Introduction
Carpal tunnel syndrome is caused by the constriction of a nerve in the carpal area. This constriction can lead to pain and loss of sensitivity. Accordingly, the therapy is mainly aimed at giving this nerve more space again and alleviating the symptoms. Depending on the cause of carpal tunnel syndrome, the therapy varies.
Conservative therapy
If the symptoms were caused by a severe overloading of the wrist, the therapy of choice is to spare the affected joint. However, if the strain continues for a longer period of time, for example at work, it may be necessary to consider further relief measures or a change of profession. If the symptoms are mild and do not have a major impact on the function and mobility of the hand, the therapy may consist merely of splinting the hand during the night.
This is done by means of a wrist splint and is intended to ensure the best possible blood circulation, as most people have their wrists bent at night and therefore the blood circulation in the hand area is reduced. Apart from the fixation in the neutral hand position, this wrist splint exerts a slight pressure, which should counteract inflammation. Pain relief can be achieved by taking anti-inflammatory and painkilling medication.
Non-steroidal anti-rheumatic drugs (NSAIDs) meet these requirements and are probably the most commonly prescribed drugs in orthopedics and not reserved for rheumatics alone, as the name might lead one to believe. They work reliably up to a certain level of pain. Products of the 1st choice for carpal tunnel syndrome are NSAIDs such as Diclofenac (Voltaren®), Ibuprofen (Imbun®), Indometacin (Amuno®), Naproxen (Proxen®) or Piroxicam(Felden®).
The main advantage of NSAIDs over conventional painkillers such as acetylsalicylic acid (Aspirin®) or paracetamol (Benuron®) is their strong anti-inflammatory effect. They have a calming effect at the site of pain development. The inflammatory tissue can swell and possibly lead to a reduction in pressure in the carpal tunnel.
Like all drugs, NSAIDs also have side effects. The main problem is the damaging influence of NSAIDs on the stomach and intestines, especially in long-term therapy. Pain in the upper abdomen, nausea, diarrhea and even the development of bleeding stomach and intestinal ulcers can be the result.
It may therefore be advisable to combine the intake of NSAIDs with the simultaneous intake of a stomach protection preparation. NSAIDs are also available in the form of ointments or gels for external use (Voltaren Emulgel®, Ibutop Creme®). There are almost no side effects when used externally, but the effectiveness is also significantly lower.
Local allergic reactions are rarely observed. If the inflammation is more pronounced, additional cortisone can be administered. Local infiltrations with a cortisone preparation (15 mg methylprednisolone) by means of an injection into the carpal tunnel are possible, but involve the risk of nerve injury (maximum 3 injections).
Cortisone has an anti-inflammatory effect and is said to calm the hypersensitive median nerve. Oral cortisone therapy in tablet form may be promising. Prednisolone 20 mg in the morning for 2 weeks, then 10 mg for another 2 weeks is recommended.
However, both forms of therapy should only be used for a relatively short period of time, as cortisone has serious side effects in long-term therapy. Vitamin B is said to have a stabilizing and calming effect on nerves, which is why it is more often prescribed for nerve damage of any kind. Since there are almost no side effects, an experiment can be made, even if a positive effect on carpal tunnel syndrome could not be scientifically proven.
There is also the possibility of alleviating the symptoms with the help of ultrasound waves. The above-mentioned therapy options all fall into the group of conservative therapy, which is suitable for mild to moderate disease progression. If the tingling in the fingers or the functional impairment of the hand lasts longer and is no longer improved by the above-mentioned measures, surgical therapy may be considered.
The ligament (Ligamentum carpi transversum or carpal ligament) is split, which limits the carpal tunnel like a roof to the top, in order to create more space for the trapped nerve. This type of surgery is usually performed by a hand or neurosurgeon and is performed under local anesthesia. It can therefore also be performed on an outpatient basis.An advanced age or an existing pregnancy do not represent any contraindications, since altogether with this smaller operation few complications are to be counted on.
There are two surgical procedures available: open and endoscopic or closed surgery. In open surgery, the surgeon makes an incision in the longitudinal axis of the forearm at the level of the wrist. This provides optimal visibility of the carpal ligament, the underlying nerves and other structures in the carpal tunnel.
He first cuts through the ligament and removes excess tissue in the carpal tunnel itself to create more space for the nerve. This type of surgery is chosen if the anatomy of the wrist deviates from the norm, if it is a repeated operation at the same location or if the wrist function is already severely restricted. In addition to the general risks of bleeding, infection and swelling that are present in any surgery, certain other complications can occur with open surgery.
For example, a nerve can be injured, which can lead to numbness in the affected fingers. In very rare cases, there can also be very painful continuous soft tissue swelling with decalcification of the bone. In the context of this disease, namely Sudeck’s disease, joint stiffness can also occur.
In addition, the scar can react very sensitively to touch or strain for several weeks and, in the worst case, become infected. In endoscopic surgery, the surgeon makes a very small skin incision on the wrist, through which he passes his instruments and operates there. The advantage of this type of surgery is, of course, that the actual incision is smaller and therefore causes less discomfort.
In addition, the hand can be loaded again earlier after endoscopic surgery than with open surgery. However, in the end, the result of both surgical procedures can be regarded as equivalent. Possible dangers of the endoscopic procedure are the slightly increased risk of nerve injury, since the view of the structures is reduced compared to the conventional procedure.
If difficulties arise during the operation, it may also be necessary to switch to open surgery. Also worth mentioning is the so-called snap finger, the most common late complication in both surgical procedures. This can occur if a tendon sheath is injured or jammed during the operation.
In this case, individual fingers can snap or be very painful. However, this can usually be remedied with another operation under local anesthesia. The regression of numbness in the hand after the operation can sometimes last several weeks.
This is especially the case in patients who have already suffered from severe loss of function due to carpal tunnel syndrome before the operation. However, the sensation of touch usually returns sooner or later and possibly after a new operation. In exceptional cases, however, the numbness can last a lifetime, especially in patients who have been treated very late.
Directly after the operation, a plaster cast is usually applied to immobilize the arm for about one day. Swelling can be avoided by elevating the arm. Common painkillers can be used against the pain.
It is important, however, that finger exercises should be started within the first 24 hours after the operation. The stitches of the skin incision are removed about eleven days after the procedure and should be kept dry until then. A plastic bag over the forearm is suitable for this purpose when taking a shower, for example.
It is also important not to lift anything heavy with the affected arm during this time and not to support it anywhere. After both types of surgery, however, it is important to start as early as possible with exercises for the wrist and fingers to promote mobility as much as possible. Especially the stretching of the arms and wrist has a very positive effect on the healing process, even though this may cause some pain shortly after the operation.
The whole procedure should be done over one to three weeks. After that the hand can and should be used as before the surgery. However, if the hand is taken too much care of during this period, further complications such as swelling or increased pain may occur.
The length of the period of incapacity to work depends on the extent to which the arm must be used at work. After such an operation, however, work should generally be paused for three to four weeks and no sports should be done.Depending on the type of employment, however, a return to work is possible earlier in the case of low stress and later than after four weeks in the case of heavy stress.
