the medical team determines treatments based on:
-the severity of the condition
-history of previous treatments for the condition
-overall health and the demands of occupation/daily activities
-the patient's preference
In the earliest stages, the numbness and tingling can be relieved simply by shaking the hand, which eases the pressure on the median nerve. If symptoms persist and worsen, getting rid of the numbness and tingling becomes increasingly difficult.
Waking up in the night with numbness and tingling is common, since sleep positions often hyperextend or hyperflex the wrist, pinching the median nerve.
Special physical therapy exercises, heat treatments and massage may alleviate some discomfort, along with avoiding the movements or strain on the wrist that provoke the symptoms.
If symptoms persist, more aggressive treatments are available. Most patients, but not all, improve following treatment.
Four treatment strategies are used, depending on the severity of the condition: A splint or brace; nonsteroidal, anti-inflammatory drugs; cortisone injections; and surgery (open incision or endoscopic).
Splint or Brace
In the early stages of CTS, a night splint is the first treatment recommended. This splint keeps the wrist in a neutral position (not bent back too far nor down too far) during sleep, minimizing pressure on the median nerve and relieving the nighttime symptoms of tingling and numbness. The splint can also be effectively used during the day. Using a splint can make CTS symptoms disappear in some patients.
Splinting the wrist at a neutral angle helps to decrease repetitive flexion and rotation, thereby relieving mild soft tissue swelling or tenosynovitis. Splinting is probably most effective when it is applied within three months of the onset of symptoms.
The optimal splinting regimen depends on the patient's symptoms and preferences. Nightly splint use is recommended to prevent prolonged wrist flexion or extension. When worn at night for four weeks, a specially designed wrist brace was found to be more effective than no treatment in relieving the symptoms of carpal tunnel syndrome.
Some patients choose to wear a wrist splint all of the time. Compared with nighttime-only splint use, full-time use has been shown to provide greater improvement of symptoms and electrophysiologic measures; however, compliance with full-time use is more difficult.
Manu hand brace for the conservative treatment of carpal tunnel syndrome (palmar and dorsal views). This specially designed brace provides gentle pressure to the heads of the metacarpal bones while stretching the third and fourth fingers.
Nonsteroidal Anti-inflammatory Drugs
Diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), pyridoxine (vitamin B6), and orally administered corticosteroids have been used with varying degrees of success in patients with carpal tunnel syndrome.
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDS) may help relieve pain caused by swelling of the carpal tendons. They may be most effective when used in combination with other nonsurgical treatments; which makes it difficult to know how much the NSAIDS are adding to the known benefits of the other treatments.
If inflammation is not the cause of a patient's pain, NSAIDS are unlikely to help. They also won't help with other symptoms such as tingling, numbness or weakness. The potential side effects of taking NSAIDS over a long period of time must also be weighed.
Orally administered corticosteroids have been shown to be more effective than NSAIDs or diuretics in the short-term treatment of carpal tunnel syndrome.
Cortisone Injections
Injecting the affected area with a steroid drug such as cortisone may provide some relief from symptoms. This treatment may be useful in pregnancy-related carpal tunnel syndrome or in cases where using a splint and nonsteroidal, anti-inflammatory drugs have failed to relieve the symptoms. Relief can last up to six months and sometimes longer. If symptoms recur, injections can be repeated, but not more than once every six weeks.
The injected steroid drug spreads around the swollen membranes and surrounding tendons and shrinks them, relieving the pressure on the median nerve. The cortisone amount is small and when used this way, usually has no harmful side effects.
Combined injection of a corticosteroid and a local anesthetic into or proximal to the carpal tunnel can be used in patients with mild to moderate carpal tunnel syndrome. Such injections can be diagnostic as well as therapeutic.
Method of injecting directly into the carpal tunnel.Injection occurs along the right side of the palmaris longus tendon, which can be identified by having the patient pinch the thumb and fifth fingers together while slightly flexing the wrist. If the palmaris longus tendon cannot be identified, the needle is inserted slightly ulnar to the midline. The needle is angled downward at a 45-degree angle toward the tip of the middle finger and advanced 1 to 2 cm as it traverses the flexor retinaculum. Discomfort in the fingers should prompt repositioning of the needle.
Method of injecting proximal to the carpal tunnel.Injection occurs at the distal wrist crease between the tendons of the palmaris longus and flexor carpi radialis muscles. The mixture is introduced as a bolus and massaged toward the carpal tunnel. The needle should be advanced slowly and repositioned if resistance is encountered or the patient reports pain or paresthesias in the fingers.
Direct injection into the carpal tunnel by either method carries the potential for needle injury to the median nerve, intratendinous injection and tendon rupture, or dysesthesias (secondary to intrafascicular injection) that may persist for months. An alternative approach is to place the injection proximal to the carpal tunnel, rather than directly in it. This approach lowers the risk of damage to the median nerve and theoretically treats concomitant swelling at the volar side of the forearm. With any method, injection of corticosteroid into the median nerve must be avoided.
Splinting is generally recommended after local corticosteroid injection.If the first injection is successful, a repeat injection can be considered after a few months. Surgery should be considered if a patient needs more than two injections.
Iontophresis is a newer way to get cortisone medications into the carpal tunnel. An electrical current is used to move the molecules of the medication through the skin into the carpal tunnel. The technique is less painful than an injection, but may not be as effective in some people.
Surgery
Surgery should be considered in patients with symptoms that do not respond to conservative measures and in patients with severe nerve entrapment as evidenced by nerve conduction studies, thenar atrophy, or motor weakness.
Surgery/Carpal tunnel release surgery (Open Incision or Endoscopic)
Carpal tunnel surgery "releases" pressure on median nerve.
Surgery to relieve CTS is called carpal tunnel release. It involves cutting the ligament that forms the roof of the carpal tunnel to relieve the pressure on the median nerve. It may be performed as an endoscopic or as an open procedure.Surgeons in orthopedic surgery, plastic surgery and neurosurgery may be involved.
Carpal tunnel release surgery is an outpatient procedure that is performed using regional anesthesia. The traditional surgical approach uses a long palmar curvilinear incision to facilitate division of the transverse carpal ligament and its overlying structures.
Endoscopic (Minimally Invasive) Surgery
At times, surgery can be done with an endoscope, a device with a tiny television camera attached to it that allows the surgeon to see inside the carpal tunnel and perform the surgery through small incisions in the hand or wrist. The endoscopic method is more technically demanding and it is important to select a medical center experienced in this technique.
Endoscopic carpal tunnel release is a newer procedure that allows division of the transverse carpal ligament with the overlying structures left intact. Use of this procedure purportedly lessens scar formation and allows an earlier return to work and activities of daily living. The wrist is generally splinted for three to four weeks after surgery.
Open Incision
In open surgery, the surgeon makes an incision in the wrist over the carpal tunnel and releases the nerve.
An open and endoscopic procedures are done under local anesthesia, and patients usually go home soon after surgery. In most cases, surgery results in significant improvement in symptoms, but some residual numbness, pain or weakness may persist.
Ultrasound therapy
Ultrasound therapy may be beneficial in the longer term management of carpal tunnel syndrome. More studies are needed to confirm the usefulness of ultrasound therapy for carpal tunnel syndrome.
Following Surgery
Following surgery, most surgeons permit light use of the hand and wrist within a few days. Unrestricted use may take from several weeks to as long as a few months.
If surgery appears to be the best alternative for relieving symptoms or preventing further muscle atrophy, the patient and surgeon should discuss the procedure that will work best.
Management/Prevention
Mild symptoms usually can be treated with home care. The sooner the treatment, the better your chances of stopping symptoms and preventing long-term damage to the nerve.
You can do a few things at home to help your hand and wrist feel better:
-Stop activities that cause numbness and pain. Rest your wrist longer between activities.
-Ice your wrist for 10 to 15 minutes 1 or 2 times an hour. Try taking nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain and reduce swelling.
-Wear a wrist splint at night to keep your wrist in a neutral position. This takes pressure off your median nerve. Your wrist is in a neutral position when it is straight or only slightly bent. Holding a glass of water is an example of your wrist in a neutral position.
See your doctor if your symptoms do not get better after 1 to 2 weeks of home care, or if you have had bad symptoms from the start. You may need medicine for carpal tunnel syndrome or for a health problem that made you likely to get carpal tunnel syndrome.
Surgery is an option. But it's usually used only when symptoms are so bad that you can't work or do other things even after 3 to 12 months of other treatment.
During surgery, the doctor cuts the ligament at the top of the carpal tunnel. This makes more room in the tunnel and relieves pressure on the nerve. Surgery usually works to ease symptoms. But in some cases it does not completely get rid of numbness or pain.
How can you keep carpal tunnel syndrome from coming back?
To keep carpal tunnel syndrome from coming back, take care of your basic health. Stay at a healthy weight. Don't smoke. Exercise to stay strong and flexible. If you have a long-term health problem, such as arthritis or diabetes, follow your doctor’s advice for keeping your condition under control.
You can also try to take good care of your wrists and hands:
-Try to keep your wrist in a neutral position.
-Use your whole hand-not just your fingers-to hold objects.
-When you type, keep your wrists straight, with your hands a little higher than your wrists. Relax your shoulders when your arms are at your sides.
-If you can, switch hands often when you repeat movements.
http://www.youtube.com/watch?v=xuqcfRG2phk - carpal tunnel release surgery
http://www.youtube.com/watch?v=M4hTY1vyrxg - endoscopic surgery
http://www.youtube.com/watch?v=4vYiqeeUWNU&feature=related - endoscopic surgery
http://www.youtube.com/watch?v=TG9Ucds-ElY - exercises
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