Carpal Tunnel Syndrome

C. Sabin Cranford, MD Abstract

Jason Y. Ho, MD Carpal tunnel syndrome is the most common compressive
David M. Kalainov, MD neuropathy of the upper extremity. As a result of median nerve
Brian J. Hartigan, MD compression, the patient reports pain, weakness, and paresthesias
in the hand and digits. The etiology of this condition is
multifactorial; anatomic, systemic, and occupational factors have
all been implicated. The diagnosis is based on the patient history
and physical examination and is confirmed by electrodiagnostic
testing. Treatment methods range from observation and splinting,
to cortisone injection and splinting, to surgical intervention. Both
nonsurgical and surgical management provide symptom relief in
most patients. The results of open and endoscopic surgery
essentially are equivalent at 3 months; the superiority of one
technique over the other has yet to be established.

S ymptoms of median nerve com-

Dr. Cranford is Orthopaedic Resident,
Northwestern Memorial Hospital,
Chicago, IL. Dr. Ho is Orthopaedic
Resident, Northwestern Memorial
Hospital. Dr. Kalainov is Attending
Surgeon, Northwestern Memorial
Hospital. Dr. Hartigan is Attending
Surgeon, Northwestern Memorial
Hospital.
None of the following authors or the
department with which they are affiliated
has received anything of value from or
owns stock in a commercial company or
institution related directly or indirectly to
the subject of this article: Dr. Cranford,
Dr. Ho, Dr. Kalainov, and Dr. Hartigan.
Reprint requests: Dr. Hartigan,
Northwestern Memorial Hospital, Suite
450, 676 N St. Clair Street, Suite 450,
Chicago, IL 60611.
J Am Acad Orthop Surg 2007;15:537-
548
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.
pression at the wrist were first
described in patients with distal
radius fractures by Sir James Paget
in 1854.1 The term carpal tunnel
syndrome (CTS) was coined by
Moersch2 8 decades later, and wide
recognition of the condition was
achieved in the 1950s because of the
work of Phalen.3 Today, CTS is well
recognized by health care workers
and the population at large because
of its significant health consequenc-
es and economic impact. In the
United States, region-specific inci-
dences of 0.99 and 3.46 cases of CTS
per 100,000 person-years have been
reported.4 Approximately 500,000
surgical procedures are performed
each year, and the economic impact
of this condition is estimated to ex-
ceed $2 billion annually.5
Anatomy and
Pathophysiology
The carpal tunnel is bordered dor-
sally by the concave arch of the car-
pus and volarly by the transverse car-
pal ligament (TCL), with a variable
depth of 10 to 13 mm.6 Ten struc-
tures from the volar forearm pass
through the carpal tunnelnine
flexor tendons and the median nerve
(Figure 1). The median nerve is the
most superficial structure within the
canal, entering the space in the mid-
line or just radial to the midline.
The median nerve may divide in
the forearm or split within the carpal
tunnel. Both conditions are associ-
ated with a persistent median artery.
The thenar motor branch of the me-
dian nerve usually originates in an
extraligamentous position distal to
the TCL. Less commonly, the motor
branch projects from beneath the
TCL (subligamentous) or perforates
through the TCL (transligamentous).7
The median nerve is susceptible
to compression within the carpal ca-
nal because of the unyielding fibro-
osseous borders.8 Normal pressure
within the carpal tunnel measures
2.5 mm Hg.9 A decrease in epineural
blood flow and edematous changes
occur when the pressure reaches 20
to 30 mm Hg. At pressures >30 mm

Volume 15, Number 9, September 2007 537

Carpal Tunnel Syndrome
Figure 1
Carpal tunnel enclosing the median nerve and nine flexor tendons (the flexor pollicis
longus tendon, four flexor digitorum profundus tendon slips, and four flexor
digitorum superficialis tendon slips). (Reproduced with permission from DArcy C,
McGee S: Does this patient have carpal tunnel syndrome? JAMA 2000;283:
3110-3117.)
Hg, nerve conduction diminishes.10
A continued rise or a prolonged ele-
vation in pressure may lead to a
complete median nerve block.9,10
Etiology
Acute CTS is caused by a rapid and
sustained increase in pressure with-
in the carpal tunnel. The onset of
symptoms is sudden and may
prompt a decision for urgent surgical
decompression. Precipitating factors
producing acute CTS include wrist
trauma, infection, high-pressure in-
jection, and hemorrhage.11 Chronic
CTS is a much more frequent condi-
tion, with the pathogenesis divided
into four categories: idiopathic, ana-
tomic, systemic, and exertional. The
538
during the third trimester, vary in
pathogenesis of CTS is outlined in
Table 1.
Idiopathic
Most cases of CTS do not have an
identifiable etiology. Women are
more commonly affected than men,
and incidence increases with age.12,13
The histologic appearance of teno-
synovial tissue in idiopathic cases
involves edema and fibrous hypertro-
phy, with minimal findings of in-
flammation. In a recent study of nine
patients with idiopathic CTS, a pres-
sure guidewire system measured the
greatest compression of the median
nerve at a distance of 10 mm distal
to the distal wrist crease. This point
coincides with the thickest part of
the TCL.14
Journal of the American Academy of Orthopaedic Surgeons
Anatomic
Anomalies such as a persistent
median artery, infection, ganglion
cyst, or tumor can occupy space
within the carpal canal and increase
interstitial fluid pressure.15 Trauma
may result in canal volume restric-
tion from edema, hemorrhage, dis-
tortion of anatomy, and/or scar for-
mation.11 The end-pathway in all
cases is similar: compression of the
median nerve.
Systemic
CTS can be associated with a
number of medical conditions, in-
cluding obesity, drug toxicity, alco-
holism, diabetes, hypothyroidism,
rheumatoid arthritis, primary amy-
loidosis, and renal failure.12,15 Rheu-
matoid arthritis and renal failure
may lead to an increase in pressure
within the carpal tunnel secondary
to pannus formation and amyloid
deposition, respectively. Drug toxic-
ity, diabetes, and alcoholism may
have direct injurious effects on the
median nerve.
CTS can occur during pregnancy,
with a reported incidence of 20% to
45%.16 Symptoms typically develop
severity, and abate postpartum with
nonsurgical management. The etiol-
ogy of gestational CTS remains un-
certain, but symptom onset is con-
ceivably related to fluid retention.
Exertional
In the workplace, CTS has been
attributed to repetitive use of the
wrist and digits, to repeated impact
on the palm, and to the operation of
vibratory tools.17-19 Extremes of wrist
flexion and extension have been
shown experimentally to elevate
pressure within the carpal tunnel.9
Finger flexion also increases the
interstitial canal pressure as the
lumbrical muscles are drawn proxi-
mally.20 Task-related factors are vari-
able and inconsistent, however, and
the mechanisms by which they
may contribute to CTS are poorly
defined.19 A direct relationship be-

Table 1
Pathogenesis of Carpal Tunnel Syndrome
Idiopathic
Anatomic
Trauma
Posttraumatic swelling/hemorrhage/scar
Posttraumatic arthritis
Carpal dislocation
Distal radius malunion
High-pressure injection injury
Small carpal canal
Basal joint arthritis
Anomalous structures
Muscles
Palmaris profundus
Anomalous slip of the flexor pollicis longus
Proximal origin of a lumbrical
Reversed palmaris longus
Vascular
Persistent/thrombosed median artery
Masses/tumors
Ganglion
Lipoma
Fibroma/lipofibroma
Synovial sarcoma
Neuroma/neurofibroma/neurilemoma
Hemangioma
tween repetitive work activity (eg,
keyboarding) and CTS has never
been objectively demonstrated.
Diagnosis
The history and physical examina-
tion are key in making the diagnosis
of CTS. Patients with CTS report
nocturnal pain, numbness, and tin-
gling in the thumb and one or more
radial fingers. Daytime paresthesias
are often elicited with activities in-
volving prolonged wrist flexion and/
or extension. Shaking and wringing
of the hands may alleviate symp-
toms. Bilateral CTS is common,
with the condition most noticeable
in only one hand.21 An atypical pre-
sentation of CTS involves paresthe-
sias in the radial digits but with pain
Volume 15, Number 9, September 2007
C. Sabin Cranford, MD, et al
Systemic
Disorders affecting fluid balance
Pregnancy
Renal failure
Thyroid disease
Congestive heart failure
Obesity
Myxedema
Acromegaly
Inflammatory conditions
Rheumatoid arthritis
Lupus
Gout/pseudogout
Scleroderma
Dermatomyositis
Amyloidosis
Hemorrhagic disorders
Leukemia
Hemophilia
Anticoagulation
Neuropathic
Diabetes
Thyroid disease
Vitamin/nutritional deficiency
Vitamin toxicity
Alcoholism
Myeloma
Medication (lithium, blocker, ergot)
Infection
Constitutional factors
Advancing age
Female sex
Exertional (occupational)
Vibratory exposure
radiating proximally along the medi- in the radial digits signify disruption
an nerve to the elbow and some- of the sympathetic fibers carried by
times to the shoulder. Occasionally, the median nerve. Active motion
a dysesthesia can exist in the ulnar measurements of the cervical spine
nerve distribution that does not rule and all major joints in both upper ex-
out CTS. With chronic median tremities are obtained. Manual mus-
nerve compression, symptoms in- cle strength testing is performed,
clude a gritty or numb sensation in and grip and pinch measurements
the fingers, grip and pinch weakness, are recorded. Spurlings maneuver is
and diminished finger dexterity with helpful in excluding a cervical radic-
a history of dropping objects. A self- ulopathy, particularly of the sixth
completed Katz and Stirrat22 hand cervical nerve root, which can mim-
symptom diagram can be useful in ic symptoms of CTS. Percussion of
making the correct diagnosis (Figure all major peripheral nerves may
2). point to an unsuspected area of
A thorough physical examination nerve entrapment. Deep tendon re-
including the cervical spine and en- flexes in both upper extremities are
tire upper extremities is warranted. measured, and assessment of blood
The soft tissues are assessed for skin flow to each hand is completed.
and muscle atrophy. Cold intoler- Wrights hyperabduction maneu-
ance, dryness, and unusual textures ver, Adsons test, and the costocla-
539
Carpal Tunnel Syndrome

Figure 2

Katz and Stirrat hand diagram. A, Classic pattern. Symptoms affect at least two of digits 1, 2, or 3. The classic pattern permits
symptoms in the fourth and fifth digits, wrist pain, and radiation of pain proximal to the wrist, but it does not allow symptoms on
the palm or dorsum of the hand. B, Probable pattern. Same symptom pattern as classic, except palmar symptoms are allowed
unless confined solely to the ulnar aspect. In the possible pattern (not shown), symptoms involve only one of digits 1, 2, or 3.
C, Unlikely pattern. No symptoms are present in digits 1, 2, or 3. (Reproduced with permission from Golding D, Rose D,
Selvarajah K: Clinical tests for carpal tunnel syndrome: An evaluation. Br J Rheumatol 1986;25:388-390.)

Table 2 vicular test are occasionally useful

Clinical Tests for Carpal Tunnel Syndrome in diagnosing a thoracic outlet syn-
drome that can mimic CTS. Wrights
Test Maneuver Positive Results
maneuver is conducted by abducting
Tinels sign Percussion over the median Electrical shock sensation in and externally rotating the patients
nerve at the wrist and the median nerve arm and having the patient inhale
palm distribution deeply. Adsons test is performed by
Phalens test Wrist flexed by gravity for Numbness/tingling in the having the patient extend the neck,
60 seconds median nerve distribution turn the face toward the affected
side, and inhale deeply. The costo-
Durkans Manual pressure over the Numbness/tingling in the clavicular test is performed by hav-
median nerve median nerve at the median nerve distribution
compression carpal tunnel for 30 ing the patient move the shoulders
test seconds downward and backward with the
chest protruding. A positive response
Reverse Phalens Wrist and fingers actively Numbness/tingling in the for each test involves reproduction of
test extended for 2 minutes median nerve distribution
the patients pain symptoms, often
Tourniquet test Arm tourniquet inflated Numbness/tingling in the combined with a decrease in the ra-
above systolic pressure for median nerve distribution dial pulse. With thoracic outlet syn-
60 seconds drome, arm heaviness is reported
Hand elevation Hand elevated above head Numbness/tingling in the during Wrights hyperabduction ma-
test for 60 seconds median nerve distribution neuver and Adsons test.
Sensory testing alternatives for
Wrist flexion Elbow extended, forearm Numbness/tingling in the
and carpal supinated, and wrist median nerve distribution CTS include innervation density
compression flexed; clinician applies measurements using static or mov-
test direct pressure over the ing 2-point discrimination and
median nerve at the threshold sensory measurements
carpal tunnel using Semmes-Weinstein monofila-
Closed fist sign Tight fist for 60 seconds Numbness/tingling in the ments or vibrometry. Threshold sen-
median nerve distribution sory tests are more sensitive than in-
nervation density measurements in

540 Journal of the American Academy of Orthopaedic Surgeons


detecting early CTS.23,24 In the office
setting, most hand surgeons obtain
only static 2-point discrimination
and/or Semmes-Weinstein monofil-
ament measurements.
Several provocative tests to diag-
nose CTS have been described (Table
2). Tinels sign is elicited by gently
tapping on the median nerve at the
carpal tunnel. A positive response is
noted if the patient describes an
electrical shock sensation in the me-
dian nerve distribution. Phalens test
is performed by placing the patients
elbow on an examination table and
allowing the wrist to flex for 60 sec-
onds. If the patient reports paresthe-
sias in the median nerve distribu-
tion, this test is considered positive.
Durkans median nerve compression
test involves direct compression of
the median nerve at the carpal tun-
nel for 30 seconds.25 This test is con-
sidered positive if the patient reports
numbness and/or tingling in one or
more of the radial digits.
Durkan25 reported a sensitivity of
87% and a specificity of 90% for the
median nerve compression test in de-
tecting CTS, with even greater sen-
sitivity (89%) and specificity (96%)
using a calibrated pressure device.
The sensitivities and specificities of
Tinels sign and Phalens test are low-
er.26 Szabo et al27 determined a prob-
ability of 0.86 in correctly diagnosing
CTS in the presence of a positive me-
dian nerve compression test, a posi-
tive hand diagram, night pain, and
abnormal Semmes-Weinstein mono-
filament testing.
Diagnostic Studies
Electrodiagnostic Testing
An electrodiagnostic study in-
cludes measurements of nerve con-
duction alone or in combination with
electromyography (EMG). Nerve con-
duction measurements are obtained
by electrically stimulating a nerve at
one point with data collection at a
separate point along the course of the
nerve. EMG involves insertion of a
needle into a muscle innervated by
Volume 15, Number 9, September 2007
the nerve under study and subse-
quent recording of electrical activity.
With stimulation of the median
nerve proximal to the carpal tunnel,
the distal motor latency may be mea-
sured greater than 4.5 ms. When
stimulating from distal to proximal,
the distal sensory latency may be
measured greater than 3.5 ms.28
In chronic and severe cases, EMG
demonstrates increased insertional
activity, fibrillation potentials, pos-
itive sharp waves, and/or fascicula-
tion of the abductor pollicis brevis
muscle.
Electrodiagnostic testing is help-
ful in confirming the diagnosis of
CTS and in excluding other patholo-
gy (eg, cervical radiculopathy).29-31
Additionally, test results can provide
a baseline for comparison with fu-
ture studies during the course of
treatment. Although uncommon,
CTS may occur in the absence of an
abnormal electrodiagnostic study,
and positive findings may be ob-
tained in individuals without clini-
cal symptoms of CTS.32
Imaging Studies
Baseline radiographs of the wrist
are frequently obtained during the
initial office evaluation and can be
useful in detecting unsuspected
wrist pathology. However, the im-
portance of routine radiographic im-
aging of the wrist is uncertain given
the reported low yield of abnormal
findings.33 Both ultrasound and mag-
netic resonance imaging have been
reported as effective diagnostic tools
for CTS.34,35 The cross-sectional area
of the median nerve and the space
available for the nerve in the carpal
tunnel are measured and compari-
sons made to normal values. The di-
agnosis of CTS is primarily clinical,
however, and ancillary imaging
studies are usually not required for
this purpose.
Serologic Studies
No blood tests specifically sup-
port the diagnosis of CTS. However,
diabetes and hypothyroidism are
C. Sabin Cranford, MD, et al
common diseases in the population
at large, and assessments of fasting
blood glucose and thyroid function
may be helpful in the general man-
agement of each patient. Several
medical conditions can lead to
symptoms that mimic CTS. Exam-
ples include pernicious anemia with
vitamin B12 depletion, folate defi-
ciency, vasculitis, and fibromyalgia.
Referral to an internist, neurologist,
and/or a rheumatologist may be
helpful in situations in which the di-
agnosis of CTS is uncertain or when
a concomitant medical condition is
suspected.
Treatment
Management decisions rely on sev-
eral factors, including the etiology
and chronicity of CTS, symptom se-
verity, and individual patient choic-
es. Nonsurgical treatment measures
are appropriate in the initial man-
agement of most idiopathic cases of
CTS. Splinting and corticosteroid in-
jections may be prescribed, and they
have proven benefits.36-38 Surgical
treatment is indicated in acute cases
of CTS from trauma or infection, in
chronic cases with denervation of
the abductor pollicis brevis muscle
or a pronounced sensory loss, and in
cases unresponsive to conservative
management.
Nonsurgical
Splinting
Immobilization of the wrist at
night and intermittently during the
day has been shown to diminish re-
ports of CTS.36,38 Pressure in the car-
pal tunnel is lowest with the wrist in
2 9 of extension and 2 6 of ul-
nar deviation.9,39,40 Prefabricated
splints typically align the wrist in
20 to 30 of extension. However,
CTS may be more effectively ad-
dressed with the wrist immobilized
in a neutral position.39
Oral Medications
Several medications have been
advocated in the treatment of CTS,
541
Carpal Tunnel Syndrome
including diuretics, nonsteroidal
anti-inflammatory drugs (NSAIDs),
oral corticosteroids, and vitamin B6
(pyridoxine). Diuretics, NSAIDs,
and oral corticosteroids are thought
to decrease interstitial fluid pres-
sure within the carpal canal. Vita-
min B6 is a cofactor in neuronal
protein synthesis. Supplementation
with vitamin B6 may avert cofactor
deficiency associated with alter-
ations in peripheral nerve metabo-
lism.41
Celiker et al42 compared the effec-
tiveness of NSAIDs and splinting
with corticosteroid injections in
treating CTS. They found that both
methods of treatment led to statisti-
cally significant improvement in
symptoms at 2 months. Chang et
al43 compared the use of NSAIDs, di-
uretics, oral corticosteroids, and pla-
cebo in four groups of patients with
mild to moderate CTS. In contrast
with the findings of Celiker et al,42
these authors detected no significant
symptom improvements with the
use of NSAIDs (or diuretics). Howev-
er, oral corticosteroids were shown
to be effective at short-term (4
weeks) follow-up.
The initial enthusiasm for vita-
min B6 supplementation has waned.
A review by Aufiero et al41 cited sev-
eral studies supporting and disprov-
ing the efficacy of vitamin B6 for
treatment of CTS. Only two studies
cited by the authors were random-
ized and blinded in design, and both
studies detected no improvement in
CTS symptoms with administration
of vitamin B6.
Corticosteroid Injections
A corticosteroid injection can be
useful not only in nonsurgical man-
agement but also in confirming the
diagnosis of CTS as well as in pre-
dicting the results of surgery. Edgell
et al44 reported a significant (P < 0.05)
difference in the surgical success
rates between patients who obtained
some relief following an injection
(87%) and patients who experienced
no change in their symptoms (54%).
542
Gelberman et al37 found that a
single corticosteroid injection im-
proved CTS symptoms in 76% of pa-
tients after 6 weeks. However, only
22% remained symptom-free at 1
year. An injection was determined to
be most effective in patients with
mild CTS symptoms, symptoms
present for <1 year, normal sensibil-
ity testing, and only minor electrodi-
agnostic study abnormalities.
Careful technique is required
when administering a carpal tunnel
corticosteroid injection to avoid in-
jury to the median nerve and adja-
cent flexor tendons. Regrettably, lit-
tle information is available to guide
the choice of corticosteroid prepara-
tion. A transient elevation in blood
glucose can be anticipated in pa-
tients with diabetes; thus, a less sol-
uble corticosteroid preparation may
be considered (eg, triamcinolone
acetonide). Diabetic patients should
be instructed to monitor their serum
glucose levels closely for the first
few days because there have been
case reports of hyperglycemia fol-
lowing local corticosteroid injec-
tion.45
To our knowledge, there are no
absolute contraindications to ad-
ministration of a cortisone injection
during the third trimester of an
uncomplicated pregnancy or in a
healthy breast-feeding woman with
a healthy infant. However, lidocaine
and corticosteroids are category B
and C drugs, respectively; therefore,
a discussion with the mothers ob-
stetrician and/or childs pediatrician
might be prudent to obtain up-to-
date information and reduce the po-
tential concerns of all involved.46
Other Modalities
Ultrasound therapy, ergonomic
modifications, nerve and tendon
gliding exercises, laser therapy, and
iontophoresis have been advocated
as adjunct and/or alternative treat-
ment measures for CTS. In a
randomized study comparing ultra-
sound treatment with sham ultra-
sound treatment, ultrasound ther-
Journal of the American Academy of Orthopaedic Surgeons
apy led to significantly (P < 0.05)
improved symptoms at 2 weeks, 7
weeks, and 6 months.47 However, an-
other study demonstrated no appre-
ciable benefit at 2 weeks from this
form of treatment.48 Ergonomic
changes at home and in the work
place can be considered for general
patient comfort and satisfaction.
Many recommended measures, how-
ever, including specially designed
desk chairs and computer keyboards,
have not been scientifically proved
to prevent or ameliorate symptoms
of CTS.49
Theoretically, nerve and tendon
gliding exercises enhance venous
blood flow and decrease pressure
within the carpal tunnel. Rozmaryn
et al50 evaluated 240 patients with
CTS, half of whom were instructed
to perform nerve and tendon gliding
exercises. In the group of patients
who did not perform these exercises,
71% eventually underwent carpal
tunnel release surgery, whereas in
the group of patients who did per-
form these exercises, 43% under-
went surgery. Akalin et al51 conduct-
ed a prospective, randomized trial
comparing splint usage alone with
splint usage and nerve and tendon
gliding exercises. In contrast with
the findings of Rozmaryn et al,50
soft-tissue gliding exercises were
found to provide no significant ben-
efit.
Laser therapy and iontophoresis
for treatment of CTS remain contro-
versial. Few published data are avail-
able in the English-language litera-
ture to determine the efficacy of
either treatment modality.52,53
Surgical
Release of the TCL may be per-
formed in an open or endoscopic
manner and under general, intrave-
nous regional, or local infiltration
anesthesia.54
Open Carpal Tunnel Release
Open surgical release is the most
common method of carpal tunnel
decompression. The length of the

skin incision varies but typically is
<4 cm. The palmar fascia and TCL
are incised longitudinally to expose
the median nerve. The release is ex-
tended to the superficial palmar arte-
rial arch distally and for a limited
distance proximally beneath the
wrist flexion creases. Care is taken
to avoid injury to the motor branch
and palmar cutaneous branches of
the median nerve.
Internal neurolysis, epineuroto-
my, and tenosynovectomy are rarely
indicated in primary open carpal
tunnel release surgery.55-57 In addi-
tion, routine reconstruction of the
TCL has not been found to be neces-
sary to prevent bowstringing of the
flexor tendons.58
Endoscopic Carpal Tunnel
Release
Endoscopic techniques were in-
troduced to address problems occa-
sionally encountered with open car-
pal tunnel release surgeryscar
tenderness, pillar pain, and pro-
tracted time away from work. Popu-
lar approaches include the single
portal technique reported by Agee et
al59 and the dual portal technique
devised by Chow.60 In the Agee sin-
gle-portal endoscopic technique, a
small transverse skin incision is
made at the ulnar border of the
palamaris longus tendon, that is,
midway between the flexor carpi ra-
dialis and flexor carpi ulnaris ten-
dons, proximal to the wrist flexion
creases. A distally based flap of fore-
arm fascia is elevated to expose the
proximal end of the carpal canal.
With the wrist held in slight exten-
sion, the endoscopic blade assembly
is inserted into the canal, making
sure that the blade is aligned with
the axis of the ring finger. The distal
edge of the transverse carpal liga-
ment is identified, and the ligament
is sectioned distally to proximally.
The dual portal technique requires a
proximal incision and a distal inci-
sion deep to the TCL (Figure 3). Rec-
ognized learning curves are associ-
ated with each technique as well as
Volume 15, Number 9, September 2007
known surgical contraindications,
including wrist stiffness, prolifera-
tive synovitis, and tumorous infil-
tration into the canal.61
Limited Open Carpal Tunnel
Release
Limited-incision carpal tunnel re-
lease techniques similar to endo-
scopic surgery were developed to de-
crease palmar discomfort and hasten
the return to activities.62,63 A variety
of instruments has been designed for
these purposes. The surgical ap-
proach involves a small skin inci-
sion in the palm followed by release
of the distal end of the TCL under di-
rect visualization. The proximal
TCL is incised in a distal-to-prox-
imal direction using a cutting guide
(Figure 4). Attention to anatomic de-
tail is necessary in directing the
blade because injury to the median
nerve has been reported.64 Open car-
pal tunnel release is recommended
over relatively blind release proce-
dures (Figure 5).
Outcomes/Comparative
Studies
Nonsurgical Versus
Surgical Management
A recent prospective, randomized
trial comparing the efficacy of surgi-
cal decompression to local cortico-
steroid injection for the treatment of
CTS has challenged the notion that
surgery is more effective than non-
surgical management.65 The authors
concluded that local injection was
superior to surgery in the short term
but that surgery led to better func-
tional improvements at 1 year. Hui
et al66 performed a similar random-
ized trial comparing surgery and
corticosteroid injections. Contrary
to the findings of Ly-Pen et al,65 the
surgically treated patients had great-
er symptomatic and neurophysio-
logic improvement at 5 months
compared with patients treated with
injection.
C. Sabin Cranford, MD, et al
Open Versus Endoscopic
Carpal Tunnel Release
Endoscopic surgery has been
found to shorten recovery time com-
pared with open carpal tunnel de-
compression, with a 2- to 3-week
earlier return to work.67-69 Neverthe-
less, studies have demonstrated no
substantial differences in final out-
come between endoscopic and open
carpal tunnel release surgery. A re-
cent randomized double-blind study
evaluated open and endoscopic tech-
niques in 25 patients with bilateral
CTS.70 One hand in each patient was
treated by open carpal tunnel release
surgery; the other hand was treated
endoscopically. The outcome mea-
surements at 3 months demon-
strated no significant differences be-
tween treatment groups. However,
overall satisfaction was lower in the
endoscopic patients secondary to a
5% rate of revision surgery.
Bilateral Carpal Tunnel
Release
The potential benefits of simulta-
neous carpal tunnel release surgery
include decreased time away from
work and more efficient use of surgi-
cal resources.71 Retrospective studies
have shown that the costs associated
with simultaneous carpal tunnel re-
leases are decreased and that the dis-
ability following simultaneous de-
compressions is no greater than with
sequential carpal tunnel decompres-
sion.72,73 These results must be inter-
preted with caution, however, be-
cause there are no prospective,
randomized studies comparing si-
multaneous with staged carpal tun-
nel release surgery.
Rehabilitation and
Complications
Wrist immobilization after carpal
tunnel surgery has not been shown
to confer any benefit in reference to
pain relief or surgical outcome.74-76
Active-motion exercises of the wrist
and fingers are encouraged postoper-
atively in nearly all patients.
543
Carpal Tunnel Syndrome

Figure 3

Chow two-portal endoscopic technique. A, Entry portal. B, Exit portal. C, The endoscope and blade assembly are passed from
the proximal incision through the distal incision, deep to the transverse carpal ligament (TCL). D, The distal edge of the TCL
is released using a probe knife. E, A second cut is made in the midsection of the TCL with a triangular knife. F, The first and
second cuts are connected with a retrograde knife. G, The endoscope is repositioned beneath the TCL through the distal portal.
H, A probe knife is inserted to release the proximal edge of the TCL. I, A retrograde knife is inserted into the midsection of the
TCL and drawn proximally to complete the release. (Panels A, B, D, E, F, H, and I are adapted with permission from Chow JCY:
Endoscopic carpal tunnel release: Two portal technique. Hand Clin 1994;10:637-646.)

544 Journal of the American Academy of Orthopaedic Surgeons


Figure 4
Limited incision technique. A, The
carpal tunnel tome is an example of
an instrument designed for a limited
incision technique. B, Through a 1.0- to
1.5-cm palmar incision, the distal edge
of the transverse carpal ligament (TCL)
is exposed and divided under direct
visualization. The wrist is held in slight
extension and the tome is positioned
into the defect with the blunt surface
deep to the TCL. Using a gentle
pushing motion, division of the TCL is
completed in a distal-to-proximal
direction (arrow). C, The angle
demonstrates that the wrist is held in
slight extension, approximately 30.
(Panel A is reproduced, and panels B
and C are adapted, with permission
from Lee WPA, Strickland JW: Safe
carpal tunnel release via a limited
palmar incision. Plast Reconstr Surg
1998;101:418-424.)
Complications have been report-
ed with all techniques of carpal
tunnel release surgery, including but
not limited to injuries to the mo-
tor branch and palmar cutaneous
branches of the median nerve, hy-
pertrophic scar formation, pillar
pain, laceration of the superficial
palmar arterial arch, incomplete re-
lease of the TCL, tendon adhesions,
infection, wound hematoma, finger
Volume 15, Number 9, September 2007
C. Sabin Cranford, MD, et al
Figure 5
Incision through
transverse
carpal ligament
Hook of
Hamate
Pisiform
Skin and
Flexor carpi aponeurosis
ulnaris reflected
Radius
Ulnar nerve
and artery Flexor carpi radialis
Median nerve
Flexor digitorum
superficialis
Open carpal tunnel release. The transverse carpal ligament is divided in a distal to
proximal direction near the hook of the hamate. A Carroll or Lorenz elevator may be
placed beneath the transverse carpal ligament to protect the median nerve.
(Adapted with permission from Stern SH [ed]: Key Techniques in Orthopaedic
Surgery. New York, NY: Thieme, 2001, p 84.)
stiffness, and recurrence.77 The most mary carpal tunnel release sur-
common complication with open gery.80 Several revision techniques
carpal tunnel release surgery is pillar have been described, including neu-
pain, followed by laceration of the rolysis of the median nerve with fat
palmar cutaneous branch of the me- transfer, muscle transfer, and vein
dian nerve. Pillar pain occurs in ap- wrapping.81-83 Factors that can help
proximately 25% of surgical cases, to predict an unfavorable outcome
with symptom resolution reported before primary carpal tunnel release
in most patients by 3 months.78 In- surgery include poor scores on
complete release of the TCL with patient-reported measures of upper
persistent or recurrent CTS symp- extremity function and mental
toms is the most frequent complica- health status, pending legal action,
tion attributed to endoscopic carpal and excessive alcohol intake.84
tunnel release surgery.67-69
Recurrent CTS develops in 7% to
Summary
20% of surgical cases.79 The problem
is difficult to address, and revision CTS is a common problem with sig-
surgery is less successful than pri- nificant economic impact. Several
545
Carpal Tunnel Syndrome
risk factors are associated with dis-
ease development, but the primary
etiology in most cases remains un-
known. A thorough history and
physical examination are key in
making the diagnosis; electrodiag-
nostic testing can be useful as a con-
firmatory study. Nonsurgical treat-
ment (eg, splinting, oral medications,
corticosteroid injections) and surgi-
cal treatment (eg, open carpal tunnel
release, endoscopic carpal tunnel re-
lease, limited open carpal tunnel re-
lease) are both beneficial in providing
symptom relief in most patients.
The results of open and endoscopic
surgery are essentially equivalent af-
ter 3 months, and the superiority of
one technique over the other has yet
to be definitively established. Addi-
tional basic science and clinical out-
come studies are needed to resolve
the many uncertainties and contro-
versies surrounding CTS.
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