's own fibers, the fibers that come through this connection from the heart failure suffer (which can contribute to a false diagnosis of CTS). In this case, in addition to the clinical manifestations of the FN lesion, weakness of the muscles innervated through the HF anastomosis may additionally occur, as well as in the case of the presence of sensory fibers in the anastomosis, sensitivity disorders characteristic of the HF lesion. Sometimes the anastomosis itself can be an additional potential lesion site due to compression from the adjacent muscles.

read also the post: Anastomosis Martin-Gruber(to the website)

Characterizing the course of the disease, many authors distinguish two phases: irritative (initial) and the phase of loss of sensory and motor disorders. R. Krishzh, J. Pehan (1960) distinguish 5 stages of the disease: 1st - morning numbness of the hands; 2nd - night attacks of paresthesia and pain; 3rd - mixed (night and day) paresthesias and pains, 4th - persistent disturbance of sensitivity; 5th - motor disorders. Later, Yu.E. Berzinysh et al. (1982) somewhat simplified this classification and proposed to distinguish 4 stages: 1st - episodic subjective sensations; 2nd - regular subjective symptoms; 3rd - violations of sensitivity; 4th - persistent movement disorders. In addition to the above classifications, which are based only on clinical manifestations and objective examination data, a classification has been developed that reflects the degree of damage to the nerve trunks and the nature of the manifestation of neuropathies.

Based on the International classification of the degree of damage to the nerve trunk (according to Mackinnon, Dellon, 1988, with additions by A.I. Krupatkina, 2003), neuropathies are divided according to the severity of compression: I degree (mild) - intraneural edema, in which transient paresthesias are observed, an increase in vibration sensitivity threshold; movement disorders are absent or slight muscle weakness is observed, the symptoms are inconsistent, transient (during sleep, after work, during provocative tests); II degree (moderate) - demyelination, intraneural fibrosis, increased threshold of vibration and tactile sensitivity, muscle weakness without atrophy, transient symptoms, no permanent paresthesia; III degree (pronounced) - axonopathy, Wallerian degeneration of thick fibers, decreased skin innervation up to anesthesia, atrophy of the muscles of the eminence of the thumb, paresthesias are permanent. When formulating a clinical diagnosis, V.N. Stock and O.S. Levin (2006) recommend indicating the degree of motor and sensory defects, the severity of the pain syndrome, the phase (progression, stabilization, recovery, residual, with a remitting course - exacerbation or remission).

Diagnostics

Diagnosis of CTS includes: [ 1 ] medical history, including any medical problems, illnesses, injuries that the patient has had, current symptoms, and an analysis of daily activities that may cause these symptoms; [ 2 ] hand diagrams (the patient fills in the diagram of his hand: in what places he feels numbness, tingling or pain); [ 3 ] neurological examination and provocation tests: [ 3.1 ] Tinel test: tapping with a neurological hammer on the wrist (above the site of passage of CH) causes a tingling sensation in the fingers or irradiation of pain (electric lumbago) in the fingers (pain can also be felt in the area of tapping); [ 3.2 ] Durkan's test: compression of the wrist in the area of CH passage causes numbness and/or pain in fingers I-III, half of the IV fingers (as in Tinel's symptom); [ 3.3 ] Phalen test: 90° flexion (or extension) of the hand results in numbness, tingling, or pain in less than 60 seconds (a healthy person may also develop similar sensations, but not earlier than 1 minute); [ 3.4 ] Gillet's test: when the shoulder is compressed with a pneumatic cuff, pain and numbness occur in the fingers (note: in 30 - 50% of cases, the described tests give a false positive result); [ 3.5 ] Goloborodko test: the patient is opposite the doctor, the patient’s hand is held palm up, the doctor’s thumb is placed on the eminence of the thenar muscles, the doctor’s 2nd finger rests on the patient’s 2nd metacarpal bone, the thumb of the doctor’s other hand rests on the elevation of the hypothenar muscles, 2 the th finger of the doctor's hand rests on the 4th metacarpal bone of the patient; a “disintegrating” movement is made at the same time, stretching the transverse ligament of the wrist and briefly increasing the cross-sectional area of the posterior duct, while a decrease in the intensity of manifestations of HF neuropathy is observed for several minutes.

If CTS is suspected, [ !!! ] carefully study the sensitivity (pain, temperature, vibration, discrimination) in fingers I - III, then evaluate the motor activity of the hand. Basically, they examine the long flexor of the thumb, the short muscle that abducts the thumb of the hand, and the muscle that opposes it. An oppositional test is performed: with severe thenar weakness (which occurs at a later stage), the patient cannot connect the thumb and little finger; or the doctor (researcher) can easily separate the closed thumb and little finger of the patient. It is important to pay attention to possible vegetative disorders.

read also: article “Validation of the Boston Carpal Tunnel Questionnaire in Russia” by D.G. Yusupova et al. (journal "Neuromuscular diseases" No. 1, 2018) [read]

The "gold standard" of instrumental diagnostics is electroneuromyography (ENMG), which allows not only to objectively examine the nerves, but also to assess the prognosis of the disease and the severity of CTS. MRI is usually used to determine the location of nerve compression after unsuccessful surgical interventions on the carpal tunnel and as a method of differential diagnosis in cases with doubtful symptoms, as well as for the diagnosis of volumetric formations of the hand. MRI allows visualization of the ligamentous, muscular apparatus, fascia, subcutaneous tissue.

One of the methods to visualize the structure of the nerve in CTS is ultrasonography (ultrasound), which allows visualization of HF and surrounding structures, which helps to identify the causes of compression. For the diagnosis of HF lesions at the level of the SC, the following indicators are significant (Senel S. et al., 2010): [ 1 ] increase in the cross-sectional area of the CH in the proximal part of the SC (≥0.12 cm²); [ 2 ] decrease in the cross-sectional area of CH in the middle third of the SC; [ 3 ] change in the echostructure of SN (disappearance of internal division into bundles), visualization of SN before entering the SC during longitudinal scanning in the form of a strand with an uneven contour, reduced echogenicity, homogeneous echostructure; [ 4 ] identification using color-coded techniques of the vasculature within the nerve trunk and additional arteries along the course of heart failure; [ 5 ] thickening of the ligament - tendon retainer (≥1.2 mm) and an increase in its echogenicity. Thus, when scanning the HF, the main ultrasound signs of the presence of compression-ischemic CL are: thickening of the HF proximal to the carpal tunnel, flattening or decrease in the thickness of the HF in the distal CL, decreased echogenicity of the HF before entering the CL, thickening and increased echogenicity of the flexor retinaculum ligament.

X-ray examination of the hands in CTS carries [ !!! ] limited information content. It acquires its main significance in traumas, systemic connective tissue diseases, osteoarthritis.

Treatment

Conservative and surgical treatment of CTS is possible. Conservative treatment is recommended for patients with mild disease, mainly in the first six months from the onset of symptoms. This includes splinting and wearing a brace (with the hand in a neutral position; it is usually recommended to brace the hand during nighttime sleep for 6 weeks, but some studies have demonstrated high effectiveness of wearing a splint/brace during the daytime), as well as injections of glucocorticoids (GC) into ZK, which reduce inflammation and swelling of the tendons (however, HA has a detrimental effect on tenocytes: they reduce the intensity of collagen and proteogligan synthesis, which leads to tendon degeneration). According to the recommendation of the American Association of Orthopedic Surgeons (2011), HA injections are made between 2 and 7 weeks from the onset of the disease. Due to the risk of developing adhesions in the canal, many specialists do no more than 3 injections with an interval of 3-5 days. If there is no improvement in clinical and instrumental data, surgical treatment is recommended. The effectiveness of NSAIDs, diuretics and B vitamins, physiotherapy, manual therapy and reflexology has not been proven (Evidence B).

The operation for CTS is to decompress (reduce pressure in the area of the SC) and reduce the compression of the SN by dissecting the transverse carpal ligament. There are three main methods of heart failure decompression: classical open approach, minimally invasive open approach (with minimal tissue dissection - about 1.5 - 3.0 cm) and endoscopic surgery. All of them are aimed at effective decompression of CH in the canal by complete dissection of the carpal ligament. Endoscopic decompression is as effective as the open technique of CT surgery. The advantages of endoscopic HF decompression over open decompression methods are the smaller size of the postoperative scar and less pronounced pain syndrome, however, due to access restriction, the risk of nerve or arterial injury increases. Factors affecting the outcome of the operation are: older age of patients, permanent numbness, the presence of subjective weakness of the hand, thenar muscle atrophy, the presence of diabetes mellitus, stage III CTS.

read also the article “Immediate and long-term results of median nerve decompression in carpal tunnel syndrome” Gilveg A.S., Parfenov V.A., Evzikov G.Yu.; Federal State Autonomous Educational Institution of Higher Education “First Moscow State Medical University named after I.I. THEM. Sechenov" Ministry of Health of the Russian Federation, Moscow (journal "Neurology, neuropsychiatry, psychosomatics" No. 3, 2018) [read]

More about SZK in the following sources:

article "Carpal Tunnel Syndrome: Anatomical and Physiological Basis for Manual Therapy" by A.V. Stephanidi, I.M. Dukhovnikova, Zh.N. Balabanova, N.V. Balabanova; Irkutsk State Medical Academy of Postgraduate Education, Irkutsk (magazine "Manual Therapy" No. 1, 2015) [read];

article "Diagnosis and treatment of carpal tunnel syndrome" Pilgun A.S., Shernevich Yu.I., Bespalchuk P.I.; Belarusian State Medical University, Department of Traumatology and Orthopedics, Minsk (magazine "Innovations in Medicine and Pharmacy" 2015) [read];

article "Carpal (carpal) tunnel syndrome" A.A. Bogov (Jr.), R.F. Masgutov, I.G. Khannanova, A.R. Gallyamov, R.I. Mullin, V.G. Topyrkin, I.F. Akhtyamov, A.A. gods; Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan; Kazan (Privolzhsky) Federal University, Kazan; Kazan State Medical University, Kazan (Practical Medicine magazine No. 4, 2014) [read];

article “Carpal Tunnel Syndrome (Literature Review)” Khalimova A.A., “Rakhat” Medical Center, Almaty, Kazakhstan (magazine “Vestnik AGIUV” special issue, 2013) [read];

article "Carpal Tunnel Syndrome in the Elderly" by A.S. Gilveg, V.A. Parfenov; First Moscow State Medical University. THEM. Sechenov (magazine "Doctor Ru" No. 1, 2017) [read];

article "Carpal tunnel syndrome in the postpartum period" I.A. Strokov, V.A. Golovacheva, N.B. Vuytsik, E.A. Mershina, A.V. Farafontov, I.B. Filippova, V.E. Sinitsyn, G.I. Kuntsevich, G.Yu. Evzikov, Z.A. Suslin, N.N. Yakhno; Department of Nervous Diseases of the First Moscow State Medical University. THEM. Sechenov; Center for Radiation Diagnostics of the Federal State Budgetary Institution "Treatment and Rehabilitation Center" of the Ministry of Health of the Russian Federation; Federal State Budgetary Institution "Scientific Center of Neurology" RAMS, Moscow (Neurological Journal, No. 3, 2013) [read];

article "Carpal tunnel syndrome in rheumatic diseases" E.S. Filatov; Federal State Budgetary Institution "Research Institute of Rheumatology named after N.N. V.A. Nasonova" RAMS, Moscow (journal "Neuromuscular Diseases" No. 2, 2014) [read];

article "Possibilities of ultrasound in the diagnosis of carpal tunnel syndrome" E.R. Kirillov, Kazan State Medical University of the Ministry of Health of the Russian Federation, Kazan (Practical Medicine magazine No. 8, 2017) [read] ( additional literature);

article "Change in the cross-sectional area of the median nerve at various stages of carpal tunnel syndrome" Maletsky E.Yu., Aleksandrov N.Yu., Itskovich I.E., Lobzin S.V., Villar Flores F.R.; GBOU VPO North-Western State Medical University. I.I. Mechnikov, St. Petersburg (Medical Visualization magazine No. 1, 2014) [read];

article "The study of tactile sensitivity using Semmes-Weinstein monofilaments in patients with carpal tunnel syndrome and healthy individuals" I.G. Mikhailyuk, N.N. Spirin, E.V. Salnikov; State Healthcare Institution of the Yaroslavl Region "Clinical Hospital No. 8", Yaroslavl; SBEI HPE "Yaroslavl State Medical Academy" of the Ministry of Health of the Russian Federation (journal "Neuromocular Diseases" No. 2, 2014) [read];

article "Modern methods for diagnosing carpal tunnel syndrome" N.V. Zabolotskikh, E.S. Brileva, A.N. Kurzanov, Yu.V. Kostina, E.N. Ninenko, V.K. Bazoyan; FPC and teaching staff of GBOU VPO KubGMU Ministry of Health of the Russian Federation, Krasnodar; Research Institute-KKB No. 1 im. prof. S.V. Ochapovsky MZ KK, Krasnodar (magazine "Kuban Scientific Medical Bulletin" No. 5, 2015) [read];

article "Electroneuromyography in the diagnosis of carpal tunnel syndrome" N.G. Savitskaya, E.V. Pavlov, N.I. Shcherbakova, D.S. Yankevich; Scientific Center of Neurology of the Russian Academy of Medical Sciences, Moscow (magazine "Annals of Clinical and Experimental Neurology" No. 2, 2011) [read];

article "Dynamic carpal tunnel syndrome: manual muscle testing to determine the level and cause of damage to the median nerve" A.V. Stephanidi, I.M. Dukhovnikov; Irkutsk State Medical Academy of Postgraduate Education, Irkutsk (Journal "Manual Therapy No. 2, 2016) [read];

article "The use of local administration of corticosteroids in the treatment of carpal tunnel syndrome" V.N. Kiselev, N.Yu. Aleksandrov, M.M. Korotkevich; FSBI All-Russian Center for Emergency and Radiation Medicine named after V.I. A.M. Nikiforov" Ministry of Emergency Situations of Russia, St. Petersburg; FGBOU DPO "North-Western State Medical University named after N.N. I.I. Mechnikov, Ministry of Health of the Russian Federation, St. Petersburg; Russian Research Neurosurgical Institute. prof. A.L. Polenova (branch of the Federal State Budgetary Institution "National Medical Research Center named after V.A. Almazov" of the Ministry of Health of the Russian Federation), St. Petersburg (journal "Neuromuscular Diseases" No. 1, 2018) [read];

article "Treatment of carpal tunnel syndrome (tunnel compression mononeuropathy of the median nerve)" M.G. Bondarenko, teacher of massage and physiotherapy, Kislovodsk Medical College of the Ministry of Health of the Russian Federation (magazine "Massage. Body Aesthetics" No. 1, 2016, con-med.ru) [read];

article "Carpal tunnel syndrome: the current state of the issue" A.V. Baitinger, D.V. Cherdantsev; Federal State Budgetary Educational Institution of Higher Education "Krasnoyarsk State Medical University. professor V.F. Voyno-Yasenetsky" Ministry of Health of the Russian Federation, Krasnoyarsk; ANO "Research Institute of Microsurgery", Tomsk (magazine "Issues of Reconstructive and Plastic Surgery" No. 2, 2018) [read];

article "Issues of diagnosis and treatment of carpal tunnel syndrome" Gilveg A.S., Parfenov V.A., Evzikov G.Yu.; Federal State Autonomous Educational Institution of Higher Education “First Moscow State Medical University named after I.I. THEM. Sechenov" Ministry of Health of the Russian Federation, Moscow (journal "Neurology, neuropsychiatry, psychosomatics" 2019, App. 2) [read]

Compression-ischemic lesion of the median nerve in the carpal (carpal) canal. It is manifested by pain, decreased sensitivity and paresthesia in the area of the palmar surface of the I-IV fingers, some weakness and awkwardness when moving the brush, especially if you need a gripping movement with your thumb. The diagnostic algorithm includes an examination by a neurologist, electrophysiological testing, a biochemical blood test, radiography, ultrasound, CT or MRI of the wrist area. Treatment is mainly conservative - anti-inflammatory, anti-edematous, analgesic, physiotherapy. If it fails, an operative dissection of the carpal ligament is shown. The prognosis is favorable, subject to the timeliness of therapeutic measures.

ICD-10

G56.0

General information

Carpal tunnel syndrome (carpal tunnel syndrome) - compression and ischemia of the median nerve with a decrease in the volume of the carpal tunnel in which it passes, passing from the forearm to the hand. In neurology, it belongs to the so-called. tunnel syndromes. The carpal canal is located at the base of the hand from its palmar surface, is formed by the bones of the wrist and the transverse ligament stretched over them. Passing through it, the median nerve enters the palm. In the canal under the trunk of the median nerve, the tendons of the flexor muscles of the fingers also pass. On the hand, the median nerve innervates the muscles responsible for abduction and opposition of the thumb, flexion of the proximal phalanges of the index and middle fingers, and extension of the middle and distal phalanges of the same fingers. Sensitive branches provide superficial sensitivity of the skin of the tenor (elevation of the thumb), the palmar surface of the first three and half of the 4th finger, the rear of the distal and middle phalanges of the 2nd and 3rd fingers. In addition, the median nerve provides autonomic innervation to the hand.

Causes of Carpal Tunnel Syndrome

Carpal tunnel syndrome occurs in any pathological process that leads to a decrease in the volume of the canal. A tendency to disease may be due to congenital narrowness or structural features of the canal. Thus, women have a narrower carpal tunnel, and carpal tunnel syndrome occurs in them much more often than in men.

One of the reasons for the narrowing of the carpal tunnel is a wrist injury: bruise, fracture of the bones of the wrist, dislocation in the wrist joint. In this case, the volume of the canal can decrease not only due to displacement of the bones, but also due to post-traumatic edema. A change in the ratio of the anatomical structures that form the carpal canal due to excessive bone growth is observed in the case of acromegaly. Carpal tunnel syndrome can develop against the background of inflammatory diseases (synovitis, tendovaginitis, rheumatoid arthritis, deforming osteoarthritis, acute and chronic arthritis, joint tuberculosis, gout) and tumors (lipomas, hygromas, chondromas, synoviomas) of the wrist area. The cause of carpal syndrome can be excessive swelling of tissues, which is noted during pregnancy, renal failure, endocrine pathology (hypothyroidism, menopause, condition after oophorectomy, diabetes mellitus), oral contraception.

A chronic inflammatory process in the area of the carpal tunnel is possible with constant trauma associated with professional activities involving repeated flexion-extension of the hand, for example, in pianists, cellists, packers, carpenters. A number of authors suggest that prolonged daily work on a computer keyboard can also provoke carpal tunnel syndrome. However, statistical studies have not revealed significant differences between the incidence among keyboard workers and the average incidence of the population.

Compression of the median nerve primarily leads to a disorder of its blood supply, i.e., to ischemia. At the beginning, only the sheath of the nerve trunk suffers, as the pressure increases, pathological changes affect the deeper layers of the nerve. First, the function of sensory fibers is disturbed, then motor and autonomic. Long-term ischemia leads to degenerative changes in nerve fibers, replacement of the nervous tissue with connective tissue elements and, as a result, persistent loss of median nerve function.

Symptoms of Carpal Tunnel Syndrome

Carpal tunnel syndrome manifests with pain and paresthesia. Patients note numbness, tingling, "shooting" in the palm area and in the first 3-4 fingers of the hand. Pain often radiates up the inside of the forearm, but may radiate down from the wrist to the fingers. Nocturnal pain attacks are characteristic, forcing patients to wake up. The intensity of pain and the severity of numbness decrease when rubbing the palms, lowering the brushes down, shaking or waving them in the lowered state. Carpal syndrome can be bilateral, but the dominant hand is more often and more severely affected.

Over time, along with sensory disturbances, there are difficulties in hand movements, especially those that require the grasping participation of the thumb. It is difficult for patients with an affected hand to hold a book, draw, hold on to the upper handrail in transport, hold a mobile phone near their ear, drive a car steering wheel for a long time, etc. ". A disorder of the autonomic function of the median nerve is manifested by a sensation of “swelling of the hand”, its cooling or, conversely, a feeling of an increase in temperature in it, increased sensitivity to cold, blanching or hyperemia of the skin of the hand.

Diagnosis of carpal tunnel syndrome

A neurological examination reveals an area of hypoesthesia corresponding to the zone of innervation of the median nerve, a slight decrease in strength in the muscles innervated by the median nerve, autonomic changes in the skin of the hand (color and temperature of the skin, its marbling). Additional tests are carried out that reveal: Phalen's symptom - the occurrence of paresthesia or numbness in the hand during its passive flexion-extension for a minute, Tinel's symptom - tingling in the hand that occurs when tapping in the area of the carpal canal. Accurate data on the topic of the lesion can be obtained using electromyography and electroneurography.

In order to study the genesis of the carpal syndrome, a blood test is performed for the RF, blood biochemistry, radiography of the wrist joint and hand, ultrasound of the wrist joint, CT scan of the wrist joint or MRI, if indicated, its puncture. It is possible to consult an orthopedist or traumatologist, endocrinologist, oncologist. It is necessary to differentiate carpal tunnel syndrome from radial nerve neuropathy, ulnar nerve neuropathy, upper limb polyneuropathy, vertebrogenic syndromes caused by cervical spondylarthrosis and osteochondrosis.

Treatment of carpal tunnel syndrome

The basis of therapeutic tactics is the elimination of the causes of the narrowing of the carpal canal. These include reduction of dislocations, immobilization of the hand, correction of endocrine and metabolic disorders, relief of inflammation and reduction of tissue swelling. Conservative therapy is carried out by a neurologist, if necessary, together with other specialists. The issue of surgical treatment is decided with a neurosurgeon.

Conservative methods of therapy are reduced to immobilization of the affected hand with a splint for a period of about 2 weeks, anti-inflammatory, analgesic, decongestant pharmacotherapy. NSAIDs are used (ibuprofen, indomethacin, diclofenac, naproxen, etc.), in severe cases, they resort to prescribing glucocorticosteroids (hydrocortisone, prednisolone), with severe pain syndrome, therapeutic blockades of the wrist area are performed with the introduction of local anesthetics (lidocaine). Decongestant therapy is carried out with the help of diuretics, mainly furosemide. A positive effect is provided by vitamin therapy with drugs gr. B, mud therapy, electrophoresis, ultraphonophoresis, compresses with dimethyl sulfoxide. Vascular therapy with pentoxifylline, nicotinic acid allows to reduce ischemia of the median nerve. After achieving clinical improvement, to restore the function of the nerve and strength in the muscles of the hand, physiotherapy exercises, hand massage, myofascial massage of the hand are recommended.

With the ineffectiveness of conservative measures, carpal syndrome requires surgical treatment. The operation consists in dissection of the transverse ligament of the wrist. It is performed on an outpatient basis using endoscopic techniques. With significant structural changes in the area of the carpal canal due to the impossibility of using endoscopic techniques, the operation is performed using an open method. The result of the intervention is an increase in the volume of the carpal tunnel and the removal of compression of the median nerve. 2 weeks after the operation, the patient can already perform hand movements that do not require a significant load. However, it takes several months for the brush to fully recover.

Forecast and prevention of carpal tunnel syndrome

With timely complex treatment, carpal tunnel syndrome, as a rule, has a favorable prognosis. However, about 10% of cases of compression do not respond to even the most optimal conservative treatment and require surgery. The best postoperative prognosis is in cases that are not accompanied by a complete loss of sensation and atrophy of the muscles of the hand. In most cases, a month after the operation, the function of the hand is restored by about 70%. However, awkwardness and weakness can be noted after a few months. In some cases, there is a recurrence of carpal tunnel syndrome.

Prevention consists in the normalization of working conditions: adequate equipment of the workplace, ergonomic organization of the work process, change of activities, availability of breaks. Preventive measures also include the prevention and timely treatment of injuries and diseases of the wrist area.

5413 1

Carpal tunnel syndrome (ICD 10 - G56.0) is a common problem that affects the functioning of the hand and wrist.

The violation occurs when nerve compression inside the wrist.

Any condition that affects the size of the canal or causes tissue to grow inside it can trigger the syndrome.

What happens in case of violation

The wrist is surrounded by bundles of fibrous tissue, which performs a supporting function for the joint. The space between these fibrous tissue strips and the bony parts of the wrist is the carpal tunnel.

The median nerve passes through the wrist and provides sensation to the thumb, index and middle fingers.

Any condition that causes swelling or changes in the position of tissue in the wrist can compress and irritate this nerve.

Irritation of the median nerve leads to tingling and numbness of the thumb, index and middle fingers, a condition referred to as "carpal tunnel syndrome".

Causes and risk groups

Causes of carpal tunnel syndrome:

Swelling due to damage to the forearm and hand.
Swelling of tissues in pregnant women, especially in the later stages, and in women using oral contraceptives.
Chronic inflammation and swelling of the structures of the carpal tunnel with constant occupational trauma.
Swelling of tissues as a result of certain diseases of internal organs, endocrine disorders.
Narrowing of the synovial membranes of the tendons and thickening of their walls due to acute or chronic inflammation in systemic connective tissue disorders, metabolic disorders, and tuberculosis.
The discrepancy between the size of the canal and the size of its contents due to genetically inherited indicators or abnormal growth of the bones of the hand and wrist.
Tumor of the median nerve.

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The risks of occurrence include:

use of force;
pose;
wrist position;
monotony of action;
hypothermia;
vibration.

At-risk groups:

people with a genetic predisposition;
people of short stature, overweight;
people suffering from tuberculosis, renal failure;
people with rheumatoid arthritis, thyroid problems;
women in menopause and when using hormonal contraceptives.

Anatomy of the wrist

Symptoms and signs

The syndrome has the following symptoms - gradual numbness in parts whose sensitivity is controlled by the median nerve.

After that, pain appears in the places of innervation. Also among the symptoms of carpal tunnel syndrome, it can be noted that numbness occurs in the hand, especially in the morning after a night's sleep. The patient shakes and rubs the brushes all night long, which gives a little improvement.

The pain may radiate up to the shoulder and even the neck. As the disease worsens, the thumb muscles may stop working, causing awkwardness in actions when it is necessary to take, for example, a cup.

It is difficult for the patient to touch the tips of other fingers with the tip of the thumb, to hold different objects.

Diagnostic methods and tests

The doctor will ask about the signs and medical history, perform an examination of the wrist and hands. The examination will consist of checking for strength, tenderness, and signs of nerve irritation or damage.

Other tests:

electrodiagnostic tests;
x-ray;

The syndrome should be distinguished from Arnold-Chiari anomaly and cervical hernia.

How to treat pathology

Treatment may be conservative or surgical.

Conservative treatment

The activity that causes the symptoms should be stopped.

Avoid repetitive hand movements, strong grasping movements, holding vibrating objects, or bending or arching the wrist.

If you smoke, give up this habit. Lose weight if you are overweight. Reduce the amount of caffeine.

Wrist brace facilitates manifestations in the early stages of the disorder. It keeps the wrist at rest. When the wrist is in the correct position, the channel has a normal volume, so there is enough space for the nerve.

The bandage helps to neutralize numbness and pain, it does not allow the brush to bend during sleep. The bandage can also be worn during the day to reduce manifestations and provide rest to the tissues of the wrist.

In addition, the following exercises help:

Shake your hands.
Clench your hands into a fist, hold for 3 seconds, then fully unclench for 6 seconds. Repeat 10 times.
Stretch your arms in front of you, raise and lower them 5 times.
Describe 10 circles with your fingertips.
Press with one hand on the fingers of the other hand 10 times in a row.

Through these exercises, blood circulation in the muscles improves.

It is important that the movements are different.

It should be borne in mind that KTS - SZK appears in people not only because they carry out monotonous movements, but also because they do it for a long time.

Medical treatment

Anti-inflammatory drugs can also help eliminate swelling and symptoms of the lesion (, aspirin). Large doses of vitamin B-6 help to neutralize symptoms.

If simple measures fail to curb symptoms, consideration should be given to cortisone shots into the carpal tunnel. This tool is used to relieve swelling in the canal, it can temporarily eliminate symptoms.

Cortisone can help the doctor make a diagnosis. If the patient does not feel better after the injection, this may indicate another disorder that causes these manifestations.

If the symptoms disappear after the injection, then they appeared in the wrist.

Physiotherapy

The doctor may refer you to a physiotherapist or an occupational health specialist. The primary goal of treatment is to reduce the impact or eliminate the cause of pressure in the wrist.

A physical therapist can check the workplace and the way work tasks are performed. He can suggest how best to position the body, and in what position to hold the wrist, prescribe exercises and suggest how to prevent problems in the future.

Surgical treatment

If attempts to control the manifestations fail, the patient may be offered surgery to reduce compression of the median nerve.

There are several different surgeries to relieve pressure on the nerve.

After the pressure on the nerve is removed, the blood supply to the nerve is restored, and most patients feel relief. But if the nerve is compressed for a long time, it can thicken, and a scar can form on it, which will prolong recovery after the procedure.

The most common operation is an open intervention using a local anesthetic that blocks nerves located only in a specific part of the body.

This operation is performed on an outpatient basis, meaning you can leave the hospital right away.

Complications

Carpal tunnel syndrome is not a life-threatening disorder.

A long-term ill person may eventually lose the ability to normally carry out individual movements with his hand or fingers.

And only timely started competent treatment can prevent such a complication and help restore the work of the hand.

Preventive measures

Warning measures:

conclusions

Complications of the syndrome are rare and include atrophy and weakness of the muscles at the base of the thumb.

This can become a permanent disorder if not treated on time. Such a violation affects the motor skills of the hand and the performance of certain movements.

As a rule, the prognosis for the disorder is positive, and it turns out to cure it conservatively or surgically.

Carpal tunnel syndrome (CTS) is caused by nerve compression and irritation in the wrist, resulting in pain, numbness, tingling, and/or weakness in the wrist and hand. Repeated sprains and fractures, unusual anatomy of the wrist, arthritis, and some other conditions can reduce the space in the carpal tunnel, thereby increasing the risk of CTS. Associated symptoms can often be managed at home, but sometimes medical attention is required for a complete cure.

Steps

Part 1

CTS treatment at home

Try not to pinch the median nerve. The carpal tunnel is a narrow tunnel made up of small carpal bones connected by ligaments. This channel protects the nerves, blood vessels and tendons. The main nerve responsible for the movement of the palm and its sensitivity is called the median. Therefore, activities that compress and irritate the median nerve should be avoided, such as frequent flexing of the arm at the wrist, lifting heavy objects, sleeping with crooked wrists, and punching hard surfaces.

Make sure that wristwatches and bracelets sit loosely on the wrist - if they are too tight around the wrist, this can lead to irritation of the median nerve.
In most cases of CTS, it is difficult to identify a single cause. Typically, CTS is caused by a combination of factors, such as frequent wrist strain combined with arthritis or diabetes.
The anatomy of the wrist can also contribute - in some people, the bones of the carpal tunnel at the same or not quite the right shape.

Stretch your wrists regularly. Stretching your wrists daily can help reduce or eliminate the symptoms of CTS. In particular, stretching the wrists helps expand the median nerve space within the carpal tunnel by stretching the ligaments that surround the carpal tunnel. The best way to stretch both wrists at the same time is to assume the “prayer pose”. Place your palms together at a distance of about 15 cm from your chest and raise your elbows until you feel a stretch in both wrists. Hold this position for 30 seconds, then lower your elbows again. Repeat the exercise 3-5 times a day.

Shake your palms. If you feel numbness or aching pain in one or both palms (or wrists), shake them well for 10-15 seconds, as if shaking off water from them. In this way, you will achieve a quick, albeit temporary, improvement. This shaking will increase blood circulation and improve blood flow to the median nerve, causing symptoms to temporarily disappear. You can do this exercise, which helps fight the symptoms of CTS, many times a day, literally taking a few seconds off your work.
- Symptoms of CTS most often appear (and first appear) in the thumb, index and middle fingers, and part of the ring finger. This is why CTS sufferers seem clumsy and often drop objects.
- Only the little finger is not affected by CTS symptoms, since it is not associated with the median nerve.
Wear a special wrist support bandage. This semi-rigid bandage or splint will help avoid symptoms of CTS throughout the day by keeping the wrist in a natural position and preventing it from bending too much. A wrist splint or bandage should also be worn during activities that can aggravate CTS symptoms, such as working at a computer, carrying heavy bags, driving a car, or playing bowling. Wearing a supportive bandage while you sleep can help prevent nighttime symptoms, especially if you have a habit of slipping your palms under you while you sleep.
- You may need a support bandage for several weeks (day and night) in order to noticeably reduce the symptoms of CTS. However, in some cases, the supporting bandage has a negative effect.
- Wrist splints are also helpful if you have CTS and are pregnant, as your hands (and feet) are more likely to swell during pregnancy.
- Support bandages and wrist splints can be purchased at a pharmacy or health supply store.
Consider changing the position in which you sleep. Certain positions can significantly aggravate the symptoms of CTS, reducing sleep duration and quality. The worst posture is one in which your fists are tightly clenched and/or your palms (with arched wrists) are tucked under your body; the posture in which the hands are above the head is also unfavorable. Instead, try to sleep on your back or on your side with your arms close to your body, with your wrists straight and your palms open. Such a posture will ensure normal blood circulation in the wrists and blood supply to the median nerve.
- As noted above, using supportive bandages while you sleep helps prevent misalignment of the hands and wrists, but it will take some time to get used to.
- Don't sleep on your stomach with your hands under the pillow, as this will compress your wrists. Sleeping in this position, people upon awakening often experience numbness and tingling in the palms.
- Most wrist bands are made of nylon and fasten with Velcro, which can irritate your skin. In this case, place a sock or piece of thin cloth under the bandage to reduce skin irritation.
Take a look at your workplace. In addition to poor sleep posture, CTS symptoms can be caused or exacerbated by poor workplace layout. If a computer keyboard, mouse, desk, or chair is placed inappropriately and inconsistently with your height and build, it can put strain on your wrists, shoulders, and mid-back. Make sure the keyboard is positioned so that you don't have to bend your wrists all the time while typing. Get an ergonomic keyboard and mouse designed to reduce the strain on your hands and wrists. Your employer may reimburse the costs.

Take over-the-counter medications. The symptoms of CTS are often associated with inflammation and swelling in the wrist, which further irritates the median nerve and adjacent blood vessels. Therefore, non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin, Advil) or naproxen (Aliv) often help reduce symptoms of CTS, at least in the short term. Pain relievers such as paracetamol (Tylenol, Panadol) can also be taken to relieve pain caused by CTS, but they do not reduce inflammation and swelling.

Part 2
Medical care for CTS
1. Make an appointment with a doctor. If you experience any of the symptoms listed above in your wrist/hand for several weeks or more, you should see a doctor. Your doctor will examine you and likely order x-rays and blood tests to rule out possible diseases and injuries that mimic CTS, such as rheumatoid arthritis, osteoarthritis, diabetes, a stress fracture in the wrist, or blood vessel problems.
  
  See a physical therapist or massage therapist.
  
  Try corticosteroid injections. To relieve pain, inflammation, and other symptoms of CTS, your doctor may recommend injections of a corticosteroid drug (such as cortisone) into your wrist or the base of your hand. Corticosteroids are a powerful and fast-acting drug that can relieve swelling in the wrist and relieve pressure on the median nerve. They can also be taken orally, but this is considered to be much less effective than injections and also causes more severe side effects.
  - Other steroid drugs such as prednisolone, dexamethasone, and triamcinolone are also used in the treatment of CTS.
  - Corticosteroid injections can lead to complications such as local infection, profuse bleeding, weakening of the tendons, muscle atrophy, and nerve damage. Therefore, they are usually made no more than twice a year.
  - If steroid injections do not lead to a significant improvement in the condition, surgery should be considered.
2. Carpal tunnel surgery should be considered as a last resort. If other treatments have failed to relieve the symptoms of CTS, a doctor may recommend surgery. Surgery is only used as a last resort because there is a risk of worsening the condition even more, although for many patients, surgery helps to completely eliminate the symptoms of CTS. The purpose of this operation is to relieve pressure on the median nerve by cutting the main ligament pressing on it.

It includes:

median nerve
The motor branch of the median nerve, with options for branching from the median nerve:

Out of bond 50%
Under the bundle 30%
Through a bundle 20%

pressure in the carpal tunnel

Lowest at rest with the wrist in a neutral position (2.5 mmHg). 11 rises up to 30 mm Hg. Art. with full flexion of the wrist. With carpal tunnel syndrome, the pressure rises to 30 mm Hg. Art. and 90 mm Hg. Art. respectively (Phalen's test provokes a rise in pressure).

anomalies

They can confuse the clinical picture when inappropriate signs appear (for example, numbness of the fifth finger in carpal tunnel syndrome).

Martin Gruber: motor connecting branch from the median nerve to the ulnar nerve on the forearm
Riche-Cannieu: motor and sensory connecting branches from the median to the ulnar nerve on the hand.

The reasons

Idiopathic - most common, typically in women between 35 and 55 years of age.
Traumatic - 5% wrist fractures, 60% lunate dislocations
Metabolic - pregnancy (most common), renal failure and hemodialysis, hypothyroidism (rare).
Vibration
Repetitive monotonous movements (vague picture, overload, monotonous repetitive movements and position are considered predisposing, but objectionable).
There is no clear evidence to correlate with carpal tunnel syndrome
Synovitis - exacerbation of rheumatism. Osteoarthritis of the wrist joint.
Very rarely - mucopolysaccharidosis, mucolipidosis, amyloidosis, diseases leading to space filling (ganglion, nerve tumor, abnormal short flexor of the fingers).

Diagnostics

Symptoms

Nocturnal dysesthesia, including reflex shaking or hanging of the hand.
Decreased sensation or tingling in the zone of innervation of the median nerve:

Goosebumps appear when holding the steering wheel of a car
Holding the handset causes a tingling sensation

Decreased dexterity of movements when grasping with the first and three-phalangeal fingers:

Difficulty or inability to fasten shirt buttons
Inability to grasp small objects (such as coins)
Inability to hold the needle while sewing.

signs

Positive Tinel percussion test:

Sensitivity 60%, specificity 67%

Positive Phalen flexion test for 60 seconds:

Sensitivity 75%, specificity 47%

Test for direct compression of the nerve: with pressure on the nerve by a doctor for 30 seconds. tingling appears:

Sensitivity 87%, specificity 90%

Threshold tests (monofilaments and vibration) for diagnosis are not indicative, but reflect the severity
Density tests (discriminatory sensitivity) have no sensitivity or specificity. They show a decrease in sensitivity.

Electrophysiology

NB: NOT REQUIRED for typical clinical presentation
They can be misleading because in 10% of cases with a typical picture after surgery, the indicators are normal, especially in young women.
Diagnostic parameters: latency of terminal sensitivity >3.5 msec or conduction velocity of sensitivity >0.5 msec compared to the other side; motor latency >4.5 ms or motor impulse conduction velocity > 1.0 ms compared to the other side.
Electromyography reveals fibrillation and positive sharp teeth with severe compression with muscle atrophy.
Values do not return to normal even after successful decompression and are therefore of little value in diagnosing chronic or recurrent carpal tunnel syndrome.

Differential Diagnosis

Radiculopathy C6
pronator syndrome
Proximal compression of the median nerve at the level of the brachial plexus.

Conservative treatment

Observation: spontaneous resolution is possible, for example, during pregnancy, untreated exacerbation of rheumatism.

Splinting: Effective when only nocturnal symptoms are present. When muscles are affected, an opposing splint or C-shaped insert is used in the first interdigital space (adductor contracture)

Steroid hormone injections: temporary relief, but cure is rare except for early symptoms or overt tenosynovitis. Risk of iatrogenic nerve injury. The temporary effect confirms the diagnosis.

Dissection of the carpal ligament

open intervention

A longitudinal incision along the 4th ray (along the line from the radial edge of the fourth finger to the middle of the distal carpal fold) above the carpal canal prevents damage to the cutaneous nerves. Dissect the palmar fascia, dissect the transverse carpal ligament closer to the ulnar edge to avoid damage to the motor branch of the median nerve and provide shelter for the nerve after surgery. It is necessary to ensure that the ligament and fascia are dissected at the level of the distal margin and proximally under visual control, as well as to examine and verify the integrity of the thenar branch. Endoneurolysis does not provide additional benefits.

Endoscopic Ligament Dissection

One or two portal endoscopy. Some acceleration in recovery of function and return to work, but greater risk of iatrogenic nerve/tendon/superficial arterial arch injuries and incomplete decompression, especially in the early recovery curve.

results

In 95% of cases, it is recommended to treat nocturnal dysesthesia, regardless of age, severity of symptoms before surgery, duration of the disease. Numbness and muscle weakness may persist, especially in old age and long-term illness. It takes 4 to 6 weeks to heal and regain grip strength.

Complications

Complex regional pain syndrome.
Painful scar (usually within a few weeks, therapy helps resolve).
Pain on support (cause unclear, pain over bony margin, refractive effect possible, persisting for several months, usually with subsequent resolution).
Infection
Relapse: less than 1% of cases. Re-intervention is effective only in 70% of cases. Nerve conduction does not play a role in diagnosis due to persistence of changes even after successful decompression.

Reconstructive interventions

Transposition to restore opposition is possible in the absence of opposition due to weakness of the abductor digiti brevis muscle and is performed at the time of surgery (for age > 70 years or prolonged decompression) or if function is not restored within six months of decompression (age<70 лет и кратковременная декомпрессия).

Donor muscles:

Superficial flexor of the fourth finger
Own extensor of the second finger
Long palmar muscle with fascia (Camitz):

It can be performed simultaneously with decompression of the carpal tunnel through the same access, although the muscle is not as strong as the superficial flexor of the fourth finger or its own extensor of the second finger.

Abductor Fifth Finger Muscle (Huber):

Good for children
Provides muscle mass in the area of the eminence of the thumb.
Immobilization is possible in the postoperative period without adverse consequences, the method is designed for muscle contraction, and not for tendon sliding.