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peripheral nerve entrapment syndromes

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a condition caused by compression of the median nerve in the carpal tunnel, characterized especially by discomfort and disturbances of sensation on the hand. At the base of the palm is a tight canal or "tunnel" through which tendons and nerves must pass on their way from the forearm to the hand and fingers. This narrow passage between the forearm and hand is what we call the carpal tunnel.

The carpal tunnel is normally tight with just barely enough room in it for the tendons and nerves to pass through it. If anything takes up extra room in the canal, things become too tight and the nerve in the canal becomes constricted or "pinched." This pinching of the nerve causes numbness and tingling in the area of the hand where the nerve travels. The condition that results when the median nerve is being pinched is commonly referred to as carpal tunnel syndrome. Symptoms tend to be worsen at night and include numbness and a feeling of "pins and needles" in the middle finger, index finger and thumb.

Treatment Options for Carpal Tunnel Syndrome:

Medication

Anti-inflamatory medications and local steroid injections are know to be effective in relieving pain caused by carpal tunnel syndrome. Physical therapy, certain exercises and wrist splinting can also help relieve symptoms.

Surgery

Open Carpal Tunnel Release

If all of the previous treatments fail to control the symptoms of carpal tunnel syndrome, surgery may be required to reduce pressure on the median nerve. There are several different surgical procedures designed to achieve this. The most common are the traditional open incision technique described below and the newer endoscopic carpal tunnel release using a smaller incision and a fiberoptic TV camera to help see inside the carpal tunnel.

During the procedure, a small incision, usually less than two inches, is made in the palm of the hand to reveal the palmar fascia. An incision is made through this material as well so that the carpal ligament can be seen. Once the carpal ligament is visible, it is cut to relieve pressure on the median nerve. The incision is then closed. At the end of the procedure, only the skin incision is repaired. The carpal ligament remains open and the gap is slowly filled by scar tissue.

Endoscopic Carpal Tunnel Release

This procedure involves the use of an endoscope (a small fiberoptic TV camera) to look into the carpal tunnel through a small incision in the wrist. The release is then accomplished using special instruments designed to cut the transverse carpal ligament - without cutting through the overlying palmar skin.

A small incision is made in the wrist just below the crease where the palm starts, allowing the surgeon to access the carpal tunnel. Once the surgeon is sure that the instruments can be passed into the carpal tunnel, a metal or plastic cannula (tube) is placed alongside the median nerve. The endoscope can be placed into the tube to look at the undersurface of the carpal ligament and make sure that the nerves and arteries are safely out of the way.

A special knife is inserted through the cannula. This knife has a hook on the end that cuts backwards as it is pulled back out of the cannula. The slot in the cannula allows the hook to cut only in the direction the slot is facing. The nerves in the carpal tunnel are protected by the tube everywhere else. Once the knife is pulled all the way back, the transverse carpal ligament is divided - without making an incision in the palmar skin. Once transverse carpal ligament is divided, the median nerve is no longer compressed and begins to return to normal.

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Ulnar Neuropathy

Ulnar neuropathy is a condition involving impaired movement or sensation in the wrist and hand caused by damage to the ulnar nerve. Ulnar pertaining to the hand, forearm and elbow and neuropathy means a disturbance to the peripheral nerve system. This condition occurs when there is damage to the ulnar nerve, which travels down the arm supplying flexion to the wrist and aiding in movement and sensation of the wrist and hand.

The ulnar nerve runs down the inside of the arm and elbow or "funny bone" and controls strength in most of the hand and sensation to the little and ring fingers. The usual causes of ulnar neuropathy are direct trauma, prolonged external pressure on the nerve and compression of the nerve from nearby body structures. Entrapment involves pressure on the nerve where it passes through a narrow structure.

The damage involves destruction of the myelin sheath of the nerve, or destruction of part of the nerve cell (the axon). This damage slows or prevents conduction of impulses through the nerve.

The ulnar nerve is commonly injured at the elbow because of elbow fracture, dislocation or degenerative changes. The ulnar nerve is near the surface of the body where it crosses the elbow, so prolonged pressure on the elbow or entrapment of the nerve may cause damage.

Treatment Options

Medication and/or Physical Therapy

Ulnar neuropathy may be treated conservatively with simple nerve-flexing exercises, nighttime braces to hold the arm straight and over-the-counter medications, such as ibuprofen, to lessen swelling and pain. If symptoms are unresponsive to more conservative treatment, or there is evidence of nerve degeneration, surgical intervention may be necessary.

Use of an elbow splint at night will keep the elbow from being bent during sleep. A pad around the elbow during the day will protect the nerve from trauma. Splint and elbow pads are usually custom made by a hand or physical therapist. If severe, the nerve compression can be relieved with surgery.

Surgery

Most people can easily cope with mild weakness. Significant weakness which interferes with hand function is the second most common reason to consider surgery.

The surgical procedure of choice is referred to as an ulnar transposition. As constant stretching and compression of the nerve is the culprit, simply moving the nerve to the topside of the elbow is often sufficient in stopping pain. This transposing of the nerve will often stop further muscle wasting as well, but atrophy present in the hand may be irreversible.

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