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Carpal Tunnel Syndrome

- Discussion:
    - median nerve compression syndrome at the wrist;
    - most common form of nerve entrapment;
    - first described by Paget;
           - references: The First Description of Carpal Tunnel Syndrome. James Paget FRS
    - pathophysiology:
           - nerve compression may result in ischemia, focal demyelination, decrease in axonal caliber, and finally axonal loss;
           - ref: A Histological and Immunohistochemical Study of the Subsynovial Connective Tissue in Idiopathic Carpal Tunnel Syndrome.
    - anatomy of carpal tunnel
    - differential dx
    - electrodiagnosis

- Initial Work Up:
    - history:
           - presence of pain in the wrist and/or fingers and presence of paresthesias in fingers;
           - night pain may be especially predictive;
    - physical exam
    - differential dx
    - EMG studies
    - carpal tunnel injection / median nerve block
    - references:
           - The surgical treatment of the carpal-tunnel syndrome correlated with preoperative nerve-conduction studies.
           - Carpal tunnel syndrome. An evaluation of the provocative diagnostic tests.

- Radiographic Studies:
    - cross table lateral (for cervical spondylosis)
    - carpal tunnel view
    - MRI: (indicated w/ atypical CTS, ie. ? tumor, ? anomalous muscle).
    - references:
           The use of routine wrist radiography in the evaluation of patients with carpal tunnel syndrome.

- Non Operative Treatment:
    - carpal tunnel injection / median nerve block

- Surgical Treatment:
    - anatomy of carpal tunnel
    - preoperative considerations:
           - goals of surgery:
                  - eliminate compression by the tenosynovium;
                          - tenosynovectomy is performed if tissue is bulky, displaces flexor tendons;
                  - restore the gliding capacity of the nerve
                  - remove constriction by external epineurium, & liberate fascicles from internal adhesions; (latter two goals are controversial);
                  - eliminate pain:
                          - females who do not perform manual labor may not experience as much relief as male patients who do perform manual labor;
           - factors influencing surgical results:
                  - The influence of age on outcome after operation for the carpal tunnel syndrome. A prospective study. 
                  - Pre-operative factors and treatment outcome following carpal tunnel release.
                  - Results of treatment of severe carpal tunnel syndrome.
                  - Clinical Outcomes of Surgical Release Among Diabetic Patients With Carpal Tunnel Syndrome: Prospective Follow-Up With Matched Controls 
                  - Topographical Assessment of Symptom Resolution Following Open Carpal Tunnel Release 
    - Surgical Treatment Options:
           - open surgical release
           - enodscopic carpal tunnel release
           - post op care and complications
           - references:
                  - Endoscopic versus open carpal tunnel release: a randomized trial.
                  - A systematic review of reviews comparing the effectiveness of endoscopic and open carpal tunnel decompression.
                  - Outcomes of Open Carpal Tunnel Release at a Minimum of Ten Years

- References for Carpal Tunnel Syndrome

  commercial devices for CTS
       AM Surgical Endoscopic
       CTRS - Carpal Tunnel Release System
       Biomet Carpal Tunnel Release System

       Ortho-Active Splint
       Promed Braces

       Medi-Dx 7000
       Spectrum Dx Services
       neurometrix nerve conduction studies
       neumedinc nerve conduction studies

       ASSI surgical instruments
       Lone Star Retractors

       Pain Relievers - carpal tunnel products