Carpal Tunnel Syndrome - Stephen Powell, MD

Sechrest: Hello I'm Dr. Randale Sechrest, your host for eOrthopodTV. Today we are interviewing Dr. Stephen Powell. Dr. Powell finished his medical school training at Indiana University. He then went on to complete an orthopedic residence at the University Hospitals of Indiana University. He then completed two fellowships, one an arthritis fellowship in Denver and another fellowship in hand surgery in Indianapolis, IN. Today we're going to be talking about a very common condition called trigger digit which occurs in the thumb and all fingers of the hand. Good afternoon Dr. Powell.

Powell: Hello Randy.

Sechrest: Let's start out, I think everybody has heard about carpal tunnel syndrome. And I think there's a lot of myths about carpal tunnel syndrome, there's a lot of confusion about exactly what's going on and what causes it, how it's best treated. So let's start by just talking a little bit about the disease process. What is carpal tunnel syndrome?

Powell: Carpal tunnel syndrome is caused by compression of the median nerve with the result being usually numbness, often pain in the area of the hand. The numbness usually occurs in the thumb, the index finger, the middle finger and the ring finger sometimes, but sometimes patient's have a hard time determining exactly where that numbness is. The problem being that there is pressure on the nerve caused from something outside the nerve, either the ligament that crosses over the top of the carpal tunnel, they can show you in their hand if their ligament goes across the top of the wrist. There are bones underneath the wrist that form the floor of the carpal tunnel and the nerve and several tendons go through that canal, that tunnel and can be compressed. The compression can be caused by lots of causes, the typical cause is uncertain. Probably some ligament thickening, probably some tendon thickening. It can also be caused by arthritis in the bones of the wrist. Pregnancy is the most common cause probably for carpal tunnel but fortunately it's something that usually goes away when the pregnancy is finished and the child is born. There are other conditions like thyroid disease can cause carpal tunnel syndrome with increase of the contents of the carpal tunnel. So, the bottom line is pressure on the nerve causing the numbness and sometimes pain in the hand and then ultimately if people have it long enough, they can develop weakness and ever paralysis of some of the muscles in the hand.

Sechrest: So when you see patient's in the office and they come in with these symptoms, what's the common presentation? What do patient's normally complain of?

Powell: The typical patient complains of the hand falling asleep. Very frequently during the daytime of activity, often at nighttime waking them up with 1,2, 3 times a night interruption of their sleep. Very frequently they'll have problems fingering objects such as the buttons of their shirt, dropping things such as pencils or even larger things. So, the primary complaint is usually numbness. Pain is also something they may have complaint of and it may be going on for years, it could be a relatively recent onset.

Sechrest: So, when people come in they normally complain first of this numbness. Can you show me on the hand where most folks feel this numbness?

Powell: The median nerve distribution, which is the nerve that goes through the carpal tunnel, affects the thumb, the index finger, the long finger and half of the ring finger typically. There can be some variation.

Sechrest: Yeah, you know, it's funny. When I talk to patient's, a lot of them will come in and you'll say well where's the numbness? And they'll say my whole hand and so you have to tell them to go home and say well, next time you wake up, I want you to take a safety pin and prick each finger. Come back and tell me which fingers are numb at that point. A lot of times that's all it takes for a diagnosis is they can make the diagnosis themselves.

Powell: I find the same thing with patient's having a difficult time telling where that numbness is.

Sechrest: And, during the day, what sort of things might kick off the numbness or the pain during the day? What activities do you note that patient's really complain of?

Powell: It varies typically, people will tell you if they're writing, talking on the telephone, holding their hand up to drive, holding a book, something holding their hands up. Vibratory activities such as vibratory tools or jack hammers and cause problems. There are people who have some effect from keyboard use and mouse use but it can be a whole host of things that can cause their problems. Sometimes people only have problems at nighttime. That happens occasionally as well.

Sechrest: Now, the weakness that you referred to, which muscles are we talking about get weak in the hand?

Powell: The only muscle that the median nerve, after it goes through the carpal tunnel effects is the muscles that moves the thumb called the thenar muscles. It's this outpooching of muscles in the base of the thumb that helps to move the thumb over toward the little finger and the other fingers.

Sechrest: And if that starts to get weak, how do patient's know that?

Powell: Well, typically it's the weakness of pinch and holding on to things. Sometimes, of course, that's caused by numbness in the hand and they can't feel well. But, if they are starting to have problems pinching things and a lot of times they'll start getting actually muscle wasting and atrophy and the muscle getting smaller in their thumb.

Sechrest: So if they look at both hands, one is smaller than the other.

Powell: That's correct.

Sechrest: Causes? You know, it's always a question especially in the work comp population, so, people who have a work comp injury. And, a lot of patient's that I see come in and say, well why could I have carpal tunnel syndrome? I don't do anything repetitive. So, I think there's a myth out there that you don't get carpal tunnel syndrome without some sort of repetitive activity. Is that accurate?

Powell: The accuracy of that statement is really questionable and I don't mean to be facetious but there have been swings both toward the feeling that you have to have something that is going on with your hands frequently, repetitively to make it have carpal tunnel syndrome and now the pendulum is swinging away from that. There has been studies recently at the Mayo Clinic and in Scandinavia that show that keyboarding doesn't really affect carpal tunnel syndrome unless you have thousands of keystrokes a day or certainly a week that causes you to have repetitive stress to your hands. The worker's compensation cases are typically things that we see that are usually allowed so legally, carpal tunnel is considered to be an occupational disease but the data for how strong that relationship is, is pretty weak at that point.

Sechrest: Now what other disease processes, the one's I am aware of is the thyroid disease and you mentioned diabetes sometimes is considered. There's other ones that tend to cause thickening of the lining around the tendons and that sort of stuff. What other typical disease processes are associated with carpal tunnel syndrome?

Powell: Well, certainly arthritis can be, whether it's systemic arthritis such as rheumatoid arthritis or other types of arthritis that is body wide if you will that can cause swelling of th e tendons as you mentioned. Osteoarthritis which causes swelling around the individual joints of the hand can cause compression of the nerve. But I think the thyroid condition and the pregnancy that I mentioned are probably the most common.

Sechrest: And probably one we ought to mention also is fractures. You know, you see a lot of patient's who had wrist fractures or something like that, that then later go on and they heal and then they develop, well either they develop carpal tunnel syndrome as part of the wrist fracture or later on as it heals they begin to develop problems with the nerves.

Powell: Either case can happen, that's correct.

Sechrest: Well, how do you make the diagnosis of carpal tunnel syndrome? When you see a patient that you're suspicious may have carpal tunnel syndrome, is this a clinical diagnosis that you're perfectly comfortable just making that diagnosis based on seeing the patient? Do you do x-rays? Do you do an MRI scan? Any other testing necessary?

Powell: Good questions. My personal feeling is the diagnosis of carpal tunnel syndrome is a clinical diagnosis. Diagnosis of carpal tunnel syndrome was made years ago without any other studies being made, x-ray perhaps but it is a clinical diagnosis at the outset and it is still today. We use other tests for confirmation if we need to. I feel very comfortable if somebody has the classic history of their hand falling asleep in the typical distribution and they have the physical findings that I'm not going to go into right now that show that they have compression of their median nerve consistent with carpal tunnel syndrome and they've had, particularly if they've had some treatment that perhaps have given them some benefit that we usually use to treat carpal tunnel syndrome, I feel very comfortable making that diagnosis and working off that diagnosis clinically. If I have questions or if there is perhaps some legal or occupational medicine type of concern that we have to worry about, I may give some diagnostic studies, a nerve conduction study which is short of like a volt meter testing the nerve to see how it works is one that we use frequently, but I don't use it on every patient. If someone comes in with a classic picture, I'm going to tell them that if they have a carpal tunnel syndrome based on what I find on clinical examination, that that other test doesn't add anything because it could be negative and they still have carpal tunnel syndrome.

Sechrest: Okay.

Powell: Let me, I forgot to answer your question about the x-rays. I personally don't x-ray every patient with carpal tunnel syndrome, however there is a set of patients I think that should be x-rayed because there are some patient's, as we talked about, who have old fractures in their wrist, have arthritis in their wrist and if you notice those patient's have an abnormal wrist, their motion is abnormal, they have thickening in their wrist, tenderness about their wrist, they may have a condition that is underlying the carpal tunnel, maybe not related to the carpal tunnel but which can affect the treatment. So, I will x-ray patient's if I am concerned about a concomitant or coexisting cause or condition that goes along with the carpal tunnel because it may change my treatment.

Sechrest: Okay, so what you're saying is that you can't just treat the carpal tunnel. Carpal tunnel is a symptom of another underlying disease and you're also interested in treating that underlying disease.

Powell: In those cases, that's for sure.

Sechrest: Okay, gotcha. Well, let's talk a little bit about treatment. Let's say that I'm a person who has just developed these symptoms, maybe I have had them for two or three months, and I come to you and I say, Dr. Powell, my hand is falling asleep at night, I can't sleep, during the day I'm okay, if I'm driving it may fall asleep, but during the day it does get to normal. What do you tell that patient?

Powell: That's very typical in early cases of carpal tunnel syndrome. People who have early carpal tunnel we'll treat them as conservatively as we can. We don't rush into surgery certainly. People very frequently will respond to splinting, particularly if their symptoms are at nighttime or with certain specific activities during the daytime that a splint can be worn.

Sechrest: And this splint you're talking about, this is something you make? This is something the patient can buy at the drugstore? What are we talking about?

Powell: It could be either. Any splint that holds their wrist in a relatively neutral position so that it's not dropped down or way back such as nighttime, people will drop their wrist down and very frequently that's one of the problems they have and during the daytime they cut down the amount of wrist motion that they have which can irritate the wrist. Those splints can be commercial or made professionally by a therapist. The splints are something that I have patients use mostly at nighttime and for activities that don't involve a lot of use, people who use their wrist heavily, carpenters etc. have a hard time wearing something like a splint. But, in early cases a splint very frequently will help. If they are having bad symptoms and I think we need to give them a little bit more treatment than just see how the splint goes, I will consider an injection of some synthetic cortisone into their carpal tunnel. You make an injection all the way from the median nerve in a safe area down into the area around the tendons because the linings of the tendons, as I said, can cause compression of the nerve and if we can shrink those linings down, frequently the patient's symptoms will improve.

Sechrest: And that's what cortisone does.

Powell: That's what it does. But it rarely works in cases that aren't the type you mentioned. The people that have had symptoms for months, years, that's rarely effective.

Sechrest: What about pills? I mean, you know, people commonly come in and have been prescribed an anti-inflammatory for example. Do you think any medications are beneficial to people with carpal tunnel syndrome?

Powell: I think they're occasionally helpful but not typically.

Sechrest: There was a time where people really were pushing vitamin B6. Any benefit to that?

Powell: Well, there were some studies that showed that it helped but I don't think that, again, it's something that in the long standing case it's going to be a problem. It's been rather hit and miss in my experience.

Sechrest: Okay. And what about physical therapy, exercises?

Powell: I think exercises, some sorts are helpful for the patients. I'm not sure that specific physical therapy is very important. I think that a therapist or a physic an or a nurse can explain the types of things that patients should so for carpal tunnel syndrome and I advise myself, the patient to get up in the morning, stretch the forearm musculature, and the tendons of their wrist and fingers in both directions for 20-30 seconds in the shower is a good time to do that and periodically if they're in a situation where they're in one position or one activity for a while to take a break every couple of hours and do the stretching exercises. They're pretty straight forward exercises, I don't think that physical therapy has much of a role, the splinting is part of the physical therapy often.

Sechrest: Any other treatments that you think are beneficial that people should at least try to see if they help?

Powell: I can't think of any. There has been some discussion about some new laser treatments that seem to have sort term benefit but there's no data that shows that that's helpful. I can't think of any others.

Sechrest: So when do you advise patient's to have surgery? I mean, when should a patient really give up on trying to manage this? When are they causing permanent nerve damage? When is the time that they should say, now is the time to consider surgery?

Powell: Well the easiest is the patient who has already has had nerve damage who's already having atrophy or paralysis of the muscle to the thumb that we mentioned earlier. The patient who has profound numbness when you test them with a safety pin or another sharp object, they can't feel it or some of the fingers can't feel it and those patients who obviously have had that for some time and those are pretty clear indications for surgery. Patient's who don't have those situations but who have symptoms that they cannot tolerate may have none of the other problems but only symptoms and they're not responsive to the conservative therapy with splinting and injections of the carpal tunnel in early cases, those people are probably candidates for carpal tunnel but that is the case where the patient has as much to do with the decision to do surgery as the surgeon does. I have seen patients who have gone years and years without having nerve damage after a carpal tunnel release their hands return to normal. That doesn't mean that the patient might not develop long standing nerve damage, paralysis of the thumb, sensation loss in the fingers, but typically if the patient does not have objective data that supports nerve compromise, I don't think that's a hard decision to make on the surgeons part. I don't mean hard, I mean of the hard and fast rumor. The patient is a big part of that decision making process.

Sechrest: So if I'm a person who has symptoms primarily at night and I'm wearing braces and I'm not getting any sleep and yet I don't have a lot of symptoms during the day but you're convinced that it's carpal tunnel and I'm having symptoms I can't sleep, eventually I may come and just say I'm tired of this. You know, it's affecting the rest of my life, let's try the surgery. And, that's a reasonable approach.

Powell: I think that's most patients unfortunately.

Sechrest: I agree. Well, let's talk a little bit about the surgery itself. I guess first, what do you advise patients in terms of proceeding with surgery? How successful is this operation?

Powell: I think carpal tunnel surgery is very successful. I mean, that doesn't mean there aren't failures, there are a small percentage of patients. Carpal tunnel release is a pretty straight forward operation if done technically correctly, which the vast majority are. There are failures, people who have had long standing carpal tunnel syndrome have a bit higher chance of having some persistent numbness in their hand and particularly in the older patient, the 70-year-old, 80-year-old patient who have had it for a long time. They don't have the same symptoms they have before surgery frequently, but they'll notice for months or maybe permanently some lack of feeling objects as opposed to having their hand fall asleep as they did before surgery. So, there is a difference. But there is a failure rate of carpal tunnel surgery which I think is probably in the 5% and probably the same rate of recurrence in my view. Overall, it's a very successful operation if done well.

Sechrest: And when you say recurrence you mean, if I have carpal tunnel surgery and I ask you what's the chances of me having to have this redone five years from now.

Powell: Or 10 or 20 even.

Sechrest: So it is possible to have the surgery and then that recur and you would have to go back and do a surgery a second time.

Powell: And the longer the interval between the primary surgery and a repeat surgery, the better the chance the patient's going to do well. The patient who fails the first surgery within weeks or months is unlikely to do well after a repeat carpal tunnel release.

Sechrest: Okay. Now in general, the type of surgery that's done for carpal tunnel release, I'm assuming that this is pretty much outpatient surgery. You don't have to stay in the hospital through the night.

Powell: That's correct.

Sechrest: Do you do these in the office or do you do these in a surgery center? Where do you perform surgery?

Powell: I do them in any outpatient surgery section that the patient wants to go to or we agree to go to. Typically we use a surgery center __????__ and the patient comes in an hour before surgery, goes home an hour after surgery and may have them done under either a general anesthetic if they're particularly squeamish or if I think there is some reason to do it under general or we can even do it just with a simple local anesthetic into the skin without even blocking the arm nerves which is a better way to do it. So, there are variable ways of doing it, all of which outpatient model is a very good way to do it.

Sechrest: Now, what's your opinion about the different techniques? I know there is open techniques where we just make an incision through the skin, there is also the endoscopic technique where we use an endoscope to be able to look under the skin of the palm and do the incision from the inside out so to speak. Do you do both?

Powell: Yes.

Sechrest: So you do endoscopic. Do you think there is any advantage to the endoscopic over an open technique?

Powell: There are advantages to both. The advantage of the endoscopic technique compared to the open technique is that there is less incision in the sensitive skin of the palm and the very thick skin in the palm which tends to get pretty significant scar which remains tender for a while. Now, we're not talking about months typically, we're talking about six or eight weeks before a patient after a carpal tunnel release can use their hand for vigorous activities and after an open carpal tunnel release. An endoscopic tunnel release in which we make an incision in the wrist and either make no incision or a small incision in the palm and place an endoscope underneath the carpal tunnel ligament, the transverse carpal ligament and as you say cut it from the inside out. That recovery is about half as long in my experience as far as getting patients back to using their hands for firm grasp three or four weeks instead of six to eight weeks.

Sechrest: So how do you make the decision?

Powell: Most of the time, frankly I have the patient make the decision. I do both. I probably do a little bit more endoscopic than I do open. The older patients who have soft skin who typically don't have that problem with a thick scar, painful scar developing, a 70 year olds, they don't really have that much of an advantage for an endoscopic carpal tunnel release and there is a slight risk with that operation which you want to avoid, you have to see well with an endoscopic carpal tunnel just like you do an open carpal tunnel. And if you're seeing something that you're not sure what it is and you proceed with the operation you could injure something. So, I tell patients that if I can't see well when I'm doing the operation that we may have to convert that to an open operation. So, the risk is that if you have somebody who doesn't see well and they continue the operation, they might damage a tendon or even a nerve and that's happened and so I tell patients that it's unlikely, but there is that risk and if the patient is not comfortable with that risk we have an open carpal tunnel release done. If they are anxious to have a faster recovery then we'll proceed with the endoscopic. The treatment of course is to release the transverse carpal ligament either by making an incision along the crease near the crease in the palm somewhere. Some people go across the wrist crease, I don't and going down through that tissue, that thick tissue underneath the skin, the fat and then through the transverse carpal ligament, allowing the ligament which is covering the nerve to expand and to heal longer and thinner over the top of the nerve and you can do that either from the top or the bottom. There are complications of doing it the open way too. There are some nerves there that can be injured and one has to be careful either way but there is an associated risk with endoscopic carpal tunnel release that people might not want to assume that risk and they would rather have an open carpal tunnel.

Sechrest: And after this procedure is open, sort of, can you give us some idea of what the ideal recuperation period is. When they leave the surgery center, I'm assuming the patients are in a bandage, if they've had an open procedure they have sutures in the skin.

Powell: Yes.

Sechrest: How long does it take for them to be able to shower, for example, to get this wet. To begin to resume certain activities. Give us the rundown.

Powell: Well, let's start with the open first. Open carpal tunnel release has a wound that's longer, has to be protected a bit longer because you have stitches in the skin. Those stitches can wick fluid water in so we have to keep it pretty dry. You don't want to be immersing your hand in water, going out and running a marathon, playing handball where you're going to get real sweaty and it causes increased chance of infection. So you've got to care for the wound. Sutures usually come out at about two weeks. Maybe a little shorter period of time. The hand at that time is rather swollen and rather tender. Up to that time, they have been using their hand for light activities and not getting it wet, we send the patients home from the hospital or the outpatient surgery center in a bulky dressing around the palm leaving their fingers out so they can still do things with their fingertips typing even after a few days and then the dressing comes off and they have to protect it until the stitches come out. After the stitches come out it's just the matter of how tender they are, how sore they are as far as what they can do with their hand. They find usually that they can do medium activities. That's things like picking up a briefcase, maybe carrying some plates, that sort of thing. Five, ten pounds worth of weight at about three weeks pretty comfortably. They can drive usually after just a few days after surgery. But it takes, as I said, six to eight weeks to get that hand at a point typically where you can hammer, use wrenches and other gripping activities. If people have both hands done at the same time it takes longer because they don't have another hand to fall back on, but for a single sided carpal tunnel release, that's a good guesstimate as to how long they'll get back to their activities.

Sechrest: I think one thing we ought to probably point out is if you have both hands done, personal hygiene can become a real challenge.

Powell: Well, for a couple of days. Fortunately we have gloves that you can use for certain activities and most people who have it done on both sides are happy they had it done at both sides but there are people who wouldn't even think about having it done on both sides but I think that that's dealers choice.

Sechrest: Rehab. Any physical therapy after these wounds heal? Do you typically have folks see a hand therapist, a physical therapist and for how long if you do?

Powell: I typically don't unless the patient is having some problems. The patient who's uncomplicated, I personally do not think physical therapy adds much to it. There are surgeons who think that the therapist is important as far as regaining gliding of the tendons but I have not seen data scientifically produces that shows that there is an advantage to doing active physical therapy rather than encouraging the patients to move their fingers and move their wrists on their own.

Sechrest: So you give them instructions and basically just have them do some rehab on their own.

Powell: Yes, if they have problems I think they're not coming along the therapists are very important.

Sechrest: Complications. I mean, what do you fear the most when you do this operation? What bothers you about this operation and what do you tell patients that you want them to know the potential risk are?

Powell: I always tell patients the risks of surgery include infection, very rare in carpal tunnel syndrome. I can't recall one frankly. The next compilation is really not a complication but an expectation. They expect to get well and I can't promise them all their numbness is going to go away.

Sechrest: Right.

Powell: Typically all or most of the numbness goes away in 95% of the patients I think. There are certain groups of patients you can look at and predict they may have a less favorable prognosis but that's pretty much the average. Stiffness of the wrist and fingers is something that you have to warn them about and that's why we have them do the motion exercises, and it's not usually a problem. A tender scar is probably the most common thing we see with carpal tunnel release surgery where that ligament that I told you that expanded and the heel is thinner ends up as some scar tissue kind of around the rounded off edges right over a couple of bones here, that we call the pillars and some people have some tenderness there for a while. A very small percentage frankly, but some people have it for a longer period of time and utilizing physical therapy is probably important for those. There is a nerve that's very important that comes into the muscle that I was mentioning earlier that if it's misplaced in the anatomy, the patient's anatomy is different, you may injure that nerve if you're not carefully watching for it or sometimes even if you are carefully watching. If it's in a very unfavorable spot and you can have damage to that nerve or any of the other branches of the nerve if they're in scar tissue. I think the most worrisome thing that happens besides the soreness is that some patient's don't respond as well as you'd like. There are some patients who just don't get better. A small percentage, very small percentage and that's not really a complication as much as an outcome.

Sechrest: Anything that you would advise patient's who are faced with this decision. Trying to find a physician to take care of it. Trying to decide whether to have surgery. Any pearls you can offer to those patients? How should they go about finding an appropriate surgeon to evaluate then and if they're going to have surgery how should they go about choosing a surgeon to do this procedure?

Powell: I think that the training of the physician is the most important thing. Carpal tunnel surgery has been felt by some physicians to be a relatively simple surgery. It can have complications as I mentioned and you want to make sure that the release is done completely. There has been a lot of patient data that show that patients who have failed to get better and the surgeon is not a hand surgeon or orthopedic surgeon or neurosurgeon or plastic surgeon who has been trained in that might not completely release the pressure of the nerve so you don't want to have that happen, you don't want to have a nerve injury. So, I think that the important thing is that you look at the physician's training, this surgeon's training. We're talking about surgeons here and the typical orthopedic surgeon, hand surgeon, plastic surgeon and neurosurgeon should be well qualified to do a carpal tunnel release but it is probably wise to ask them as I would any surgery, what their experience is in doing carpal tunnel and what the types of options they can be offered. Whether it's open carpal tunnel release or an endoscopic carpal tunnel release, what their expertise is, what they're feeling's about it and asking their own personal physician is very frequently a good way of handling it. You can ask your friends but their data is probably a little less clear cut on that.

Sechrest: Well, thanks, it's been very interesting discussion. Anything we haven't covered? Anything that we should make sure that patient's with carpal tunnel syndrome know.

Powell: I think we've covered that pretty well. I think the important thing is to realize that having a carpal tunnel diagnosis made at a time when you're having questionably nerve damage, you don't feel, you don't have good function in your hand. That's probably the time when you want to maybe think that you should get to the physician, either your physician or an orthopedic, hand surgeon, plastic surgeon because you could be having some problems that could be not only limiting you but cause further problems and also barring that that the patient's decision as to when the surgery is, is just as valid as the surgeon's. But, I think the patients usually know at the time they're in the office that it's time to have surgery otherwise they wouldn't be there.

Sechrest: Yeah, I hear ya. Well, thank you very much.

Powell: You're welcome, thank you.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.