Tunnel syndrome

Manual workers, who for tens of years have been daily exposed to an increased load on hands and hand joints, in the second half of their life often complain about pain, numbness and loss of sensation in the hands. One of the causes could be carpal tunnel syndrome, which can be treated and even late treatment results are good.

What is carpal tunnel syndrome?

There are many nerves in the forearm: the major ones are ulnar and median nerves. At the site where the palm is connected to the forearm the bones are held together by ligaments, joints and joint capsules. One of the main ligaments holding the palm joint is the ligament going across the base of the palm on the face of the palm. In is strong and massive, but as any other part of the body exposed to any excessive impact – of cold, humidity, acids, physical load – it changes. In its turn, the body strengthens any part exposed to a significant load or external impact by making it thicker. It also thickens as a result of any inflammations and adhesions, but mainly the thickening is caused by hard work, for example, a farm worker who manually milks numerous cows every day. Carpal tunnel syndrome is also common among fishermen who pull nets with their bare hands, women mending nets every day, long distance drivers, tractor drivers and factory workers exposed to chemicals or working with fingers every day, those who work at the computers and people of any other occupation.
Under those ligaments called carpal tunnel, there are two major nerves, the main being the median nerve. In case of an inflammation at this site, adhesions are formed and the site thickens pressing on the nerve and small blood vessels supplying the nerve. In such case the patients complain about numbness in the hands, that they cannot milk cow or knit, or the hands are so numb that they cannot hold a steering wheel.
However, we should remember that the numbness, burning sensation, pain or loss of sensitivity can also be caused by the inflammation of the median nerve; the nerve can be entrapped after bone fractures of the forearm or upper arm in the elbow or shoulder joints. These symptoms can also appear if the nerve is entrapped at the neck level and the numbness of the fingers can be due to osteochondrosis. Only a specialist can tell these nuances apart, but in many cases the doctors prescribe their patients drugs or nerve blocks without finding the actual cause of the hand numbness and forgetting that at first they need to get to the bottom of the problem.

Diagnostics

There are following ways to find out which nerve is entrapped: electromyography (evaluates nerve vitality and conductivity), magnetic resonance (examination showing the structure of the nerve, spinal marrow, spinal marrow roots) or computed tomography (gives a good picture of bone spurs, cartilages, adhesion sites) and blood tests (to discover if there is an inflammation in the body).

Treatment options

When you first experience numbness in your hands, you do not need to see a specialist straight away. Initially, you should take hand baths before going to bed by holding your hands in a basin with warm water with one or two handfuls of rock salt or bath salts sold in pharmacies and shops (follow the instructions on the label). Then dry the hands and apply cream, preferably baby cream, which would soften both the skin and the ligaments under the skin. As a preventive measure, the hand baths should be used by everyone who in his/her everyday work has an increased load on the hands and hand joints. The hands should be protected from cold and heat by wearing gloves and from mechanical injuries.
If the salt baths do not help, it is advisable to see your GP, but you can also go directly to a neurologist, neurosurgeon or orthopaedist. Depending on your complaints the specialist will prescribe drugs, ointment, injections, recommend physiotherapy or refer you to one of the examinations mentioned above.
If the problem appears to be more serious, you will have to go to one of five neurosurgical clinics in Rīga, or a central clinic in Rēzekne, Daugavpils or Liepāja to perform a nerve block or even a hand surgery. The nerve block is performed to deliver a drug to the nerve entrapment site: it can be an anaesthetic, anti-inflammatory, anti-adhesion medication, etc. It is decided individually by a specialist.
“Do not fear the surgery, fear … the surgeons,” I read this humorous quote on a wall in a clinic in the USA. This joke is partly true. The carpal tunnel syndrome operation seems very simple: the ligament is resected and one side of the tunnel is open to release the nerve, but the use of optics is required during the surgery to avoid damaging tissue. Worldwide practice shows that complications are possible in 1% of the surgery cases, of which the patients must be informed before the surgery. Bleeding is possible during the surgery, as an artery is close, and without proper caution tendons and other surrounding tissues can be damaged. Endoscopic surgery is another good method, but it is used only in case of very specific professional indications.
The patients should know that the surgery may not bring the desired effect in case of poor healing of the wound and scar formation. Scar tissue from the incision can promote the narrowing of the tunnel. That is why your doctor should be informed if there is any scar formation after the surgery or trauma and, possibly, try to eliminate the problem with endoscopy or drugs. There is also a possibility that median nerve is severely entrapped and neither drug nor surgery can remedy that.
Often tunnel syndrome affects both hands, but it is unadvisable to operate on both hands at once, even if the patient insists, as the patient will need at least one hand to get dressed or eat. For at least two weeks after the surgery any physical labour should be avoided, but it is impossible, gloves should be worn. The healing is impaired if a patient is using alcohol or fails to protect the hand, which can easily lead to an infection. For 5 to 7 days after the surgery a gypsum splint or a special orthosis should be used.
Carpal tunnel surgery is paid for by the state. In a private clinic it would cost 99,- lats.
Having worked over 25 years in neurosurgery, I have observed how often patients turn to the doctor when the condition has already progressed. Often the patients have had a chaotic treatment using drugs of their own choice, physical therapy of their own choice and asking their doctor to perform a nerve block. Such chaotic treatment aggravates the condition, as a rule the diagnosis is superficial and often those people have been disappointed with the medical options for the treatment of tunnel syndrome. However, unsuccessful cooperation between the patient and the doctor is often to blame for the ineffective treatment.