October 22, 2012

Shedding Light on Carpal Tunnel Syndrome
By Denise M. O’Neal
For The Record
Vol. 24 No. 19 P. 8

Carpal tunnel syndrome (CTS), a term frequently heard in the medical transcription community, carries a lot of weight within the profession, yet there are misconceptions about its origin, causes, and symptoms.

“This is a syndrome whereby a nerve that goes to the hand is simply pinched or compressed. The layman’s term would be ‘pinched nerve,’” says Mark S. Cohen, MD, an orthopedic surgeon at Rush University Medical Center in Chicago. “In medical terms, it’s a nerve that is being compressed or deformed. In this case, there is impingement or encroachment on the path of the nerve as it travels to the hand. The median nerve, which provides the sensation to the majority of the hand, courses through the palm and wrist within a closed space called the carpal tunnel, an anatomical pathway by which the nerve passes from the forearm to the hand. That pathway has a certain circumference and within that pathway travels the median nerve and the flexor tendons of the fingers. There is a canal with a given diameter that houses tendons and one soft structure, which is the median nerve. Carpal tunnel [syndrome] is simply a condition where the nerve does not have enough room during its passage from the forearm to the hand. It gets pinched, compressed, or flattened, if you will, within this anatomical constraint of the carpal tunnel.”

Fingering a Culprit
The common assumption is that the syndrome mainly affects people who do a lot of typing. Not so, Cohen says. “There is a lot of controversy in our field regarding the association of CTS and typing,” he explains. “It’s now clear that typing [related] activities don’t cause CTS. They may cause symptoms from CTS, meaning that during typing activities your fingers may tingle. This represents a manifestation of symptoms. However, manual labor jobs such as carpentry, meat packing, and people who use heavy vibratory tools are predisposed to the condition.”

If typing brings about only a manifestation of the symptoms, what causes CTS? “It’s the most common condition that leads people to see orthopedic hand surgeons,” Cohen says. “Most cases are what we term ‘idiopathic’ with no identifiable cause, but it’s clearly seen in certain medical conditions, such as diabetes mellitus, rheumatoid arthritis, hypothyroidism, and renal failure. It is not a cause, but it is also associated with smoking and … being overweight or obese. It is seen more commonly in women than in men and also seen in people of middle age and older as opposed to adolescents and individuals in their teenage years. Lastly, there is probably a hereditary component in some cases.”

Symptoms
Medical transcriptionists should be on the alert for various signs of CTS. “Typically, individuals state that they have tingling and numbness in their fingers; their hands fall asleep; and often they wake in the middle of the night with tingling,” Cohen says. “Also, it is not uncommon for people to report that their hands fall asleep when they drive or when they talk on the telephone. This occurs because driving and talking on the phone positions your wrists in an extended or flexed position, which closes down the actual carpal tunnel pathway. When you bend your wrists into flexion, you are essentially adding to the nerve compression. When you drive with your wrists back, again you are manually pinching the nerve. Occasionally, individuals report clumsiness or dropping of objects or difficulty with fine motor skills such as buttoning one’s shirt. These would be seen in more advanced stages of the condition.”

The symptoms would seem to provide telltale signs of something being amiss, yet medical transcriptionists and others will often ignore the messages. “Getting individuals educated about carpal tunnel syndrome is vital,” Cohen says. “Many people are actually scared of the tingling and numbness. Once they know it’s mainly a lifestyle condition and the tingling is not causing any damage when it occurs, it provides them a sense of relief.”

Treatment
Once diagnosed, returning the sufferer to full health depends largely on how advanced the condition is. “There are a lot of conservative treatments that are very useful. The first stage of treating someone with CTS, as long as they don’t have advanced disease, would be wearing a brace during sleep,” Cohen says. “This keeps the wrist in neutral [straight] alignment and allows for a maximum diameter of the carpal tunnel, leading to the least amount of nerve compression possible.”

For those who may have waited a bit longer to seek treatment, a shot in the arm may be necessary. “Individuals with significant symptoms can receive a cortisone injection into the carpal tunnel,” Cohen says. “This bathes the tendons and nerves, reducing inflammation and edema, thereby taking some of the pressure off of the nerve. The shot and night splint are curative in about one-third of patients with mild CTS.”

Severe cases may require surgery. A misconception making the rounds in the transcription industry is that choosing surgery may not lead to the desired results. “I think there is a lot of misinformation out there with respect to CTS,” Cohen says. “For people who have documented CTS, this is the most successful surgery that we perform—95% to 100% of the time it is a curative surgical procedure. We diagnose the condition with a history and physical examination, and occasionally one may need a nerve test to confirm the diagnosis. At Rush, many of us perform carpal tunnel surgery under local anesthesia as an outpatient. It takes between five and 10 minutes. You can eat breakfast, come in and have your surgery, and use your hand by the afternoon. I think the stories that you hear where people failed are often in individuals who were misdiagnosed and their symptoms are from other problems or conditions.”

Lend Yourself a Hand
For busy medical transcriptionists striving to earn more money and avoid backlogs, the keyboard is their friend. Although typing isn’t the source of CTS, the activity can exacerbate symptoms. Cohen says that because the syndrome is not something that improves with strengthening, movement, or stretching, there are no real exercises to help prevent CTS.

However, there are helpful measures to limit the condition’s impact. “Make sure your workstation is ergonomically correct. Your keyboard should not be too high or too low, leaving the wrists in a poor position during typing, such as flexion,” Cohen says.

Drugs are usually not much help, Cohen notes. “There are no medications that are helpful other than, although rare, vitamin B12, which can be beneficial for carpal tunnel [syndrome] symptoms in people with a B12 deficiency,” he says.
Nevertheless, employing the necessary lifestyle changes and listening to your body can help prevent CTS from becoming debilitating.

— Denise M. O’Neal is a 15-year veteran of the transcription industry and a freelance writer based in the Chicago area.