What if you could unlock the mysteries of that persistent numbness in your fingers? Would you be eager to learn about the common culprit, Carpal Tunnel Syndrome, and the many factors that contribute to it? Dr. Edward Lin, our esteemed Chief of Hand Surgery at the Kayal Orthopaedic Center, is joining us to unravel the complexities of this condition. We'll first delve into understanding Carpal Tunnel Syndrome and its association with the median nerve in the hand. We also tackle how conditions such as diabetes, rheumatoid arthritis, and even your job could be leading to the syndrome.
Often, Carpal Tunnel Syndrome gets confused with other conditions due to the numerous sites where the median nerve can experience compression. Hence, Dr. Lin enlightens us on the importance of accurate diagnosis and the role of diagnostic imaging in the process. We highlight the benefits of an EMG nerve conduction study and how it can depict the severity of the condition. We'll then navigate through a sea of treatment options—ranging from immobilizing the wrist joint, modifying activities, to exercises like tendon gliding, and even medications that can manage the symptoms.
We don't stop at conventional treatments. Dr. Lin walks us through fascinating alternative modalities like acupuncture and physical therapy. Hear about promising natural remedies like omega-3 fatty acids and Vitamin B6 complex antioxidants. We explore how early intervention leads to better results, and the potential risks of severe Carpal Tunnel Syndrome secondary to delayed treatment. Post-surgery recovery and the chances of recurrence are also discussed. All in all, we aim to provide you with exhaustive information to help you tackle Carpal Tunnel Syndrome effectively.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is July 11th, 2023, andour special guest today is Dr
Edward Lin.
Dr Edward Lin is our chief ofthe hand service at the Kale
Orthopedic Center, Today's topicHarpal Tunnel Syndrome, and
we're so happy to have Dr Linwith us.
Welcome to the podcast, Dr Lin.
Edward Lin, MD (00:21):
Thank you, Dr Kale.
I really appreciate youinviting me here and being here.
It's been looking forward tothis podcast for a while.
Robert A. Kayal, MD, F (00:27):
Likewise , likewise, so happy to have you
, thank you.
So let's just get started andthen first let our viewing
audience know a little bit aboutyou, dr Lin.
Edward Lin, MD (00:35):
So I grew up in New York City in Flushing,
queens, born and raised and wentto junior high school in
Manhattan, did Hunter Collegejunior high school and then high
school at Stuyvesant HighSchool, also in Manhattan, and
graduated and did the eight yearBAMD program, which is an eight
(00:55):
year program with NYU whichincludes four years of
undergraduate study at NYU andthen four years at NYU Land Goal
and Medical Center for mymedical school.
And then I decided to stay atNYU for an additional five years
for orthopedic training.
It was a great, greatexperience, great residency and
I did one year of additionaltraining at the UPMC in
(01:17):
Pittsburgh for a hand in upperextremity fellowship Wow.
Robert A. Kayal, MD, (01:21):
Impressive credentials.
I'll never forget the first dayI interviewed you for the job
and I was so impressed by youand your credentials and your
training and still am today.
So we're so blessed to have youwith us today.
Dr Lin, We've had the privilegeof having you take care of so
many patients over the yearsthat you've treated so
successfully and we're just sohappy to have you with us.
As far as the conditions thatyou treat, safe to say that
(01:44):
carpal tunnel syndrome wasprobably one of the most common
conditions you see on a dailybasis.
Edward Lin, MD (01:49):
Oh yeah, as a hand surgeon, it is the most
common thing I see, I would sayon a daily basis.
I just saw one about 20 minutesago.
It's a common thing and a lotof people are dealing with this,
especially in our day-to-day.
People are using their handsall day long and that definitely
has an effect on the rate ofhaving carpal tunnel syndrome.
Robert A. Kayal, MD, FAAOS (02:10):
Okay , so let's first and foremost
define for a viewing audienceexactly what carpal tunnel
syndrome is.
Edward Lin, MD (02:17):
So that's actually a great question
because there's a lot ofconfusion out there about what
carpal tunnel is.
A lot of people come to me andthey're not sure or they think,
oh, I'm having some kind ofissue with my hand and must be
carpal tunnel.
So carpal tunnel syndrome atits base is a problem with the
nerve.
In your hand you have a nerve,it's called the median nerve.
It's one of the main nervesthat go into your hand.
(02:38):
It's about half the width ofyour pinky and what that nerve
does is it provides sensationinto the hand, particularly into
the thumb, the index and themiddle finger.
In carpal tunnel syndrome, whathappens is that nerve is being
compressed.
It's being compressed righthere in the hand.
If you look in the hand, rightin this area, right here, this
(02:59):
is where the carpal tunnel is inthe hand, and so that nerve is
being compressed.
And when the nerve iscompressed it causes problems
with the nerve.
And the first thing you'llnotice when the nerve is
compressed is you'll seenumbness and tingling in the
fingers.
Now, sometimes it's in just thethumb, the index and the middle
finger, but sometimes it can beall the fingers and that's at
(03:21):
its core what carpal tunnel isso.
If you don't have numbness andtingling in your hand, you
probably don't have carpaltunnel syndrome.
That's essentially the firstthing that people will have.
Some people also have pain, andyou can have pain in that same
distribution in the thumb, indexand middle fingers.
You can also have pain in theother fingers.
Sometimes it radiates into theforearm, into the elbow.
(03:41):
Sometimes it can even radiateup into the arm, but most of the
time most of the symptoms arelocated in the fingertips and in
the hand.
Robert A. Kayal, MD, FAAOS, (03:50):
So this nerve, the median nerve,
actually stems from the brain,right.
Edward Lin, MD (03:54):
So the nerve, all the nerves in the body,
start off in the brain.
That's where all the nervesoriginate, essentially, in the
spinal cord, and the brain sendssignals to the nerves down the
spinal cord and the nerves thenbranch out through the spinal
cord through what's called thedorsal root ganglion is also a
ventral ganglion that comes downthrough the arm and then
(04:15):
through down into the hand andinto the fingers, and what can
happen is there can be multiplesites of compression.
So you can have these nervescompressed in your neck, you can
have them compressed in theelbow, you can have them
compressed in the forearm or youcan have them compressed in the
hand of the carpal tunnel, themost common sites of compression
would be the neck and in thecarpal tunnel.
(04:37):
So when you have numbness andtingling in that distribution,
that's where my mind goes toinitially is this carpal tunnel?
Is this coming from the neck?
But potentially you can havecompression anywhere along that
nerve path which can causesimilar symptoms, which is why
sometimes it's difficult todiscern where the problem is,
(04:58):
because sometimes the problemcan be in the hand, but it can
also be further up along thepath of the nerve.
Robert A. Kayal, MD, FAAOS, (05:04):
So this nerve, it provides only
sensory, or does it also providemotor function?
Edward Lin, MD (05:09):
So the median nerve is what we call a mixed
nerve.
It's one of the major nerves inthe body and it provides both
motor and sensory.
So at the level of the hand itprovides sensation to the thumb,
the index and the middlefingers and also part of the
ring finger as well.
But it also provides motorinput to this muscle here, right
here, and this area of the handis called the thenar eminence,
(05:33):
and what happens is the courseof the nerve.
If you look at it.
It comes up this way and thenit sends a branch right over
here into this muscle.
And what you'll see in somepatients who have advanced
carpal tunnel syndrome is thattheir nerve has been compressed
for so long that this muscle haslost what we call its
innervation, meaning the signalsthat are normally being sent to
this muscle have disappeared.
(05:54):
And if that lasts long enough,eventually the muscle actually
dies and you can see patientswho have a divot.
You'll see an actual divot intheir hand where the muscle is
shrunk, and that's a telltaleside that they probably or might
have carpal tunnel syndrome.
That's been untreated for along time and has led to that
what we call atrophy of themuscle.
Robert A. Kayal, MD, FAAOS, (06:13):
So what are some of the other
symptoms that these patientswill present with, besides the
numbness and tingling theydescribed?
Edward Lin, MD (06:19):
Yeah.
So, as I said, you can havepain associated with it.
It's oftentimes a nighttimephenomenon, so a lot of times
patients will say I woke up withthis in the middle of the night
.
I can't get a good night'ssleep.
That's very common, andsometimes patients will say I
wake up in the middle of thenight and the only thing that
makes it better is if I shake myhands.
That's actually a very telltalesign that you may have carpal
(06:40):
tunnel.
Some patients also find thatthey have symptoms going up and
down the arms, but if that isthe case, then you may also have
or instead of carpal tunnel,you may have a compression in
the neck that may cause armsymptoms as well.
Robert A. Kayal, MD, FAAOS (06:54):
Yeah , and that we call a double
crush phenomenon right, whenpatients sometimes can have a
pinched nerve in their neck andalso have a pinched nerve
somewhere else in the arm.
Because, as we discussed, allof these nerves ultimately stem
from the brain and the spinalcord.
So if that nerve is involved orcompressed anywhere along its
path it can present withsymptoms in the distribution of
(07:18):
wherever that nerve goes.
If it's a sensory nerve, it canaffect the sensation, resulting
in numbness and tinglingpotentially, and if it's a motor
nerve, it can often result inweakness as well to the muscle
groups that are innervated bythat nerve.
And if you have a mixed nerve,as Dr Lin referred to, such as
the median nerve, you can bothget sensory and motor findings
(07:39):
as well.
So it can be a littlecomplicated.
Are there other nerves aroundthe elbow that potentially can
cause patients to also awakenfrom sleep and have numbness and
tingling in their hands?
Edward Lin, MD (07:51):
Yeah, absolutely so.
There's another major nerve inthe arm.
It's called the ulnar nerve andthat nerve does a lot of what
the median nerve doesn't do.
So the median nerve goes to thethumb, the index, the middle
and part of the ring.
The ulnar nerve goes to thesmall finger and part of the
ring, so it provides a sensationto those two small fingers.
(08:12):
So if you find that you'rehaving more numbness in the
small finger, that may be theulnar nerve, whereas if your
numbness is more in these threefingers, that's more of the
median nerve.
Not 100% of the time, butthat's a rough estimate of what
we think about when we havepatients coming talking about
numbness and tingling.
The ulnar nerve also controlsthe muscles in the hand.
(08:33):
So inside the hand you havemuscles.
Here you actually don't haveany muscles in the fingers, but
you do have muscles in the handitself and they help control the
motion of the fingers goingthis way and also they help
control some of the motion ofthe fingers going this way,
keeping these straight, and sothose are called intrinsic
muscles and that's governed bythe ulnar nerve.
Robert A. Kayal, MD, FAAOS, (08:55):
So why do they call it the carpal
tunnel?
Edward Lin, MD (08:58):
So the carpal tunnel is a tunnel you can think
of it like a train tunnel andit has walls, it has a floor and
it has a ceiling.
And if you think about it, thewall and the floors of the
carpal tunnel are all made ofbone.
There are many different bonesin the wrist and they form
almost a solid foundation forthe carpal tunnel.
(09:19):
And then the ceiling of thattunnel is a very thick ligament.
It's called the transversecarpal ligament and it's
thickest right here, right herein this portion of the hand.
And so the problem with thatanatomical structure is that
there's really no give becausebones are very hard, they're not
going to stretch out.
(09:39):
That ligament over time becomesvery, very thick and it's not
going to stretch out.
And so what that leads to is aproblem with the pressure inside
the carpal tunnel.
So the normal pressure inside acarpal tunnel, I would say, is
about two or three millimetersof mercury, and millimeters of
mercury is just a measure of thepressure inside anything.
(10:01):
In fact, if you look at yourblood pressure, 120 millimeters
of mercury, that's the unit ofpressure.
So normal pressure inside acarpal tunnel is about two or
three, and patients with carpaltunnel syndrome it can be 20, 30
, 40.
And so once you get above 30,the problem is that you start to
develop nerve damage.
The nerve really doesn't liketo be pressured.
(10:22):
That's one of the things thatnerves don't tolerate very well.
And once you start puttingpressure on that nerve, you're
going to have to get a littlebit of pressure.
A lot of things begin to happento that nerve that are not good
.
Robert A. Kayal, MD, FAAOS (10:31):
When you're evaluating a patient.
We already talked about thehistory and their complaints.
You said most of them wouldcomplain of pain and numbness
and tingling and sometimes evenweakness.
Are there any other parts ofthe history that are relevant to
helping you really hone in onthe diagnosis of carpal tunnel
syndrome?
Edward Lin, MD (10:49):
Yeah, absolutely so.
Carpal tunnel syndrome can becaused by a whole variety of
factors.
Most of carpal tunnel syndromeis what we call idiopathic, and
what that means is that we don'treally have a direct cause for
it.
It just happens.
But there's a good portion ofpatients who have carpal tunnel
syndrome for a specific reason,and so some of the things that
(11:12):
can cause carpal tunnel syndromeare diabetes, patients who have
a thyroid condition, patientswho have autoimmune problems,
rheumatoid arthritis, psoriaticarthritis, patients who have
kidney problems.
There's a condition calledamyloidosis, where the body
deposits amyloid, which is asubstance, into the carpal
tunnel and that can increase thepressure inside the carpal
(11:32):
tunnel.
It can also have anoccupational relationship.
So patients who are alwaysdoing repetitive tasks that's
what we hear over and over againyou may be a factory worker or
you may do something where youdo the same motion over and over
again, a thousand times a day,10,000 times a week, and that
can cause carpal tunnel to getworse.
(11:53):
Patients who use vibratorytools jack hammering, anything
that's causing vibration in thehand is going to make it worse.
Patients who are constantlysqueezing is going to make it
worse.
A lot of people ask me ifcomputer use makes it worse, but
the evidence for computersbeing linked to carpal tunnel
actually isn't that great.
So despite the conception that,oh, I have carpal tunnel and it
(12:16):
must be because of the computeruse, that link, at least
scientifically, hasn't reallybeen proven.
Robert A. Kayal, MD, FAAOS, (12:22):
But it is intuitive, isn't it?
Considering all the otherdiagnoses and associated
conditions that you've justdescribed.
The common element in all ofthem is that they, for the most
part, all result in an increasein swelling right and we already
talked about that the carpaltunnel is a closed compartment
and the nerve doesn't tolerateany type of compression, not
(12:46):
much pressure inside the carpaltunnel at all.
The carpal tunnel is already alittle crowded right.
The carpal tunnel includes themedian nerve and nine other
flexor tendons, so there'sreally not a lot of room inside
that closed compartment.
Now we compound that with somemedical conditions that are
often associated with swelling,like pregnancy, hormonal changes
(13:09):
, thyroid disorders, diabetescan definitely result in
swelling and also increased innerve injuries and neuropathy
and some of the other conditionsyou mentioned as well.
Anything that causes a crowdingphenomenon, rheumatoid arthritis
, because very often associatedwith that condition we get
(13:30):
tinocinibitis and autoimmunedisorders, where you get an
immune response and swelling andcrowding phenomenon.
So those are all conditionsthat definitely result in
swelling and crowding in thecarpal tunnel and compression on
the median nerve.
So it is somewhat intuitive toimagine that if you're using
computer a lot and overusingyour risk, that it should cause
(13:53):
that.
So to me, regardless of whatthe medical literature suggests,
I believe that overuseconditions such as computer
usage should contribute.
So I would certainly advise mypatients at least that if
they're doing too much ofanything texting and video games
(14:14):
or computer usage, to maybequiet that down a little bit to
see if it alleviates theirsymptoms.
It does make sense intuitively.
Edward Lin, MD (14:20):
Yeah, I agree, I think that's you know.
There's the medical literatureand then there's common sense,
right?
So I think as a doctor, youhave to use a little bit of both
.
You can't just look and seewhat the papers say.
You have to listen to.
You know what your common senseis telling you, but you also
have to listen to your patienttoo.
And if the patient's telling meI text over and over a thousand
times a day and this is killingmy hands, yeah, it's probably
(14:43):
causing your carpal tunnel toget worse.
Robert A. Kayal, MD, FAAOS (14:45):
They know their body's better than
we do, right.
Edward Lin, MD (14:46):
Absolutely.
I agree with that, only percentyeah.
Robert A. Kayal, MD, FAAOS, (14:49):
Now that we got inadequate history.
You've done your physical exam.
What other imaging modalitiescan you sometimes employ to help
support your diagnosis?
Edward Lin, MD (14:58):
Right.
So there are definitely otherthings that we can do with a
suspected carpal tunnel case toboth confirm the diagnosis or
even try and figure out thediagnosis if we're not sure.
So one of those things is an MRI, and an MRI can be really
useful in carpal tunnelspecifically because there are
specific things that can causecarpal tunnel syndrome.
So I had a patient who came in.
(15:19):
She was about 18 years old andshe had classic carpal tunnel
signs, which you don't usuallysee in someone who's 18.
You know, people who are intheir teens and 20s usually
don't get carpal tunnel syndromejust out of the blue.
So we did an MRI and we havefantastic MRIs at our facility
with amazing radiologists whoare reading them and we found
(15:41):
that she had a very largeganglion cyst sitting right
inside of her carpal tunnel andthat was what was causing her
symptoms, and so in that case wewere able to remove the
ganglion and address itsurgically, and she had a
wonderful result.
As soon as the next day, rightafter I removed the ganglion, I
called her up and she said wow,my symptoms are gone.
Robert A. Kayal, MD, FAA (16:01):
That's interesting.
That's an interesting almostcase report.
Yeah, you nailed it.
We don't typically see carpaltunnel syndrome in the young,
except for the pregnant women.
Right that with the hormonalchanges.
It's very rare to make thatdiagnosis in a young patient
like that.
Edward Lin, MD (16:17):
Yeah, but so without the MRI?
We got an MRI to see thatganglion cyst, to see what the
location of that cyst was and toknow that that was causing her
symptoms.
It would be difficult to makethat diagnosis without the MRI.
So that's one thing that'simportant.
One other thing that we've beenusing more and more is
ultrasound, and we have anultrasound in every single exam
(16:37):
room, which I think is somethingthat no other facility really
has.
No one else has invested thatkind of resources into having
that technology.
But the ultrasound is importantbecause there's more and more
data showing that you canactually make a diagnosis of
carpal tunnel syndrome with anultrasound machine, and the way
you do that is you take theultrasound machine and you
measure the cross-sectional areaof the nerve and if the
(17:00):
cross-sectional area is morethan about one square centimeter
, that's highly suggested thatyou have carpal tunnel syndrome.
So it's something to add toyour armitarium of things to
make a good diagnosis.
Robert A. Kayal, MD, FAAOS, (17:12):
So , dr Lin, we talked about using
MRI, we talked about usingultrasound for the diagnosis.
How about x-ray?
Do we use x-ray as well toevaluate for carpal tunnel
syndrome?
Edward Lin, MD (17:24):
Absolutely so.
The x-ray is usually the firststudy that I get.
We have an x-ray machine inevery single facility that we
have and you can make diagnosesbased on that x-ray, including
things that aren't related tocarpal tunnel.
So you may be coming in withwhat you think is carpal tunnel
and you may find that you have afracture.
There's actually a veryspecific view we do in the
(17:47):
x-rays, called the carpal tunnelview, and using that specific
view we can look straight downthe carpal tunnel and with the
x-ray machine and we can see ifthere's a lesion in there.
We can also see if sometimesyou'll have a fracture of one of
the bones that's in there.
So we can definitely pick upthings on an x-ray without any
additional imaging, butoftentimes it will lead to other
(18:09):
need for other additionalimaging as well.
Robert A. Kayal, MD, FAAOS (18:11):
Yeah , sometimes patients come in the
office and they have a tendencyto want to resist getting an
x-ray right.
But as a trained orthopedicsurgeon many of us who have
trained at world-renowned cancercenters we don't cut corners
right.
We can't cut corners, we can'tmiss the basic, fundamental
imaging of an x-ray.
(18:31):
The x-ray tells us so much itcan evaluate for bone tumors, it
can evaluate for fractures,lesions, different things that
can contribute to orthopedicconditions.
So I almost will never see apatient unless the patient gives
me the permission to get abaseline x-ray, because
certainly I never want to missanything on a patient.
(18:51):
And only after the x-ray isnegative do we consider
proceeding with MRI or furtherimaging.
Do you do the same thing?
Edward Lin, MD (18:59):
I agree, that's my practice as well and the
philosophy behind that is youdon't know what you're going to
find if you don't look.
And so if you're not getting anx-ray and you're doing an
operation or you're doing aninjection, you're almost working
in the blind a little bitbecause you haven't done your
due diligence to rule outeverything else that this could
(19:20):
be.
And you may do an x-ray andfind something.
You may do an MRI and findsomething.
I can't tell you the number oftimes I've done an MRI and I was
surprised and I was just soglad I got that MRI because if I
didn't I would not have foundtumors, I found cancers, really
serious things that if addressedsoon we can really make a
(19:41):
difference.
But if you wait, if you didn'tget that MRI, if you didn't get
that x-ray and you waited, itwould have been disastrous.
Robert A. Kayal, MD, FAAOS (19:47):
Okay , so are there any other studies
besides x-ray MRI ultrasoundthat you would use to see if
there was any damage to thenerve?
Edward Lin, MD (19:58):
Sure.
So one of the things we rely onand I alluded to would be a
nerve study.
And a nerve study is a specificstudy and it does two things.
One, it tests to see how thenerves are functioning, to see
what the speed of the electricalsignals that are going through
the nerve is.
And the nerves you can think ofthem almost like electrical
wires.
They send a signal from point Ato point B through essentially
(20:21):
we call them ions, butessentially an electric signal
through these.
We think of them as wires andthat the speed of the signal
conduction should be a certainspeed, and if the speed slows
down we know there's a problemwith the nerve.
We can also test the musclesthat the nerve goes to.
So that muscle we talked aboutthis muscle right here we can
(20:41):
test that muscle and see if thatmuscle is doing all right, to
see if it's receiving the rightsignals, and if it's not, then
we get a good sense that, okay,there's something wrong with the
nerve.
And so the test of the muscles,that's called an EMG and the
test of the nerve conduction,that's called the nerve
conduction study, and both ofthose are done by a pain
management specialist, theperson I trusted, dr Steve Nadin
(21:06):
, who's in our practice, and heis a fantastic at doing nerve
conduction studies.
So having gotten one of thesestudies, you can see if there's
a problem with the median nerve,you can see if there's a
problem with the ulnar nerve,and it helps you to really hone
in on that diagnosis.
Robert A. Kayal, MD, FAAOS (21:23):
Yeah , it targets the area of
compression.
It gives you a nice baselineevaluation as well, just in case
you're trying to monitorwhether or not this nerve is in
the future getting worse orgetting better.
So it's really critical to geta baseline EMG nerve conduction
study.
Typically we tend to want towait about two to three weeks
after the onset of symptoms,because often we won't even see
(21:46):
changes on the EMG nerveconduction study until then.
But I think it would behoovethe patient to get a baseline
EMG nerve conduction study.
This way it can help the doctormonitor your progress to
determine whether or not you'regetting worse or better with
treatment.
And is that something you doregularly?
Edward Lin, MD (22:03):
Yeah, so I routinely order a nerve
conduction study with anyone whocomes in with numbs and
tingling and it's helpful for somany different reasons.
So one thing you can tell ifwell, if it comes back normal,
that gives you information too,because if it comes back
completely normal, then it'smuch less likely to be carpal
tunnel syndrome.
However, just because a testcomes back normal doesn't mean
(22:25):
you don't necessarily havecarpal tunnel.
So all of the tests that wehave whether it's an MRI, a
nerve conduction study you haveto take a look at it
holistically with the patient,what they're presenting with,
and come up with a thoughtpattern of what diagnosis is,
taking all these points of datainto account.
But the nerve study is goodbecause it tells you if there's
(22:48):
a problem and where that problemis.
So to help locate is it at theelbow, is it at the wrist, is it
in the hand and or all theabove, or all the above.
And using that information youcan really help to hone in on
what the problem is.
And once you have a diagnosis,you can figure out what the best
course of action it would be.
Robert A. Kayal, MD, FAAOS, (23:06):
It also helps guide us as we
converse with our patients andgive them prognosis right,
because if a patient has adouble crush phenomenon and
you're opting to address thecarpal tunnel syndrome first, it
affords us the ability to atleast tell that patient look,
I'm going after the symptomsonly associated with the carpal
(23:26):
tunnel syndrome, but please beprepared that you're still going
to have some symptoms from thecompression of the nerve in your
neck right and we might have toaddress that afterwards as well
.
Edward Lin, MD (23:38):
Absolutely, and it can also help to grade the
degree of carpal tunnel that youdo have.
So carpal tunnel, you can havemild carpal tunnel, you can have
moderate and you can havesevere.
And in patients who have mildto moderate carpal tunnel let's
say you end up doing surgery tocorrect that the results are
much better than if you havesevere carpal tunnel.
It definitely gives you a goodprognosticator to say that you
(24:01):
have mild carpal tunnel, you arealmost definitely going to get
better after surgery, versus youhave severe carpal tunnel.
You have about a 50% chance ofgetting better after surgery and
so that's important.
Robert A. Kayal, MD, FAAOS (24:12):
It's like most orthopedic conditions
right the sooner we addressthem, the easier it is for us to
guarantee our results.
Right, because when you'redealing with acute, reversible
disease as opposed to chronic,sometimes irreversible
conditions, it makes it moredifficult to guarantee excellent
results Because some of thedamage to the tissues, and in
(24:34):
this particular case, the nerves, can be permanent and
irreversible.
Edward Lin, MD (24:38):
Absolutely, and this is something I'm always
telling patients that in thebeginning carpal tunnel starts
off as mild, meaning that youhave some compression of the
nerve.
But the nerve overall, theanatomy of the nerve, the
structure of the nerve is stillnormal and so if you just
relieve that compression thenerve will bounce back and
sometimes it'll bounce backinstantaneously.
I've had patients who we didthe nerve the surgery and then
(25:01):
in the recovery room they said,wow, it feels better
instantaneously.
So that tends to happen in mildcases.
But if you let that compressiongo on you're saying, oh, I'm
having some numbness andtingling, but I can deal with it
, Let me just sleep on it.
You wait a few months to a fewyears and now that carpal tunnel
that used to be mild is nowmoderate or it's now severe and
(25:22):
you're developing what we callmuscle atrophy, where that
muscle we talked about isbecoming smaller and the nerve
over time unfortunately startsto have irreversible changes,
meaning that scarring tends tohappen in the nerve.
The nerve is losing the bloodsupply because it's being
compressed for so long and atsome point these changes are
permanent.
They're irreversible, meaningeven after you do surgery to
(25:46):
decompress the nerve, thesechanges are not going to go away
, and then you're left with,unfortunately, numbness and
tingling that doesn't go away.
So this is something where, ifyou do notice numbness and
tingling in your hand, it'simportant not to just blow it
off, not to say I'm just goingto sleep on it.
Come in, have us take a look atit and see if anything needs to
(26:08):
be done.
Robert A. Kayal, MD, FAAOS, (26:09):
OK .
So, Dr Lin, now that we'vedefinitively made the diagnosis
for our patients of carpaltunnel syndrome, what's the
first line of treatment?
Edward Lin, MD (26:17):
So the initial line of treatment with carpal
tunnel syndrome depends on howsevere it is, and that's why I
keep going back to the severity.
It's important to get thesethings checked early so that you
don't let it become severe.
In the early stages mild tomoderate carpal tunnel syndrome,
the initial treatment isnon-operative and the treatment
initially is to wear a splint.
Now you've seen many of thesesplints online and we offer a
(26:40):
splint that I think is very goodand the goal of the splint is
it's a brace that you wear onyour wrist and the goal of the
splint is to keep your wrist ina neutral position, and the
reason for that is because it'sbeen found that if you have your
wrist in this position flexposition or an extended position
it greatly increases thepressure inside the carpal
tunnel.
(27:00):
So I don't know about you, butmy wife sleeps like this and so
that's really bad for the carpaltunnel.
So we give a splint and if youwear that splint at night, it
prevents your wrist from goinginto those positions and that
sometimes by itself will fix theproblem, because a lot of
patients have problems atnighttime.
If we keep the wrist straight,then it solves the problem.
Robert A. Kayal, MD, FAAOS, (27:23):
And it also helps to immobilize the
joint right, and we alreadydiscussed that.
The carpal tunnel is filledwith not only the median nerve
but nine flexor tendons and veryoften the flexor tendons are
contributing to the inflammationand swelling and compression on
the nerve because they'reoverused and swollen.
So by immobilizing the wristjoint with a wrist immobilizer,
(27:47):
theoretically we're restingthose flexor tendons, allowing
for the inflammation andswelling to subside and
therefore the compression on themedian nerve to subside as well
, absolutely.
Edward Lin, MD (27:57):
And another one of those treatments that seems
very simple but is just rest.
If you're doing something 1,000times a day and it's causing
your carpal tunnel syndrome toget worse, you should probably
not be doing those things.
So that's activitymodifications also very
important part of the treatment.
One of the things that I alwaystell my patients is there's
also an exercise that you can doto help your carpal tunnel
(28:18):
syndrome, and I'll demonstrateto you.
So what you do is you take yourhand, make it flat and then you
do this position this is calledan intrinsic plus position and
you bring it down to a full fist.
You go back into your intrinsicplus position and you go like
this that's called a tendongliding exercise, so that.
And then there's anotherportion where you go like this.
This is a Another exercise.
(28:40):
You can do another tendongliding exercise you can do.
You keep your palm flat likethis.
You move it into this positionlike this, make a full fist,
move it back into this positionand like that.
That's the first way to do it,and the second way to do this
come straight down and this iscalled a tendon gliding exercise
and that's been shown to helpwith carpal tunnel.
So between doing the bracingand the tendon gliding exercises
(29:03):
.
A lot of patients will getbetter just with non-operative
treatment.
In addition, you can takeTylenol pain medication,
anti-inflammatory medication.
There are also othermedications such as Lyrica,
neuropathic pain medications,and all of these medications can
be taken as well to help withthe symptoms.
Robert A. Kayal, MD, FAAOS (29:21):
Like in so many orthopedic
conditions, inflammation is theculprit, right?
I say this podcast afterpodcast after podcast.
Inflammation is associated withredness, warmth, pain and
swelling and in this particularcase, carpal tunnel syndrome,
inflammation and swelling is themain cause of this condition
(29:42):
because that nerve is gettingcompressed.
So any of the medications thatcan alleviate inflammation will
alleviate a lot of the symptomsassociated with carpal tunnel
syndrome.
So the typical over-the-counternon-steroidal anti-inflammatory
medications like Motrin, advil,aleve, ibuprofen would all be
(30:02):
very helpful in treating thiscondition.
It is somewhat counterintuitivethat in this particular case,
carpal tunnel syndrome, wherethere seems to be inflammation
and swelling around the mediannerve, causing the compression
and therefore the symptoms ofcarpal tunnel syndrome, the
guidelines from the AmericanAcademy of Orthopedic Surgeons
(30:24):
argues against the usage ofanti-inflammatory medications in
this condition.
Edward Lin, MD (30:28):
Correct, yeah, that's true, and I think part of
that is because the carpaltunnel, when someone comes in
with carpal tunnel syndrome.
The carpal tunnel syndrome canhave a whole variety of causes
and a lot of times it isinflammation.
Particularly patients who haveinflammatory conditions like
gout, pseudo gout, rheumatoidarthritis or an autoimmune
condition.
(30:49):
It can definitely beinflammation as the culprit.
But you also have a good subsetof patients who don't have
inflammation but have carpaltunnel syndrome for a variety of
reasons.
It could be idiopathic, meaningthat we don't really know why.
Maybe their ligament is justreally thick in that area.
It could be that they have ananatomic structure that's
causing compression, and so Ithink it's difficult to
(31:10):
recommend and say anyone who hascarpal tunnel syndrome should
get an anti-inflammatory forthose reasons.
But I do think there is asubset of patients who do have
inflammatory conditions whetherit be gout or pseudo gout or
what have you who would benefitfrom an anti-inflammatory.
Robert A. Kayal, MD, FAAOS, (31:24):
But I think it's definitely a
case-by-case basis, it seemssomewhat controversial, and I
don't believe that there'soverall unanimity in the
orthopedic community whether ornot nonsteroidal
anti-inflammatory medicationsare warranted or not.
In my own practice I do believein the usage of
anti-inflammatories because I dobelieve inflammation is
(31:46):
strongly associated with thiscondition, and that is because
of the fact that overusedconditions tend to contribute.
Swelling from other conditionslike thyroid disorders, swelling
from hormonal changes inpregnancy, all seem to
contribute.
And clinically, when I performsurgery for carpal tunnel
(32:06):
syndrome, I often do appreciateextensive inflammation inside
the carpal tunnel causingcompression on the nerve.
And so in my own practice I'm abeliever in the usage of
nonsteroidal anti-inflammatorymedications such as Motrin,
advil, aleve, ibuprofen or otherprescription
anti-inflammatories and, in rarecircumstances, potentially even
(32:30):
oral steroid usage to helpsuppress the inflammation and
swelling around the nerve.
What do you do in your practice, dr Lin?
Edward Lin, MD (32:38):
I take a similar approach in that I do prescribe
anti-inflammatory medication,but it depends on the patient's
circumstance.
So if I think that inflammationis playing a big role in the
patient's condition, I willdefinitely prescribe an
anti-inflammatory, but if Ithink that the condition is not
an inflammatory condition, thenI may hold back and say just
(32:58):
take Tylenol or try somethingelse.
But it's also something thatyou have to ask the patient have
you taken anti-inflammatoriesin the past and if you have, has
it improved your carpal tunnelsymptoms?
If it has, then by all meanscontinue taking them.
Robert A. Kayal, MD, FAAOS, (33:13):
One thing in my own practice that
has really helped support thatconcept of inflammation being
associated with it is the myriadof patients that have responded
so favorably to a cortisoneinjection.
It's almost the most rewardinginjection that we give, because
patients that are suffering fromthis pain, numbness and
(33:34):
tingling, pins and needleswaking up, having to shake that
hand literally in three days itdisappears.
And what's funny in my ownpractice is what I've
experienced is when patientshave carpal tunnel in both sides
, both the right and left handafter an injection I always find
that the other side goes awaytoo.
Edward Lin, MD (33:56):
That can be a systemic effect, because when
you're giving the cortisone, itto one hand, eventually some of
that cortisone does make it intoyour bloodstream and so it can
affect the other hand.
But that's very interesting.
Speaking of cortisoneinjections, cortisone is
injection is an importantnon-operative treatment modality
for carpal tunnel, and I use itfor two reasons.
One is therapeutic I want mypatients to get better and it's
(34:17):
a way to do that.
But it's also good for adiagnostic tool, because
sometimes patients will come inwith that double crush
phenomenon that you mentioned.
They have compression in theneck, they have compression in
the hand and you're not surewhich is really dominating.
Is the problem coming from thehand?
Is it coming from the neck?
Is it coming from both?
So when I give a cortisoneinjection and the patient tells
me that there's 70 to 80%improvement in their symptoms,
(34:39):
that tells me that most of theircarpal tunnel symptoms are
coming from the carpal tunnel.
If I do the injection and theytell me there's virtually no
improvement, that's a good signthat it's not carpal tunnel
syndrome and then you can moveon to other diagnoses.
The compression may be comingfrom the neck, it may be
somewhere else, but we can thinkit's less likely to be carpal
tunnel syndrome, so that's animportant thing to have.
(35:01):
Yeah, it's very important.
Robert A. Kayal, MD, FAAOS, (35:03):
And how about other modalities or
ancillary services like physicaltherapy, acupuncture, things
like that?
Edward Lin, MD (35:10):
So, absolutely so.
All of these things physicaltherapy, acupuncture are part of
the treatment, nonoperativetreatment of carpal tunnel
syndrome, and so there's a lotof benefit that can be had from
having a trained professionaltherapist work on your hand or
an acupuncturist work on yourhand to improve your symptoms
without doing surgery.
Right.
Robert A. Kayal, MD, FA (35:31):
Therapy .
You know why therapy?
Well, therapy can be employedto decrease inflammation and
swelling.
Sometimes there's significantswelling in the extremity, from
whatever reason.
It could be a fracture, itcould be other things that have
contributed to swelling, sotherapy can be employed to help
reduce that swelling.
So sometimes, when nerves arecompressed you already alluded
to the fact that there can besome weakness associated from
(35:54):
that nerve compression, becausethose nerves innervate muscles
and if the muscles are weak thenthey can atrophy and physical
therapy can often be employed totry to regain that strength and
function.
Why acupuncture?
Edward Lin, MD (36:08):
Well, acupuncture is a modality where
needles are placed into the handor into the body part.
It tends to work for a wholevariety of conditions.
We're not 100% sure why or howacupuncture does work, but I
have had patients come back andsay, wow, that acupuncture
really did help my carpal tunnelsymptoms, and so I encourage
(36:28):
patients to seek out acupunctureand physical therapy as
addition to modalities to helpthem, because if they can help
themselves and treat theircarpal tunnel without surgery,
then they've avoided the risksof surgery and the pain and
everything associated with that.
So that can be a useful tool.
Robert A. Kayal, MD, FAAOS (36:48):
Sure , a lot of these holistic
approaches and even naturalremedies have been found to be
helpful in some of theseneuropathies and nerve
compression syndromes.
Acupuncture has been shown tocause some microscopic trauma
which can increase some bloodflow and promote healing.
Some of the holistic medicinescan be used as well.
(37:09):
I know that Omega 3 fatty acidsand the vitamin B complex
antioxidants, things like thathave been helpful as well in the
treatment of some of thesepatients.
Edward Lin, MD (37:21):
Absolutely Vitamin B, in particular vitamin
B6, has been shown in somepapers to provide some benefit,
especially for people who arehaving nerve issues like carpal
tunnel.
Robert A. Kayal, MD, FAAOS, (37:32):
Now that we've diagnosed the
condition, we've tried to treatthem conservatively, whether it
be by anti-inflammatories orTylenol, or physical therapy,
acupuncture, holistic approaches, et cetera.
What if that fails, and howlong will you give the patients
in effort to recommend the nextline of care?
Edward Lin, MD (37:52):
So it really varies in terms of how severe
your carpal tunnel syndrome is.
So if you come in and you havesevere carpal tunnel syndrome,
either by the symptoms that youhave, by some of the testing we
can do we can test yoursensation in the office to see
if there's actual nerve damage.
There's a test called two-pointdiscrimination we can do in the
office to see how much nervedamage you have and that's a
(38:16):
very simple test we can do atthe bedside, based on your nerve
studies to see how severe yourcarpal tunnel is.
But if you have severe carpaltunnel syndrome, you really
should be looking to treat thatpatient operatively.
Meaning the window has passedfor nonoperative treatment and
we're having a discussion moreof how do we fix this surgically
.
(38:36):
For the mild to moderate carpaltunnel patients, I try to go for
at least three months ofnonoperative treatment,
including splinting andtendon-gliding exercises.
Having said that, you have tosee how you're doing so.
If a patient has tried this fora month or two and they're
saying it's getting worse, it'snot getting any better, that's
(38:56):
not a reason to continue for thethird month.
I think if you're tryingsomething and it's not working,
you have to change course, andso a lot of it just depends on
how the patient is doing and howthey're reporting their
symptoms to you.
Robert A. Kayal, MD, FAAOS, (39:10):
But what if you get an EMG nerve
conduction study and it alreadyshows that the carpal tunnel
syndrome is very severe andthere's associated muscle
atrophy and some very permanentchanges to that nerve?
What do you tell the patientand what do you do?
Edward Lin, MD (39:25):
Yes.
So in that case the nerve hasundergone severe permanent
damage and so there really isn'ta role for nonoperative
treatment, and so we're talkingmore about doing surgery to fix
that.
But even in cases where we dodo surgery for severe carpal
tunnel syndrome, the results arenot going to be as good as if
you do it for mild to moderate,and so in mild to moderate
(39:47):
carpal tunnel syndrome I wouldsay 90% of patients will get 90%
better.
But in severe cases thosenumbers are not as good.
And so there's a goodproportion of patients who, even
after carpal tunnel surgery,who have severe carpal tunnel,
who don't get better.
Or they feel better a littlebit, or it takes them a whole
(40:08):
year before their numbness andtingling goes away, or their
numbness and tingling goes awaypartially, but they always feel
a little bit numbness, and partof the reason is because even
after you release the carpaltunnel sometimes it's too late
the nerve has already hadpermanent damage, and patients
may continue to feel numbnessand tingling in the future.
Robert A. Kayal, MD, FAAOS, (40:28):
And my experience.
What I found, and when I hadthose conversations with those
patients, is that I sort of tellthem that I can't guarantee
that I'm going to help them getbetter or that they will recover
, and more than likely they willnot.
But what I have found is thateven in those patients, that
numbness and tingling that wakesthem up at night very often
(40:49):
goes away and that to them isone of the most rewarding things
because they get to enjoy, forthe most part, a good night's
sleep.
Obviously, the muscle atrophythat they are suffering from and
the numbness that theyexperience may never recover,
but the one thing that I havenoticed that most of them sleep
better at night and they don'twake up with that numbness and
(41:11):
tingling.
So it's important to have thoseconversations with patients
when it is very severe so thatwe can guide them properly and
set their expectations sothey're not disappointed when
that muscle atrophy doesn't comeback fully or maybe the
numbness does not fullydissipate.
But that just again drives homethat point that it's incumbent
(41:33):
upon us to see those patientsthe sooner the better and to
treat them before they havepermanent nerve damage and
muscle wasting.
Edward Lin, MD (41:42):
Yeah, I agree wholeheartedly, and one of the
things that I tell patients issometimes, even if you don't get
any better, an additional goalof the surgery is to prevent
them from getting worse, becauseif you do nothing and you allow
carpal tunnel syndrome toprogress, that nerve is just
going to get more and moredamaged over time.
It's almost a certainty.
And so if you let that happenand let that proceed, it's going
(42:04):
to get worse and worse andworse, to the point where you're
going to lose function of yourhand, and that's the worst thing
to say.
Robert A. Kayal, MD, FAAOS, F (42:09):
I tell them the same thing 100%
Okay, so we've decided to dosurgery that this patient needs.
Surgery has failed.
Nonoperative measures hasfailed to progress.
Still quite symptomatic.
What are the surgical options?
Edward Lin, MD (42:22):
So the surgical treatment for carpal tunnel
surgery is called the carpaltunnel release, and what we're
actually doing is we'relengthening that transverse
carpal ligament, which is thatthick ligament that sits on top
of the nerve.
It's pushing down on the nerve.
We're opening it up andcreating more room for the nerve
, and that's called the carpaltunnel release.
There are different ways to doit.
You can do it with an openprocedure, which is the
(42:46):
traditional way of doing it,where we do surgery and we open
up that ligament, eventuallythat ligament which, even if
it's open, really doesn't haveany effect on the function of
the hand.
So that ligament, if it's in alengthened position or if it's
divided, the hand will stillfunction just fine in that
condition and over time thatligament will heal back into a
(43:09):
less compressive condition.
So another way to do it isthere's something called an
endoscopic carpal tunnel release, where we use a small tiny
camera to go in and release theligament using a specialized
device through a very smallincision with the camera.
And then there are also variousother methods of doing it, but
those are the two main methods.
Robert A. Kayal, MD, FAAOS (43:30):
Both of them are done as an
outpatient.
Edward Lin, MD (43:32):
Right?
That's correct.
Yeah, the procedure itselftakes about anywhere from 10
minutes to 30 minutes and it'sdone as an outpatient, meaning
you go home, you have a softdressing on your hand and you're
going to keep it dry for thefirst few days after the surgery
.
You can move your handsimmediately after this.
Actually, I encourage patientsto move their hands immediately
after the surgery to preventscar tissue buildup, and most
(43:54):
patients are able to return towork pretty quickly.
Everyone's a little bitdifferent, but patients are able
to still use their hand.
It might be a little sore, butfor the most part, patients are
still functional after thisprocedure.
Robert A. Kayal, MD, FAAOS, F (44:07):
I liken carpal tunnel release to
some of the most rewardingsurgical procedures we do in the
field of orthopedics right Hipreplacement, shoulder
replacements.
Certainly carpal tunnelsyndrome and its release is
right up there with that.
When patients can't sleep,they're miserable and they're so
(44:28):
thankful and grateful to beable to get a good night's sleep
without having to wake uprepetitively with their hands
going numb, and it's often aninstantaneous level of
gratification that we appreciate.
I tell the patients todayyou're going to go to sleep and
you're going to sleep throughthe night.
They appreciate that reliefthat night, the night of the
(44:50):
surgery, and it's one of themost gratifying procedures, I'm
sure.
For you you're most successfuland most gratifying procedure,
I'm sure.
Edward Lin, MD (45:00):
I agree.
Personally, I love doing carpaltunnel releases for a variety
of reasons.
One is the patients do great.
It's one of the ways you canreally impact someone's life
instantaneously.
As you said, you can see whatthe problem is.
So I'm a visual person.
You can go in there and see thenerve being compressed and
(45:20):
being released, and so you knowexactly where the problem is,
you know how to fix it and theresults are great.
So it's a really rewarding andsatisfying procedure for sure.
Robert A. Kayal, MD, FAAOS (45:29):
Yeah , just like in the spine, a
severe case of spinal stenosiswhen a spine surgeon does a
lumbar decompression and freesup that nerve.
We all like to free up nerves.
When nerves get compressed,whether it's in the spine, in
the hand, in the neck, patientshurt, they suffer and it's a
really bad form of suffering.
(45:50):
It's one of the most painfulconditions you can have.
When a nerve is compressed,most debilitating.
It can have many, manydifferent consequences
neurological consequences,numbness, tingling, pain,
weakness, etc.
In all parts of the body andnerves don't like to be
compressed and so when youdecompress that nerve, patients
(46:12):
are very grateful and almostinstantaneously.
So it's an awesome surgicaloption for these patients and a
lot of them end up wondering whythey waited so long, because
it's such a minimally invasiveprocedure with such an
outstanding outcomeinstantaneous outcome that we
encourage you.
If you're suffering from thiscondition, wait no longer.
(46:33):
We have treatment alternativesavailable for you immediately.
Edward Lin, MD (46:38):
Yeah, and this is a procedure where people
often come with bilateral carpaltonal meaning in both hands, so
we can do one side and thenwait two weeks and do the other
side.
So it's something that thehealing is fairly quick and you
don't have to stop your life.
You don't have to stop doingwhat you're doing, other than
you do have to limit some of themajor sporting activities that
(47:00):
you're doing, but everyday lifethings that you're doing at home
, you can continue using yourhands for those.
Robert A. Kayal, MD, FAAOS, (47:04):
Is there any consideration given
for orthopedic biologicalregenerative medicine like
platelet-rich plasma injectiontherapy or anything like that
for carpal tunnel syndrome?
Edward Lin, MD (47:15):
Yeah.
So it kind of goes along withwhat we were talking about
before with the inflammation.
So with PRP, which isplatelet-rich plasma, which I'm
sure everyone has heard about.
The goal is really to reducethe inflammation.
So, just like doing a cortisoneinjection, you could consider
doing a PRP injection to helpreduce that inflammation and
help improve the symptomswithout surgery.
Robert A. Kayal, MD, FAAOS, (47:35):
So we've talked about the surgery
now.
Patients had the surgery.
They're home.
What's next?
Edward Lin, MD (47:41):
So usually after carpal tunnel surgery the
recovery is fairly quickcompared to other surgeries you
might have had.
We put on a soft dressing soyou're moving your wrist and
moving your hand.
Immediately after the surgeryyou come back and see us in the
office, usually within about aweek.
We check in the wound, makesure and everything is okay.
The incision itself issomething about there to there.
(48:03):
So it's just about that big foran open carpal tunnel surgery
and for endoscopic carpal tunnelsurgery the incision is
actually even smaller.
It's just about from here tothere.
It's about one centimeter and Ican perform both procedures.
Either procedure is anacceptable treatment.
I think there are pros and consto either modality and it
depends on the patient which onewe ultimately decide to pursue.
(48:27):
But the recovery is quick.
The stitches come out in about10 days.
Some patients will need therapyafterwards.
I would say the majority ofpatients don't necessarily need
therapy because a lot ofpatients come in and they have
great motion and a lot of themdon't want to go to therapy and
that's fine.
But if patients do, that'ssomething to consider as well
(48:47):
after surgery to improve theirstrength and improve the motion
of their fingers after thesurgery.
Robert A. Kayal, MD, FAAOS, (48:54):
So what about recurrent carpal
tunnel syndrome?
Is that something that canhappen, and if so, how can that
be treated?
Edward Lin, MD (49:02):
Sure.
So recurrent carpal tunnel doeshappen.
And by recurrent carpal tunnelsyndrome I'm talking about
someone who's had carpal tunnelrelease, whether endoscopically
or through an open procedure,and maybe a few months later,
maybe a year later, they havetheir symptoms in return and we
call that recurrent carpaltunnel syndrome because the
(49:23):
symptoms have come back despitehaving a successful surgery.
Usually they'll feel better fora period of time and then
slowly they'll find that theircarpal tunnel symptoms have come
back.
And in those patients, well,one thing it's really important
to make sure that they actuallydo have carpal tunnel syndrome.
Sometimes after surgery you mayfind that you still have
numbness and tingling becauseit's coming from the neck or
(49:43):
maybe you have some othercondition that's causing that.
But assuming you are dealingwith carpal tunnel syndrome, the
treatment for a recurrentcarpal tunnel syndrome is to do
a revision carpal tunnel release, and what that means is we go
back in there and we try to openup the nerve again and try to
release the compression that'scome back Now when I do that
(50:06):
procedure.
First of all, it's pretty rare.
The literature shows thatrecurrence occurs, depending on
the paper, anywhere from a fewpercent, meaning two or 3%.
Some papers show up to 20, 30%,but I think that's really
unlikely.
But I would say it's less than10% the risk of recurrence.
But when it does happen I willdo a revision.
(50:26):
Carpal tunnel procedure.
Now that procedure is a lotmore involved in the initial
procedure, meaning we have tomake a much bigger incision and
it's a bigger surgery becausewe're dealing with a lot more
scar tissue that was left behindby the first surgery.
You're definitely not doingthat endoscopically.
No, no, I would not recommenddoing that endoscopically.
And then, in addition, what Ido is I do what's called a
(50:50):
hypothyner fat flap, where Itake some fat from this area of
the hand and we move it acrossthe nerve and what that does is
that covers the nerve in a nicelayer of fat so that when it
does heal it prevents scartissue from forming around the
nerve and causing compressionagain.
But I would say that's a fairlyrare procedure.
In the most case, if you'vedone a carpal tunnel release,
(51:13):
the symptoms are not going tocome back.
Robert A. Kayal, MD, FAAO (51:15):
Right .
Well, this was a very helpfuland informative conversation, dr
Lin.
I hope that our viewingaudience found this to be the
same.
We hope they learned somethingabout carpal tunnel syndrome,
and if I can give you a takehome message, it's don't ignore
your symptoms.
Seek medical care, the soonerthe better, because it is a
(51:36):
condition that we can treat moresuccessfully when we see it
early and even with surgery ifyou need surgery outcomes will
be better when we address themilder to moderate symptoms as
opposed to the more severe andchronic conditions.
Any closing words, dr Lin?
Edward Lin, MD (51:54):
Yeah, I agree.
As I said, carpal tunnelsyndrome is one of the most
common things I see.
I see it day in and day out.
It can be very debilitating forpatients patients who come in
because your hands are soimportant.
Use your hands.
As surgeons, we appreciate thatvery personally, but people are
using their hands for a wholevariety of activities, whether
(52:15):
it be sporting, whether it be atthe job, whether it be taking
care of a loved one.
Your hands are so important andso it's important to take care
of your hands so that you cancontinue to use them for
everything you want out of life.
Robert A. Kayal, MD, FAAOS (52:30):
Well , we truly appreciate your skill
set and your education andtraining, your bedside manner,
and I'm honored to call you acolleague and physician at
Kailor Orthopedic Center.
Thank you for spending the timewith us and for educating our
population about carpal tunnelsyndrome.
All right, thank you, dr Kailor.
We appreciate it.
Pleasure is mine.
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is July 11th, 2023, andour special guest today is Dr
Edward Lin.
Dr Edward Lin is our chief ofthe hand service at the Kale
Orthopedic Center, Today's topicHarpal Tunnel Syndrome, and
we're so happy to have Dr Linwith us.
Welcome to the podcast, Dr Lin.
Edward Lin, MD (00:21):
Thank you, Dr Kale.
I really appreciate youinviting me here and being here.
It's been looking forward tothis podcast for a while.
Robert A. Kayal, MD, F (00:27):
Likewise , likewise, so happy to have you
, thank you.
So let's just get started andthen first let our viewing
audience know a little bit aboutyou, dr Lin.
Edward Lin, MD (00:35):
So I grew up in New York City in Flushing,
queens, born and raised and wentto junior high school in
Manhattan, did Hunter Collegejunior high school and then high
school at Stuyvesant HighSchool, also in Manhattan, and
graduated and did the eight yearBAMD program, which is an eight
(00:55):
year program with NYU whichincludes four years of
undergraduate study at NYU andthen four years at NYU Land Goal
and Medical Center for mymedical school.
And then I decided to stay atNYU for an additional five years
for orthopedic training.
It was a great, greatexperience, great residency and
I did one year of additionaltraining at the UPMC in
(01:17):
Pittsburgh for a hand in upperextremity fellowship Wow.
Robert A. Kayal, MD, (01:21):
Impressive credentials.
I'll never forget the first dayI interviewed you for the job
and I was so impressed by youand your credentials and your
training and still am today.
So we're so blessed to have youwith us today.
Dr Lin, We've had the privilegeof having you take care of so
many patients over the yearsthat you've treated so
successfully and we're just sohappy to have you with us.
As far as the conditions thatyou treat, safe to say that
(01:44):
carpal tunnel syndrome wasprobably one of the most common
conditions you see on a dailybasis.
Edward Lin, MD (01:49):
Oh yeah, as a hand surgeon, it is the most
common thing I see, I would sayon a daily basis.
I just saw one about 20 minutesago.
It's a common thing and a lotof people are dealing with this,
especially in our day-to-day.
People are using their handsall day long and that definitely
has an effect on the rate ofhaving carpal tunnel syndrome.
Robert A. Kayal, MD, FAAOS (02:10):
Okay , so let's first and foremost
define for a viewing audienceexactly what carpal tunnel
syndrome is.
Edward Lin, MD (02:17):
So that's actually a great question
because there's a lot ofconfusion out there about what
carpal tunnel is.
A lot of people come to me andthey're not sure or they think,
oh, I'm having some kind ofissue with my hand and must be
carpal tunnel.
So carpal tunnel syndrome atits base is a problem with the
nerve.
In your hand you have a nerve,it's called the median nerve.
It's one of the main nervesthat go into your hand.
(02:38):
It's about half the width ofyour pinky and what that nerve
does is it provides sensationinto the hand, particularly into
the thumb, the index and themiddle finger.
In carpal tunnel syndrome, whathappens is that nerve is being
compressed.
It's being compressed righthere in the hand.
If you look in the hand, rightin this area, right here, this
(02:59):
is where the carpal tunnel is inthe hand, and so that nerve is
being compressed.
And when the nerve iscompressed it causes problems
with the nerve.
And the first thing you'llnotice when the nerve is
compressed is you'll seenumbness and tingling in the
fingers.
Now, sometimes it's in just thethumb, the index and the middle
finger, but sometimes it can beall the fingers and that's at
(03:21):
its core what carpal tunnel isso.
If you don't have numbness andtingling in your hand, you
probably don't have carpaltunnel syndrome.
That's essentially the firstthing that people will have.
Some people also have pain, andyou can have pain in that same
distribution in the thumb, indexand middle fingers.
You can also have pain in theother fingers.
Sometimes it radiates into theforearm, into the elbow.
(03:41):
Sometimes it can even radiateup into the arm, but most of the
time most of the symptoms arelocated in the fingertips and in
the hand.
Robert A. Kayal, MD, FAAOS, (03:50):
So this nerve, the median nerve,
actually stems from the brain,right.
Edward Lin, MD (03:54):
So the nerve, all the nerves in the body,
start off in the brain.
That's where all the nervesoriginate, essentially, in the
spinal cord, and the brain sendssignals to the nerves down the
spinal cord and the nerves thenbranch out through the spinal
cord through what's called thedorsal root ganglion is also a
ventral ganglion that comes downthrough the arm and then
(04:15):
through down into the hand andinto the fingers, and what can
happen is there can be multiplesites of compression.
So you can have these nervescompressed in your neck, you can
have them compressed in theelbow, you can have them
compressed in the forearm or youcan have them compressed in the
hand of the carpal tunnel, themost common sites of compression
would be the neck and in thecarpal tunnel.
(04:37):
So when you have numbness andtingling in that distribution,
that's where my mind goes toinitially is this carpal tunnel?
Is this coming from the neck?
But potentially you can havecompression anywhere along that
nerve path which can causesimilar symptoms, which is why
sometimes it's difficult todiscern where the problem is,
(04:58):
because sometimes the problemcan be in the hand, but it can
also be further up along thepath of the nerve.
Robert A. Kayal, MD, FAAOS, (05:04):
So this nerve, it provides only
sensory, or does it also providemotor function?
Edward Lin, MD (05:09):
So the median nerve is what we call a mixed
nerve.
It's one of the major nerves inthe body and it provides both
motor and sensory.
So at the level of the hand itprovides sensation to the thumb,
the index and the middlefingers and also part of the
ring finger as well.
But it also provides motorinput to this muscle here, right
here, and this area of the handis called the thenar eminence,
(05:33):
and what happens is the courseof the nerve.
If you look at it.
It comes up this way and thenit sends a branch right over
here into this muscle.
And what you'll see in somepatients who have advanced
carpal tunnel syndrome is thattheir nerve has been compressed
for so long that this muscle haslost what we call its
innervation, meaning the signalsthat are normally being sent to
this muscle have disappeared.
(05:54):
And if that lasts long enough,eventually the muscle actually
dies and you can see patientswho have a divot.
You'll see an actual divot intheir hand where the muscle is
shrunk, and that's a telltaleside that they probably or might
have carpal tunnel syndrome.
That's been untreated for along time and has led to that
what we call atrophy of themuscle.
Robert A. Kayal, MD, FAAOS, (06:13):
So what are some of the other
symptoms that these patientswill present with, besides the
numbness and tingling theydescribed?
Edward Lin, MD (06:19):
Yeah.
So, as I said, you can havepain associated with it.
It's oftentimes a nighttimephenomenon, so a lot of times
patients will say I woke up withthis in the middle of the night
.
I can't get a good night'ssleep.
That's very common, andsometimes patients will say I
wake up in the middle of thenight and the only thing that
makes it better is if I shake myhands.
That's actually a very telltalesign that you may have carpal
(06:40):
tunnel.
Some patients also find thatthey have symptoms going up and
down the arms, but if that isthe case, then you may also have
or instead of carpal tunnel,you may have a compression in
the neck that may cause armsymptoms as well.
Robert A. Kayal, MD, FAAOS (06:54):
Yeah , and that we call a double
crush phenomenon right, whenpatients sometimes can have a
pinched nerve in their neck andalso have a pinched nerve
somewhere else in the arm.
Because, as we discussed, allof these nerves ultimately stem
from the brain and the spinalcord.
So if that nerve is involved orcompressed anywhere along its
path it can present withsymptoms in the distribution of
(07:18):
wherever that nerve goes.
If it's a sensory nerve, it canaffect the sensation, resulting
in numbness and tinglingpotentially, and if it's a motor
nerve, it can often result inweakness as well to the muscle
groups that are innervated bythat nerve.
And if you have a mixed nerve,as Dr Lin referred to, such as
the median nerve, you can bothget sensory and motor findings
(07:39):
as well.
So it can be a littlecomplicated.
Are there other nerves aroundthe elbow that potentially can
cause patients to also awakenfrom sleep and have numbness and
tingling in their hands?
Edward Lin, MD (07:51):
Yeah, absolutely so.
There's another major nerve inthe arm.
It's called the ulnar nerve andthat nerve does a lot of what
the median nerve doesn't do.
So the median nerve goes to thethumb, the index, the middle
and part of the ring.
The ulnar nerve goes to thesmall finger and part of the
ring, so it provides a sensationto those two small fingers.
(08:12):
So if you find that you'rehaving more numbness in the
small finger, that may be theulnar nerve, whereas if your
numbness is more in these threefingers, that's more of the
median nerve.
Not 100% of the time, butthat's a rough estimate of what
we think about when we havepatients coming talking about
numbness and tingling.
The ulnar nerve also controlsthe muscles in the hand.
(08:33):
So inside the hand you havemuscles.
Here you actually don't haveany muscles in the fingers, but
you do have muscles in the handitself and they help control the
motion of the fingers goingthis way and also they help
control some of the motion ofthe fingers going this way,
keeping these straight, and sothose are called intrinsic
muscles and that's governed bythe ulnar nerve.
Robert A. Kayal, MD, FAAOS, (08:55):
So why do they call it the carpal
tunnel?
Edward Lin, MD (08:58):
So the carpal tunnel is a tunnel you can think
of it like a train tunnel andit has walls, it has a floor and
it has a ceiling.
And if you think about it, thewall and the floors of the
carpal tunnel are all made ofbone.
There are many different bonesin the wrist and they form
almost a solid foundation forthe carpal tunnel.
(09:19):
And then the ceiling of thattunnel is a very thick ligament.
It's called the transversecarpal ligament and it's
thickest right here, right herein this portion of the hand.
And so the problem with thatanatomical structure is that
there's really no give becausebones are very hard, they're not
going to stretch out.
(09:39):
That ligament over time becomesvery, very thick and it's not
going to stretch out.
And so what that leads to is aproblem with the pressure inside
the carpal tunnel.
So the normal pressure inside acarpal tunnel, I would say, is
about two or three millimetersof mercury, and millimeters of
mercury is just a measure of thepressure inside anything.
(10:01):
In fact, if you look at yourblood pressure, 120 millimeters
of mercury, that's the unit ofpressure.
So normal pressure inside acarpal tunnel is about two or
three, and patients with carpaltunnel syndrome it can be 20, 30
, 40.
And so once you get above 30,the problem is that you start to
develop nerve damage.
The nerve really doesn't liketo be pressured.
(10:22):
That's one of the things thatnerves don't tolerate very well.
And once you start puttingpressure on that nerve, you're
going to have to get a littlebit of pressure.
A lot of things begin to happento that nerve that are not good
.
Robert A. Kayal, MD, FAAOS (10:31):
When you're evaluating a patient.
We already talked about thehistory and their complaints.
You said most of them wouldcomplain of pain and numbness
and tingling and sometimes evenweakness.
Are there any other parts ofthe history that are relevant to
helping you really hone in onthe diagnosis of carpal tunnel
syndrome?
Edward Lin, MD (10:49):
Yeah, absolutely so.
Carpal tunnel syndrome can becaused by a whole variety of
factors.
Most of carpal tunnel syndromeis what we call idiopathic, and
what that means is that we don'treally have a direct cause for
it.
It just happens.
But there's a good portion ofpatients who have carpal tunnel
syndrome for a specific reason,and so some of the things that
(11:12):
can cause carpal tunnel syndromeare diabetes, patients who have
a thyroid condition, patientswho have autoimmune problems,
rheumatoid arthritis, psoriaticarthritis, patients who have
kidney problems.
There's a condition calledamyloidosis, where the body
deposits amyloid, which is asubstance, into the carpal
tunnel and that can increase thepressure inside the carpal
(11:32):
tunnel.
It can also have anoccupational relationship.
So patients who are alwaysdoing repetitive tasks that's
what we hear over and over againyou may be a factory worker or
you may do something where youdo the same motion over and over
again, a thousand times a day,10,000 times a week, and that
can cause carpal tunnel to getworse.
(11:53):
Patients who use vibratorytools jack hammering, anything
that's causing vibration in thehand is going to make it worse.
Patients who are constantlysqueezing is going to make it
worse.
A lot of people ask me ifcomputer use makes it worse, but
the evidence for computersbeing linked to carpal tunnel
actually isn't that great.
So despite the conception that,oh, I have carpal tunnel and it
(12:16):
must be because of the computeruse, that link, at least
scientifically, hasn't reallybeen proven.
Robert A. Kayal, MD, FAAOS, (12:22):
But it is intuitive, isn't it?
Considering all the otherdiagnoses and associated
conditions that you've justdescribed.
The common element in all ofthem is that they, for the most
part, all result in an increasein swelling right and we already
talked about that the carpaltunnel is a closed compartment
and the nerve doesn't tolerateany type of compression, not
(12:46):
much pressure inside the carpaltunnel at all.
The carpal tunnel is already alittle crowded right.
The carpal tunnel includes themedian nerve and nine other
flexor tendons, so there'sreally not a lot of room inside
that closed compartment.
Now we compound that with somemedical conditions that are
often associated with swelling,like pregnancy, hormonal changes
(13:09):
, thyroid disorders, diabetescan definitely result in
swelling and also increased innerve injuries and neuropathy
and some of the other conditionsyou mentioned as well.
Anything that causes a crowdingphenomenon, rheumatoid arthritis
, because very often associatedwith that condition we get
(13:30):
tinocinibitis and autoimmunedisorders, where you get an
immune response and swelling andcrowding phenomenon.
So those are all conditionsthat definitely result in
swelling and crowding in thecarpal tunnel and compression on
the median nerve.
So it is somewhat intuitive toimagine that if you're using
computer a lot and overusingyour risk, that it should cause
(13:53):
that.
So to me, regardless of whatthe medical literature suggests,
I believe that overuseconditions such as computer
usage should contribute.
So I would certainly advise mypatients at least that if
they're doing too much ofanything texting and video games
(14:14):
or computer usage, to maybequiet that down a little bit to
see if it alleviates theirsymptoms.
It does make sense intuitively.
Edward Lin, MD (14:20):
Yeah, I agree, I think that's you know.
There's the medical literatureand then there's common sense,
right?
So I think as a doctor, youhave to use a little bit of both
.
You can't just look and seewhat the papers say.
You have to listen to.
You know what your common senseis telling you, but you also
have to listen to your patienttoo.
And if the patient's telling meI text over and over a thousand
times a day and this is killingmy hands, yeah, it's probably
(14:43):
causing your carpal tunnel toget worse.
Robert A. Kayal, MD, FAAOS (14:45):
They know their body's better than
we do, right.
Edward Lin, MD (14:46):
Absolutely.
I agree with that, only percentyeah.
Robert A. Kayal, MD, FAAOS, (14:49):
Now that we got inadequate history.
You've done your physical exam.
What other imaging modalitiescan you sometimes employ to help
support your diagnosis?
Edward Lin, MD (14:58):
Right.
So there are definitely otherthings that we can do with a
suspected carpal tunnel case toboth confirm the diagnosis or
even try and figure out thediagnosis if we're not sure.
So one of those things is an MRI, and an MRI can be really
useful in carpal tunnelspecifically because there are
specific things that can causecarpal tunnel syndrome.
So I had a patient who came in.
(15:19):
She was about 18 years old andshe had classic carpal tunnel
signs, which you don't usuallysee in someone who's 18.
You know, people who are intheir teens and 20s usually
don't get carpal tunnel syndromejust out of the blue.
So we did an MRI and we havefantastic MRIs at our facility
with amazing radiologists whoare reading them and we found
(15:41):
that she had a very largeganglion cyst sitting right
inside of her carpal tunnel andthat was what was causing her
symptoms, and so in that case wewere able to remove the
ganglion and address itsurgically, and she had a
wonderful result.
As soon as the next day, rightafter I removed the ganglion, I
called her up and she said wow,my symptoms are gone.
Robert A. Kayal, MD, FAA (16:01):
That's interesting.
That's an interesting almostcase report.
Yeah, you nailed it.
We don't typically see carpaltunnel syndrome in the young,
except for the pregnant women.
Right that with the hormonalchanges.
It's very rare to make thatdiagnosis in a young patient
like that.
Edward Lin, MD (16:17):
Yeah, but so without the MRI?
We got an MRI to see thatganglion cyst, to see what the
location of that cyst was and toknow that that was causing her
symptoms.
It would be difficult to makethat diagnosis without the MRI.
So that's one thing that'simportant.
One other thing that we've beenusing more and more is
ultrasound, and we have anultrasound in every single exam
(16:37):
room, which I think is somethingthat no other facility really
has.
No one else has invested thatkind of resources into having
that technology.
But the ultrasound is importantbecause there's more and more
data showing that you canactually make a diagnosis of
carpal tunnel syndrome with anultrasound machine, and the way
you do that is you take theultrasound machine and you
measure the cross-sectional areaof the nerve and if the
(17:00):
cross-sectional area is morethan about one square centimeter
, that's highly suggested thatyou have carpal tunnel syndrome.
So it's something to add toyour armitarium of things to
make a good diagnosis.
Robert A. Kayal, MD, FAAOS, (17:12):
So , dr Lin, we talked about using
MRI, we talked about usingultrasound for the diagnosis.
How about x-ray?
Do we use x-ray as well toevaluate for carpal tunnel
syndrome?
Edward Lin, MD (17:24):
Absolutely so.
The x-ray is usually the firststudy that I get.
We have an x-ray machine inevery single facility that we
have and you can make diagnosesbased on that x-ray, including
things that aren't related tocarpal tunnel.
So you may be coming in withwhat you think is carpal tunnel
and you may find that you have afracture.
There's actually a veryspecific view we do in the
(17:47):
x-rays, called the carpal tunnelview, and using that specific
view we can look straight downthe carpal tunnel and with the
x-ray machine and we can see ifthere's a lesion in there.
We can also see if sometimesyou'll have a fracture of one of
the bones that's in there.
So we can definitely pick upthings on an x-ray without any
additional imaging, butoftentimes it will lead to other
(18:09):
need for other additionalimaging as well.
Robert A. Kayal, MD, FAAOS (18:11):
Yeah , sometimes patients come in the
office and they have a tendencyto want to resist getting an
x-ray right.
But as a trained orthopedicsurgeon many of us who have
trained at world-renowned cancercenters we don't cut corners
right.
We can't cut corners, we can'tmiss the basic, fundamental
imaging of an x-ray.
(18:31):
The x-ray tells us so much itcan evaluate for bone tumors, it
can evaluate for fractures,lesions, different things that
can contribute to orthopedicconditions.
So I almost will never see apatient unless the patient gives
me the permission to get abaseline x-ray, because
certainly I never want to missanything on a patient.
(18:51):
And only after the x-ray isnegative do we consider
proceeding with MRI or furtherimaging.
Do you do the same thing?
Edward Lin, MD (18:59):
I agree, that's my practice as well and the
philosophy behind that is youdon't know what you're going to
find if you don't look.
And so if you're not getting anx-ray and you're doing an
operation or you're doing aninjection, you're almost working
in the blind a little bitbecause you haven't done your
due diligence to rule outeverything else that this could
(19:20):
be.
And you may do an x-ray andfind something.
You may do an MRI and findsomething.
I can't tell you the number oftimes I've done an MRI and I was
surprised and I was just soglad I got that MRI because if I
didn't I would not have foundtumors, I found cancers, really
serious things that if addressedsoon we can really make a
(19:41):
difference.
But if you wait, if you didn'tget that MRI, if you didn't get
that x-ray and you waited, itwould have been disastrous.
Robert A. Kayal, MD, FAAOS (19:47):
Okay , so are there any other studies
besides x-ray MRI ultrasoundthat you would use to see if
there was any damage to thenerve?
Edward Lin, MD (19:58):
Sure.
So one of the things we rely onand I alluded to would be a
nerve study.
And a nerve study is a specificstudy and it does two things.
One, it tests to see how thenerves are functioning, to see
what the speed of the electricalsignals that are going through
the nerve is.
And the nerves you can think ofthem almost like electrical
wires.
They send a signal from point Ato point B through essentially
(20:21):
we call them ions, butessentially an electric signal
through these.
We think of them as wires andthat the speed of the signal
conduction should be a certainspeed, and if the speed slows
down we know there's a problemwith the nerve.
We can also test the musclesthat the nerve goes to.
So that muscle we talked aboutthis muscle right here we can
(20:41):
test that muscle and see if thatmuscle is doing all right, to
see if it's receiving the rightsignals, and if it's not, then
we get a good sense that, okay,there's something wrong with the
nerve.
And so the test of the muscles,that's called an EMG and the
test of the nerve conduction,that's called the nerve
conduction study, and both ofthose are done by a pain
management specialist, theperson I trusted, dr Steve Nadin
(21:06):
, who's in our practice, and heis a fantastic at doing nerve
conduction studies.
So having gotten one of thesestudies, you can see if there's
a problem with the median nerve,you can see if there's a
problem with the ulnar nerve,and it helps you to really hone
in on that diagnosis.
Robert A. Kayal, MD, FAAOS (21:23):
Yeah , it targets the area of
compression.
It gives you a nice baselineevaluation as well, just in case
you're trying to monitorwhether or not this nerve is in
the future getting worse orgetting better.
So it's really critical to geta baseline EMG nerve conduction
study.
Typically we tend to want towait about two to three weeks
after the onset of symptoms,because often we won't even see
(21:46):
changes on the EMG nerveconduction study until then.
But I think it would behoovethe patient to get a baseline
EMG nerve conduction study.
This way it can help the doctormonitor your progress to
determine whether or not you'regetting worse or better with
treatment.
And is that something you doregularly?
Edward Lin, MD (22:03):
Yeah, so I routinely order a nerve
conduction study with anyone whocomes in with numbs and
tingling and it's helpful for somany different reasons.
So one thing you can tell ifwell, if it comes back normal,
that gives you information too,because if it comes back
completely normal, then it'smuch less likely to be carpal
tunnel syndrome.
However, just because a testcomes back normal doesn't mean
(22:25):
you don't necessarily havecarpal tunnel.
So all of the tests that wehave whether it's an MRI, a
nerve conduction study you haveto take a look at it
holistically with the patient,what they're presenting with,
and come up with a thoughtpattern of what diagnosis is,
taking all these points of datainto account.
But the nerve study is goodbecause it tells you if there's
(22:48):
a problem and where that problemis.
So to help locate is it at theelbow, is it at the wrist, is it
in the hand and or all theabove, or all the above.
And using that information youcan really help to hone in on
what the problem is.
And once you have a diagnosis,you can figure out what the best
course of action it would be.
Robert A. Kayal, MD, FAAOS, (23:06):
It also helps guide us as we
converse with our patients andgive them prognosis right,
because if a patient has adouble crush phenomenon and
you're opting to address thecarpal tunnel syndrome first, it
affords us the ability to atleast tell that patient look,
I'm going after the symptomsonly associated with the carpal
(23:26):
tunnel syndrome, but please beprepared that you're still going
to have some symptoms from thecompression of the nerve in your
neck right and we might have toaddress that afterwards as well
.
Edward Lin, MD (23:38):
Absolutely, and it can also help to grade the
degree of carpal tunnel that youdo have.
So carpal tunnel, you can havemild carpal tunnel, you can have
moderate and you can havesevere.
And in patients who have mildto moderate carpal tunnel let's
say you end up doing surgery tocorrect that the results are
much better than if you havesevere carpal tunnel.
It definitely gives you a goodprognosticator to say that you
(24:01):
have mild carpal tunnel, you arealmost definitely going to get
better after surgery, versus youhave severe carpal tunnel.
You have about a 50% chance ofgetting better after surgery and
so that's important.
Robert A. Kayal, MD, FAAOS (24:12):
It's like most orthopedic conditions
right the sooner we addressthem, the easier it is for us to
guarantee our results.
Right, because when you'redealing with acute, reversible
disease as opposed to chronic,sometimes irreversible
conditions, it makes it moredifficult to guarantee excellent
results Because some of thedamage to the tissues, and in
(24:34):
this particular case, the nerves, can be permanent and
irreversible.
Edward Lin, MD (24:38):
Absolutely, and this is something I'm always
telling patients that in thebeginning carpal tunnel starts
off as mild, meaning that youhave some compression of the
nerve.
But the nerve overall, theanatomy of the nerve, the
structure of the nerve is stillnormal and so if you just
relieve that compression thenerve will bounce back and
sometimes it'll bounce backinstantaneously.
I've had patients who we didthe nerve the surgery and then
(25:01):
in the recovery room they said,wow, it feels better
instantaneously.
So that tends to happen in mildcases.
But if you let that compressiongo on you're saying, oh, I'm
having some numbness andtingling, but I can deal with it
, Let me just sleep on it.
You wait a few months to a fewyears and now that carpal tunnel
that used to be mild is nowmoderate or it's now severe and
(25:22):
you're developing what we callmuscle atrophy, where that
muscle we talked about isbecoming smaller and the nerve
over time unfortunately startsto have irreversible changes,
meaning that scarring tends tohappen in the nerve.
The nerve is losing the bloodsupply because it's being
compressed for so long and atsome point these changes are
permanent.
They're irreversible, meaningeven after you do surgery to
(25:46):
decompress the nerve, thesechanges are not going to go away
, and then you're left with,unfortunately, numbness and
tingling that doesn't go away.
So this is something where, ifyou do notice numbness and
tingling in your hand, it'simportant not to just blow it
off, not to say I'm just goingto sleep on it.
Come in, have us take a look atit and see if anything needs to
(26:08):
be done.
Robert A. Kayal, MD, FAAOS, (26:09):
OK .
So, Dr Lin, now that we'vedefinitively made the diagnosis
for our patients of carpaltunnel syndrome, what's the
first line of treatment?
Edward Lin, MD (26:17):
So the initial line of treatment with carpal
tunnel syndrome depends on howsevere it is, and that's why I
keep going back to the severity.
It's important to get thesethings checked early so that you
don't let it become severe.
In the early stages mild tomoderate carpal tunnel syndrome,
the initial treatment isnon-operative and the treatment
initially is to wear a splint.
Now you've seen many of thesesplints online and we offer a
(26:40):
splint that I think is very goodand the goal of the splint is
it's a brace that you wear onyour wrist and the goal of the
splint is to keep your wrist ina neutral position, and the
reason for that is because it'sbeen found that if you have your
wrist in this position flexposition or an extended position
it greatly increases thepressure inside the carpal
tunnel.
(27:00):
So I don't know about you, butmy wife sleeps like this and so
that's really bad for the carpaltunnel.
So we give a splint and if youwear that splint at night, it
prevents your wrist from goinginto those positions and that
sometimes by itself will fix theproblem, because a lot of
patients have problems atnighttime.
If we keep the wrist straight,then it solves the problem.
Robert A. Kayal, MD, FAAOS, (27:23):
And it also helps to immobilize the
joint right, and we alreadydiscussed that.
The carpal tunnel is filledwith not only the median nerve
but nine flexor tendons and veryoften the flexor tendons are
contributing to the inflammationand swelling and compression on
the nerve because they'reoverused and swollen.
So by immobilizing the wristjoint with a wrist immobilizer,
(27:47):
theoretically we're restingthose flexor tendons, allowing
for the inflammation andswelling to subside and
therefore the compression on themedian nerve to subside as well
, absolutely.
Edward Lin, MD (27:57):
And another one of those treatments that seems
very simple but is just rest.
If you're doing something 1,000times a day and it's causing
your carpal tunnel syndrome toget worse, you should probably
not be doing those things.
So that's activitymodifications also very
important part of the treatment.
One of the things that I alwaystell my patients is there's
also an exercise that you can doto help your carpal tunnel
(28:18):
syndrome, and I'll demonstrateto you.
So what you do is you take yourhand, make it flat and then you
do this position this is calledan intrinsic plus position and
you bring it down to a full fist.
You go back into your intrinsicplus position and you go like
this that's called a tendongliding exercise, so that.
And then there's anotherportion where you go like this.
This is a Another exercise.
(28:40):
You can do another tendongliding exercise you can do.
You keep your palm flat likethis.
You move it into this positionlike this, make a full fist,
move it back into this positionand like that.
That's the first way to do it,and the second way to do this
come straight down and this iscalled a tendon gliding exercise
and that's been shown to helpwith carpal tunnel.
So between doing the bracingand the tendon gliding exercises
(29:03):
.
A lot of patients will getbetter just with non-operative
treatment.
In addition, you can takeTylenol pain medication,
anti-inflammatory medication.
There are also othermedications such as Lyrica,
neuropathic pain medications,and all of these medications can
be taken as well to help withthe symptoms.
Robert A. Kayal, MD, FAAOS (29:21):
Like in so many orthopedic
conditions, inflammation is theculprit, right?
I say this podcast afterpodcast after podcast.
Inflammation is associated withredness, warmth, pain and
swelling and in this particularcase, carpal tunnel syndrome,
inflammation and swelling is themain cause of this condition
(29:42):
because that nerve is gettingcompressed.
So any of the medications thatcan alleviate inflammation will
alleviate a lot of the symptomsassociated with carpal tunnel
syndrome.
So the typical over-the-counternon-steroidal anti-inflammatory
medications like Motrin, advil,aleve, ibuprofen would all be
(30:02):
very helpful in treating thiscondition.
It is somewhat counterintuitivethat in this particular case,
carpal tunnel syndrome, wherethere seems to be inflammation
and swelling around the mediannerve, causing the compression
and therefore the symptoms ofcarpal tunnel syndrome, the
guidelines from the AmericanAcademy of Orthopedic Surgeons
(30:24):
argues against the usage ofanti-inflammatory medications in
this condition.
Edward Lin, MD (30:28):
Correct, yeah, that's true, and I think part of
that is because the carpaltunnel, when someone comes in
with carpal tunnel syndrome.
The carpal tunnel syndrome canhave a whole variety of causes
and a lot of times it isinflammation.
Particularly patients who haveinflammatory conditions like
gout, pseudo gout, rheumatoidarthritis or an autoimmune
condition.
(30:49):
It can definitely beinflammation as the culprit.
But you also have a good subsetof patients who don't have
inflammation but have carpaltunnel syndrome for a variety of
reasons.
It could be idiopathic, meaningthat we don't really know why.
Maybe their ligament is justreally thick in that area.
It could be that they have ananatomic structure that's
causing compression, and so Ithink it's difficult to
(31:10):
recommend and say anyone who hascarpal tunnel syndrome should
get an anti-inflammatory forthose reasons.
But I do think there is asubset of patients who do have
inflammatory conditions whetherit be gout or pseudo gout or
what have you who would benefitfrom an anti-inflammatory.
Robert A. Kayal, MD, FAAOS, (31:24):
But I think it's definitely a
case-by-case basis, it seemssomewhat controversial, and I
don't believe that there'soverall unanimity in the
orthopedic community whether ornot nonsteroidal
anti-inflammatory medicationsare warranted or not.
In my own practice I do believein the usage of
anti-inflammatories because I dobelieve inflammation is
(31:46):
strongly associated with thiscondition, and that is because
of the fact that overusedconditions tend to contribute.
Swelling from other conditionslike thyroid disorders, swelling
from hormonal changes inpregnancy, all seem to
contribute.
And clinically, when I performsurgery for carpal tunnel
(32:06):
syndrome, I often do appreciateextensive inflammation inside
the carpal tunnel causingcompression on the nerve.
And so in my own practice I'm abeliever in the usage of
nonsteroidal anti-inflammatorymedications such as Motrin,
advil, aleve, ibuprofen or otherprescription
anti-inflammatories and, in rarecircumstances, potentially even
(32:30):
oral steroid usage to helpsuppress the inflammation and
swelling around the nerve.
What do you do in your practice, dr Lin?
Edward Lin, MD (32:38):
I take a similar approach in that I do prescribe
anti-inflammatory medication,but it depends on the patient's
circumstance.
So if I think that inflammationis playing a big role in the
patient's condition, I willdefinitely prescribe an
anti-inflammatory, but if Ithink that the condition is not
an inflammatory condition, thenI may hold back and say just
(32:58):
take Tylenol or try somethingelse.
But it's also something thatyou have to ask the patient have
you taken anti-inflammatoriesin the past and if you have, has
it improved your carpal tunnelsymptoms?
If it has, then by all meanscontinue taking them.
Robert A. Kayal, MD, FAAOS, (33:13):
One thing in my own practice that
has really helped support thatconcept of inflammation being
associated with it is the myriadof patients that have responded
so favorably to a cortisoneinjection.
It's almost the most rewardinginjection that we give, because
patients that are suffering fromthis pain, numbness and
(33:34):
tingling, pins and needleswaking up, having to shake that
hand literally in three days itdisappears.
And what's funny in my ownpractice is what I've
experienced is when patientshave carpal tunnel in both sides
, both the right and left handafter an injection I always find
that the other side goes awaytoo.
Edward Lin, MD (33:56):
That can be a systemic effect, because when
you're giving the cortisone, itto one hand, eventually some of
that cortisone does make it intoyour bloodstream and so it can
affect the other hand.
But that's very interesting.
Speaking of cortisoneinjections, cortisone is
injection is an importantnon-operative treatment modality
for carpal tunnel, and I use itfor two reasons.
One is therapeutic I want mypatients to get better and it's
(34:17):
a way to do that.
But it's also good for adiagnostic tool, because
sometimes patients will come inwith that double crush
phenomenon that you mentioned.
They have compression in theneck, they have compression in
the hand and you're not surewhich is really dominating.
Is the problem coming from thehand?
Is it coming from the neck?
Is it coming from both?
So when I give a cortisoneinjection and the patient tells
me that there's 70 to 80%improvement in their symptoms,
(34:39):
that tells me that most of theircarpal tunnel symptoms are
coming from the carpal tunnel.
If I do the injection and theytell me there's virtually no
improvement, that's a good signthat it's not carpal tunnel
syndrome and then you can moveon to other diagnoses.
The compression may be comingfrom the neck, it may be
somewhere else, but we can thinkit's less likely to be carpal
tunnel syndrome, so that's animportant thing to have.
(35:01):
Yeah, it's very important.
Robert A. Kayal, MD, FAAOS, (35:03):
And how about other modalities or
ancillary services like physicaltherapy, acupuncture, things
like that?
Edward Lin, MD (35:10):
So, absolutely so.
All of these things physicaltherapy, acupuncture are part of
the treatment, nonoperativetreatment of carpal tunnel
syndrome, and so there's a lotof benefit that can be had from
having a trained professionaltherapist work on your hand or
an acupuncturist work on yourhand to improve your symptoms
without doing surgery.
Right.
Robert A. Kayal, MD, FA (35:31):
Therapy .
You know why therapy?
Well, therapy can be employedto decrease inflammation and
swelling.
Sometimes there's significantswelling in the extremity, from
whatever reason.
It could be a fracture, itcould be other things that have
contributed to swelling, sotherapy can be employed to help
reduce that swelling.
So sometimes, when nerves arecompressed you already alluded
to the fact that there can besome weakness associated from
(35:54):
that nerve compression, becausethose nerves innervate muscles
and if the muscles are weak thenthey can atrophy and physical
therapy can often be employed totry to regain that strength and
function.
Why acupuncture?
Edward Lin, MD (36:08):
Well, acupuncture is a modality where
needles are placed into the handor into the body part.
It tends to work for a wholevariety of conditions.
We're not 100% sure why or howacupuncture does work, but I
have had patients come back andsay, wow, that acupuncture
really did help my carpal tunnelsymptoms, and so I encourage
(36:28):
patients to seek out acupunctureand physical therapy as
addition to modalities to helpthem, because if they can help
themselves and treat theircarpal tunnel without surgery,
then they've avoided the risksof surgery and the pain and
everything associated with that.
So that can be a useful tool.
Robert A. Kayal, MD, FAAOS (36:48):
Sure , a lot of these holistic
approaches and even naturalremedies have been found to be
helpful in some of theseneuropathies and nerve
compression syndromes.
Acupuncture has been shown tocause some microscopic trauma
which can increase some bloodflow and promote healing.
Some of the holistic medicinescan be used as well.
(37:09):
I know that Omega 3 fatty acidsand the vitamin B complex
antioxidants, things like thathave been helpful as well in the
treatment of some of thesepatients.
Edward Lin, MD (37:21):
Absolutely Vitamin B, in particular vitamin
B6, has been shown in somepapers to provide some benefit,
especially for people who arehaving nerve issues like carpal
tunnel.
Robert A. Kayal, MD, FAAOS, (37:32):
Now that we've diagnosed the
condition, we've tried to treatthem conservatively, whether it
be by anti-inflammatories orTylenol, or physical therapy,
acupuncture, holistic approaches, et cetera.
What if that fails, and howlong will you give the patients
in effort to recommend the nextline of care?
Edward Lin, MD (37:52):
So it really varies in terms of how severe
your carpal tunnel syndrome is.
So if you come in and you havesevere carpal tunnel syndrome,
either by the symptoms that youhave, by some of the testing we
can do we can test yoursensation in the office to see
if there's actual nerve damage.
There's a test called two-pointdiscrimination we can do in the
office to see how much nervedamage you have and that's a
(38:16):
very simple test we can do atthe bedside, based on your nerve
studies to see how severe yourcarpal tunnel is.
But if you have severe carpaltunnel syndrome, you really
should be looking to treat thatpatient operatively.
Meaning the window has passedfor nonoperative treatment and
we're having a discussion moreof how do we fix this surgically
.
(38:36):
For the mild to moderate carpaltunnel patients, I try to go for
at least three months ofnonoperative treatment,
including splinting andtendon-gliding exercises.
Having said that, you have tosee how you're doing so.
If a patient has tried this fora month or two and they're
saying it's getting worse, it'snot getting any better, that's
(38:56):
not a reason to continue for thethird month.
I think if you're tryingsomething and it's not working,
you have to change course, andso a lot of it just depends on
how the patient is doing and howthey're reporting their
symptoms to you.
Robert A. Kayal, MD, FAAOS, (39:10):
But what if you get an EMG nerve
conduction study and it alreadyshows that the carpal tunnel
syndrome is very severe andthere's associated muscle
atrophy and some very permanentchanges to that nerve?
What do you tell the patientand what do you do?
Edward Lin, MD (39:25):
Yes.
So in that case the nerve hasundergone severe permanent
damage and so there really isn'ta role for nonoperative
treatment, and so we're talkingmore about doing surgery to fix
that.
But even in cases where we dodo surgery for severe carpal
tunnel syndrome, the results arenot going to be as good as if
you do it for mild to moderate,and so in mild to moderate
(39:47):
carpal tunnel syndrome I wouldsay 90% of patients will get 90%
better.
But in severe cases thosenumbers are not as good.
And so there's a goodproportion of patients who, even
after carpal tunnel surgery,who have severe carpal tunnel,
who don't get better.
Or they feel better a littlebit, or it takes them a whole
(40:08):
year before their numbness andtingling goes away, or their
numbness and tingling goes awaypartially, but they always feel
a little bit numbness, and partof the reason is because even
after you release the carpaltunnel sometimes it's too late
the nerve has already hadpermanent damage, and patients
may continue to feel numbnessand tingling in the future.
Robert A. Kayal, MD, FAAOS, (40:28):
And my experience.
What I found, and when I hadthose conversations with those
patients, is that I sort of tellthem that I can't guarantee
that I'm going to help them getbetter or that they will recover
, and more than likely they willnot.
But what I have found is thateven in those patients, that
numbness and tingling that wakesthem up at night very often
(40:49):
goes away and that to them isone of the most rewarding things
because they get to enjoy, forthe most part, a good night's
sleep.
Obviously, the muscle atrophythat they are suffering from and
the numbness that theyexperience may never recover,
but the one thing that I havenoticed that most of them sleep
better at night and they don'twake up with that numbness and
(41:11):
tingling.
So it's important to have thoseconversations with patients
when it is very severe so thatwe can guide them properly and
set their expectations sothey're not disappointed when
that muscle atrophy doesn't comeback fully or maybe the
numbness does not fullydissipate.
But that just again drives homethat point that it's incumbent
(41:33):
upon us to see those patientsthe sooner the better and to
treat them before they havepermanent nerve damage and
muscle wasting.
Edward Lin, MD (41:42):
Yeah, I agree wholeheartedly, and one of the
things that I tell patients issometimes, even if you don't get
any better, an additional goalof the surgery is to prevent
them from getting worse, becauseif you do nothing and you allow
carpal tunnel syndrome toprogress, that nerve is just
going to get more and moredamaged over time.
It's almost a certainty.
And so if you let that happenand let that proceed, it's going
(42:04):
to get worse and worse andworse, to the point where you're
going to lose function of yourhand, and that's the worst thing
to say.
Robert A. Kayal, MD, FAAOS, F (42:09):
I tell them the same thing 100%
Okay, so we've decided to dosurgery that this patient needs.
Surgery has failed.
Nonoperative measures hasfailed to progress.
Still quite symptomatic.
What are the surgical options?
Edward Lin, MD (42:22):
So the surgical treatment for carpal tunnel
surgery is called the carpaltunnel release, and what we're
actually doing is we'relengthening that transverse
carpal ligament, which is thatthick ligament that sits on top
of the nerve.
It's pushing down on the nerve.
We're opening it up andcreating more room for the nerve
, and that's called the carpaltunnel release.
There are different ways to doit.
You can do it with an openprocedure, which is the
(42:46):
traditional way of doing it,where we do surgery and we open
up that ligament, eventuallythat ligament which, even if
it's open, really doesn't haveany effect on the function of
the hand.
So that ligament, if it's in alengthened position or if it's
divided, the hand will stillfunction just fine in that
condition and over time thatligament will heal back into a
(43:09):
less compressive condition.
So another way to do it isthere's something called an
endoscopic carpal tunnel release, where we use a small tiny
camera to go in and release theligament using a specialized
device through a very smallincision with the camera.
And then there are also variousother methods of doing it, but
those are the two main methods.
Robert A. Kayal, MD, FAAOS (43:30):
Both of them are done as an
outpatient.
Edward Lin, MD (43:32):
Right?
That's correct.
Yeah, the procedure itselftakes about anywhere from 10
minutes to 30 minutes and it'sdone as an outpatient, meaning
you go home, you have a softdressing on your hand and you're
going to keep it dry for thefirst few days after the surgery
.
You can move your handsimmediately after this.
Actually, I encourage patientsto move their hands immediately
after the surgery to preventscar tissue buildup, and most
(43:54):
patients are able to return towork pretty quickly.
Everyone's a little bitdifferent, but patients are able
to still use their hand.
It might be a little sore, butfor the most part, patients are
still functional after thisprocedure.
Robert A. Kayal, MD, FAAOS, F (44:07):
I liken carpal tunnel release to
some of the most rewardingsurgical procedures we do in the
field of orthopedics right Hipreplacement, shoulder
replacements.
Certainly carpal tunnelsyndrome and its release is
right up there with that.
When patients can't sleep,they're miserable and they're so
(44:28):
thankful and grateful to beable to get a good night's sleep
without having to wake uprepetitively with their hands
going numb, and it's often aninstantaneous level of
gratification that we appreciate.
I tell the patients todayyou're going to go to sleep and
you're going to sleep throughthe night.
They appreciate that reliefthat night, the night of the
(44:50):
surgery, and it's one of themost gratifying procedures, I'm
sure.
For you you're most successfuland most gratifying procedure,
I'm sure.
Edward Lin, MD (45:00):
I agree.
Personally, I love doing carpaltunnel releases for a variety
of reasons.
One is the patients do great.
It's one of the ways you canreally impact someone's life
instantaneously.
As you said, you can see whatthe problem is.
So I'm a visual person.
You can go in there and see thenerve being compressed and
(45:20):
being released, and so you knowexactly where the problem is,
you know how to fix it and theresults are great.
So it's a really rewarding andsatisfying procedure for sure.
Robert A. Kayal, MD, FAAOS (45:29):
Yeah , just like in the spine, a
severe case of spinal stenosiswhen a spine surgeon does a
lumbar decompression and freesup that nerve.
We all like to free up nerves.
When nerves get compressed,whether it's in the spine, in
the hand, in the neck, patientshurt, they suffer and it's a
really bad form of suffering.
(45:50):
It's one of the most painfulconditions you can have.
When a nerve is compressed,most debilitating.
It can have many, manydifferent consequences
neurological consequences,numbness, tingling, pain,
weakness, etc.
In all parts of the body andnerves don't like to be
compressed and so when youdecompress that nerve, patients
(46:12):
are very grateful and almostinstantaneously.
So it's an awesome surgicaloption for these patients and a
lot of them end up wondering whythey waited so long, because
it's such a minimally invasiveprocedure with such an
outstanding outcomeinstantaneous outcome that we
encourage you.
If you're suffering from thiscondition, wait no longer.
(46:33):
We have treatment alternativesavailable for you immediately.
Edward Lin, MD (46:38):
Yeah, and this is a procedure where people
often come with bilateral carpaltonal meaning in both hands, so
we can do one side and thenwait two weeks and do the other
side.
So it's something that thehealing is fairly quick and you
don't have to stop your life.
You don't have to stop doingwhat you're doing, other than
you do have to limit some of themajor sporting activities that
(47:00):
you're doing, but everyday lifethings that you're doing at home
, you can continue using yourhands for those.
Robert A. Kayal, MD, FAAOS, (47:04):
Is there any consideration given
for orthopedic biologicalregenerative medicine like
platelet-rich plasma injectiontherapy or anything like that
for carpal tunnel syndrome?
Edward Lin, MD (47:15):
Yeah.
So it kind of goes along withwhat we were talking about
before with the inflammation.
So with PRP, which isplatelet-rich plasma, which I'm
sure everyone has heard about.
The goal is really to reducethe inflammation.
So, just like doing a cortisoneinjection, you could consider
doing a PRP injection to helpreduce that inflammation and
help improve the symptomswithout surgery.
Robert A. Kayal, MD, FAAOS, (47:35):
So we've talked about the surgery
now.
Patients had the surgery.
They're home.
What's next?
Edward Lin, MD (47:41):
So usually after carpal tunnel surgery the
recovery is fairly quickcompared to other surgeries you
might have had.
We put on a soft dressing soyou're moving your wrist and
moving your hand.
Immediately after the surgeryyou come back and see us in the
office, usually within about aweek.
We check in the wound, makesure and everything is okay.
The incision itself issomething about there to there.
(48:03):
So it's just about that big foran open carpal tunnel surgery
and for endoscopic carpal tunnelsurgery the incision is
actually even smaller.
It's just about from here tothere.
It's about one centimeter and Ican perform both procedures.
Either procedure is anacceptable treatment.
I think there are pros and consto either modality and it
depends on the patient which onewe ultimately decide to pursue.
(48:27):
But the recovery is quick.
The stitches come out in about10 days.
Some patients will need therapyafterwards.
I would say the majority ofpatients don't necessarily need
therapy because a lot ofpatients come in and they have
great motion and a lot of themdon't want to go to therapy and
that's fine.
But if patients do, that'ssomething to consider as well
(48:47):
after surgery to improve theirstrength and improve the motion
of their fingers after thesurgery.
Robert A. Kayal, MD, FAAOS, (48:54):
So what about recurrent carpal
tunnel syndrome?
Is that something that canhappen, and if so, how can that
be treated?
Edward Lin, MD (49:02):
Sure.
So recurrent carpal tunnel doeshappen.
And by recurrent carpal tunnelsyndrome I'm talking about
someone who's had carpal tunnelrelease, whether endoscopically
or through an open procedure,and maybe a few months later,
maybe a year later, they havetheir symptoms in return and we
call that recurrent carpaltunnel syndrome because the
(49:23):
symptoms have come back despitehaving a successful surgery.
Usually they'll feel better fora period of time and then
slowly they'll find that theircarpal tunnel symptoms have come
back.
And in those patients, well,one thing it's really important
to make sure that they actuallydo have carpal tunnel syndrome.
Sometimes after surgery you mayfind that you still have
numbness and tingling becauseit's coming from the neck or
(49:43):
maybe you have some othercondition that's causing that.
But assuming you are dealingwith carpal tunnel syndrome, the
treatment for a recurrentcarpal tunnel syndrome is to do
a revision carpal tunnel release, and what that means is we go
back in there and we try to openup the nerve again and try to
release the compression that'scome back Now when I do that
(50:06):
procedure.
First of all, it's pretty rare.
The literature shows thatrecurrence occurs, depending on
the paper, anywhere from a fewpercent, meaning two or 3%.
Some papers show up to 20, 30%,but I think that's really
unlikely.
But I would say it's less than10% the risk of recurrence.
But when it does happen I willdo a revision.
(50:26):
Carpal tunnel procedure.
Now that procedure is a lotmore involved in the initial
procedure, meaning we have tomake a much bigger incision and
it's a bigger surgery becausewe're dealing with a lot more
scar tissue that was left behindby the first surgery.
You're definitely not doingthat endoscopically.
No, no, I would not recommenddoing that endoscopically.
And then, in addition, what Ido is I do what's called a
(50:50):
hypothyner fat flap, where Itake some fat from this area of
the hand and we move it acrossthe nerve and what that does is
that covers the nerve in a nicelayer of fat so that when it
does heal it prevents scartissue from forming around the
nerve and causing compressionagain.
But I would say that's a fairlyrare procedure.
In the most case, if you'vedone a carpal tunnel release,
(51:13):
the symptoms are not going tocome back.
Robert A. Kayal, MD, FAAO (51:15):
Right .
Well, this was a very helpfuland informative conversation, dr
Lin.
I hope that our viewingaudience found this to be the
same.
We hope they learned somethingabout carpal tunnel syndrome,
and if I can give you a takehome message, it's don't ignore
your symptoms.
Seek medical care, the soonerthe better, because it is a
(51:36):
condition that we can treat moresuccessfully when we see it
early and even with surgery ifyou need surgery outcomes will
be better when we address themilder to moderate symptoms as
opposed to the more severe andchronic conditions.
Any closing words, dr Lin?
Edward Lin, MD (51:54):
Yeah, I agree.
As I said, carpal tunnelsyndrome is one of the most
common things I see.
I see it day in and day out.
It can be very debilitating forpatients patients who come in
because your hands are soimportant.
Use your hands.
As surgeons, we appreciate thatvery personally, but people are
using their hands for a wholevariety of activities, whether
(52:15):
it be sporting, whether it be atthe job, whether it be taking
care of a loved one.
Your hands are so important andso it's important to take care
of your hands so that you cancontinue to use them for
everything you want out of life.
Robert A. Kayal, MD, FAAOS (52:30):
Well , we truly appreciate your skill
set and your education andtraining, your bedside manner,
and I'm honored to call you acolleague and physician at
Kailor Orthopedic Center.
Thank you for spending the timewith us and for educating our
population about carpal tunnelsyndrome.
All right, thank you, dr Kailor.
We appreciate it.
Pleasure is mine.
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