David J. Slutsky


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3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

Office hours: M-F, 9am – 5 pm

Worker’s compensation, Medicare and most insurance plans accepted.

In September 2008, we will be moving to a beautiful new 4,400 sq ft, state of the art dedicated hand center located at 2808 Columbia Ave in Torrance, CA., which will feature onsite nerve conduction studies, occupational hand therapy and digital x-ray.
 


PROCEDURES

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome (CTS) has been termed "the disease of the 90's"! The clinical stigmata of the syndrome were described as early as 1863 but it really was not widely recognized until the 1950's. The symptoms are due to acute or more commonly, chronic pressure on one of the 3 major nerves supplying the palm of the hand, i.e. the median nerve. The median nerve becomes well defined in the upper arm, and after passing underneath and supplying the forearm muscles that are responsible for finger flexion, it then passes underneath a thick ligament at the wrist level, the carpal transverse ligament. This ligament forms the roof of a natural canal or "tunnel", with the sides and floor of this tunnel being formed by the bones of the wrist. The canal also contains 9 flexor tendons. Because of this arrangement any disorder that diminishes the size of this space, will increase the pressure in the carpal tunnel. This can arise from a decrease in the physical size of the tunnel such as occurs with a dislocated wrist bone, or any increase in the size of the contents such as a tumor or thickening of the tenosynovium or “lining” of the finger flexor tendons, which is the most common cause of CTS. This increase in pressure within the carpal canal interferes with the median nerve blood supply which gradually leads to a slowing of the nerve impulse conduction. This is manifested as finger numbness. When the pressure on the nerve is relieved it is followed by a "tingling" feeling as the nerve function returns. An analogy to this situation would be the example of having your foot fall asleep after sitting for a long time in a movie theater. Once you shift position the feeling in your foot first returns with an uncomfortable "pins and needles" feeling, which is then followed by normal sensation. Historically, CTS has occurred most frequently in women between 30-50 years of age. The female to male ratio often quoted is 3:1.

Symptoms:
The most common complaint is intermittent numbness in the thumb, index or long fingers. Tingling and finger and/or volar wrist pain are frequently also present. Many people first note symptoms at night, when they are awakened from sleep by a tingling discomfort in their fingers, often described as "pins and needles." This predilection for night-time symptoms has been ascribed to sleeping in the fetal position with wrists flexed, to direct pressure on the wrists by the head, and to changes in total body fluid distribution resulting from lying horizontally. All of these factors lead to increased pressure on the median nerve in the carpal canal. For unclear reasons, the discomfort is often relieved by shaking the hand or hanging it in a dependent position.In contrast to night symptoms, many will note the onset of symptoms at work or while performing repetitive tasks. Activities such as repeated fist clenching or prolonged gripping, as in grasping a steering wheel, the handle of a tool or a tennis racquet will initiate the symptoms while cessation of such activities brings relief. Presenting symptoms of shoulder pain or upper arm pain can occur, and migration of pain from the area of the wrist toward the upper forearm and elbow are relatively common.
In early CTS, which is of short duration (3-6 months) the symptoms are mostly due to reversible inflammation with edema of the nerve fibers or axons. Treatment at this point can result in immediate cessation of the symptoms. With intermediate compression, the axons lose their insulating covering or myelin, which further slows the nerve conduction. Typically the patient will have frequent symptoms during the day with any gripping activities. Symptoms may persist for weeks following treatment until the axons regenerate the myelin lining. With longstanding nerve compression, the symptoms become constant and are associated with loss of finger sensation and atrophy of the thenar muscles. If left untreated, axons eventually die and will not regenerate even following surgery, which results in permanent nerve dysfunction.

Causes:
Although the effects of compression on the median nerve are well known, the actual cause of the typical case of CTS is not well understood. In the absence of any of the other causes of nerve compression, the elevated pressure in the carpal canal can only be related to a reduced carpal tunnel volume, possibly due to some thickening of the tissue lining the flexor tendons which are passing through the carpal tunnel. This thickening may be due to repeated mechanical stress on the tendons that occurs with repetitive gripping. CT scans have demonstrated that the carpal tunnel is smaller in women compared with men, which may explain the elevated frequency in women. There is abundant literature refuting the theory that CTS is due to typing. There is no doubt however that performing a repetitive task with the wrist and hand in an awkward position can certainly exacerbate the symptoms.

Some conditions that have been associated with carpal tunnel syndrome include rheumatoid arthritis, thyroid imbalance, diabetes, local wrist trauma, and the hormonal changes associated with menopause and pregnancy. Other conditions which can mimic the symptoms of carpal tunnel syndrome, include nerve compression in the neck, behind the clavicle or at the elbow. The median nerve may even be compressed in more than one area. It is apparent that it is important to rule out other sites of nerve compression or other more generalized nerve disorders which can masquerade as a carpal tunnel syndrome. Surgical treatment for carpal tunnel syndrome may otherwise fail to cure the problem and can result in unnecessary surgery. Nerve conduction studies may help to localize the area and degree of nerve compression.

Nonsurgical treatment:
Nonsurgical treatment of carpal tunnel syndrome is most appropriate when symptoms are mild or intermittent, relatively short in duration, or when the cause is expected to be transient in nature, such as pregnancy, where the symptoms are related to fluid retention and edema. This treatment includes wrist splinting, anti-inflammatory medication and activity modification.

Surgical treatment: (link to carpal tunnel release video)

Open and mini-incision carpal tunnel release
Surgical intervention is indicated in those in whom nonoperative treatment has failed, in those with atrophy of the thumb muscles or in almost all patients whose symptoms are constant rather then intermittent. The surgery often only takes 15 - 20 minutes, and can be done under regional anesthesia as an outpatient. It consists of dividing the carpal transverse ligament through a 3-4 cm incision in the palm. The first layer of tissue is longitudinally oriented, and is termed the palmar aponeurosis (figure 1A). The next layer is the transverse carpal ligament. It is transversely oriented and up to 5 mm thick (figure 1B). Once this ligament is released, the median nerve is visible (figure 1C). It is my preference to use a mini-incision technique using a 1-2 cm incision as compared to the standard 5 cm incision (figure 1 D, figure 1 E, figure 1 F, figure 1 G). The incision is more aesthetically pleasing and patients have less postoperative pain than with a standard 5 cm or greater incision. There is a higher risk of incomplete release of the carpal tunnel with this technique hence attention to detail and experience with this procedure is important.

Endoscopic carpal tunnel release
There has been a great deal of interest in endoscopic release of this ligament. (view endoscopic CTR video) Long term studies however have shown that the results are identical to an open procedure, although patients may be able to return to work 2 weeks earlier than that following an open procedure.
This procedure requires specialized instrumentation which are available from a variety of manufacturers. I prefer the Agee endoscopic carpal tunnel release technique. This requires strict attention to a number of anatomical landmarks to ensure that the nerve is safely released. The surgeon should obtain a clear view of the undersurface of the transverse carpal ligament prior to engaging the blade mechanism (link to figure 5A). Once the ligament is adequately released the fibers of the ligament will spread apart, which widens the canal and give the median nerve more space.

Persistent Symptoms
Recurrent CTS is uncommon, occurring in < 2% of cases in 1 large series of over 2,000 patients. Recurrent CTS, where there was a symptom free period, must be differentiated from persistent CTS where there was no initial relief in symptoms. A persistent median neuritis due to chronic nerve compression is the most common cause of residual symptoms. The best results are obtained in patients who undergo surgery before they have frequent to constant tingling or numbness and certainly before there is a motor and sensory loss. An incomplete release of the carpal tunnel is a possible cause of persistent symptoms and should be ruled out, but exuberant scar formation or fibrous proliferation within the canal is most common. When a repeat carpal tunnel release is performed, covering the nerve with tissue that has a vigorous blood supply has been shown to diminish the amount of recurrent scarring. One popular procedure is to transfer the fat from the hypothenar eminence as a pedicled flap, which is used to cover the median nerve after a repeat release (link to recurrent CTS video).

Postoperative course

Postoperatively, a wrist splint may be worn for 1-2 weeks for comfort. The sutures are then removed, followed by light gripping exercises. Most people will regain 75% of their grip strength by 8 - 10 weeks and hand function can continue to improve even up to 6 months after the surgery. The chances of obtaining excellent symptomatic improvement in people who have minimal to moderate symptoms are in the range of 80-100%.

Work Considerations
Most people can perform one-handed work activity by the 2nd week followed by light duty including clerical work at 6-8 weeks. Heavy manual labor can often be resumed by 10-12 weeks.