Numbness in the hands

04 April 2019

Article by: Dr Ravindran Thuraisingham Consultant Hand & Microsurgeon

What is the cause? Am I having a stroke? Am I having a heart attack…. These are the common questions patients ask when they experience numbness in the hand. There are numerous causes for numbness in the hands. One of the cause of numbness in the hand is nerve entrapment (compression). The nerve can be either compressed at the spine region in the neck or anywhere along the nerves in the upper limb. Carpal Tunnel Syndrome (CTS) is one of the common causes of nerve compression in the hand.

In carpal tunnel syndrome, there is pressure over the Median nerve in the hand. Patient normally experience numbness over the thumb, index, middle and ring fingers. The little finger is usually spared as it is supplied by a different nerve. In long standing cases, patients also might complain of weakness of the thumb causing them to have a tendency of dropping things while using the hand. The numbness can be worse during the night while sleeping and at times wakes them up from sleep. Frequently patients also complain of pain in the fingers in addition to the numbness. This is due to the compression causing lack of blood supply to the nerves. Patients usually find relief by shaking their hands vigorously.         

 Is it due to the type of food I’m consuming ? Is it because of my work? Do I have diabetes..... These are some of the concerns of the patients who have carpal tunnel syndrome. Patients with diabetes do have a higher risk of developing carpal tunnel syndrome but it does not mean that when a person has Carpal Tunnel Syndrome, he or she is necessarily diabetic. One the common cause of Carpal tunnel Syndrome is repetitive strain injury. It can be any form of repetitive strain to the hand, such as housework, prolong use of the computer, sports activities, playing a musical instruments continuously. The type of food is not a direct cause for Carpal tunnel Syndrome but severe malnourishment with lack of vitamins can affect the nerves in general.  

Once the patient is suspected to have Carpal tunnel Syndrome, a Nerve Conduction Test can be done to confirm the diagnosis and assess the severity. In early onset of symptoms or mild cases, a trial of non surgical treatment can be advocated. This includes use of a wrist splint, supplements, physiotherapy and a change or modification of activities. If symptoms still persist after 3 months of non surgical treatment, surgery will be advised. One of the main purpose of surgery is to prevent the condition from becoming worse. For moderate cases of Carpal tunnel Syndrome, surgery is the best option. In patients with severe Carpal tunnel Syndrome, surgery is still advised but the patient might not recover completely due to irreversible damage to the nerve.

Since the first carpal tunnel surgery in 1924 by Herbert Galloway, numerous advances have been made to refine this very common procedure. In general, carpal tunnel release can be performed using open or endoscopic procedures. The classic open carpal tunnel release technique involves complete division of the transverse carpal ligament and the deep fascia of the forearm under direct visualization. Most surgeons prefer the open technique due its lesser level of difficulty and shorter operative time. In the majority of patients, open release techniques lead to symptomatic relief with low complication rate. However, scar tenderness and grip weakness may occur after open release.

In an attempt to reduce postoperative morbidity, endoscopic technique was developed and has been evolving since the late 1980s. The two portal endoscopic carpal tunnel release utilize smaller incisions and require less dissection of the subcutaneous tissue and structures overlying the transverse carpal ligament. With endoscopic release techniques, there is less scar tenderness and earlier return to work and activities of daily living compared to the open procedure.

Since the introduction of Endoscopic carpal tunnel release (ECTR) in the 1980s, many studies have showed a high success rate for the procedure. Comparative clinical studies have showed that endoscopic carpal tunnel release resulted in less postoperative pain, faster recovery of grip and pinch strength, and earlier return to work compared with open methods.  Major controversy has ensued in the literature, however, regarding the safety, success, and, most importantly, the complication rate of this procedure. For a surgeon who is familiar with the endoscopic technique, the complication rate is equal to that of the open technique. However, there is a steep learning curve when the minimal invasive surgery is contemplated. ECTR may not be advisable for the surgeon who either performs it infrequently or is not well acquainted with arthroscopic techniques and hand anatomy.

After surgery the majority of the patients after the endoscopic procedure required minimal oral analgesics and were able to move the wrist joint immediately as the method is minimally invasive and permits early use of hand. Diminution of postoperative pain, early return to normal activities and work, smaller scar and less scar tenderness are the major benefits of a successful ECTR.

 

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