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Carpov canal wrist. Carpal tunnel syndrome (carpal tunnel syndrome)

Carpal tunnel syndrome is a pathological condition that occurs as a result of sedentary office work. Sedentary work can provoke the development of various disorders, from eye diseases to diseases of the musculoskeletal system.

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The site provides reference information. Adequate diagnosis and treatment of the disease is possible under the supervision of a conscientious doctor. Any medications have contraindications. Consultation with a specialist is required, as well as detailed study of the instructions! .

What is carpal tunnel syndrome

Carpal tunnel syndrome is a common neurological pathology.
It is characterized by compression of the median nerve, pain and shooting in the wrist.

This problem is more often encountered by people whose responsibilities include performing routine, monotonous work that involves constant flexion and extension of the wrist.

This pathology occurs when the tissues that surround the tendons swell and put pressure on the median nerve. These tissues are called synovial membranes. They produce a fluid that lubricates the tendons, facilitating their movement in the tendon sheaths.

There are factors that provoke the development of the disease:

  • Genetic predisposition;
  • Hormone imbalance;
  • Old age;
  • The presence of systemic diseases, for example, diabetes;
  • Profession;
  • Presence of bad habits: alcohol abuse, smoking;
  • Injury to the wrist, fracture of the hand;
  • The presence of tumors growing in the carpal tunnel area;
  • Overweight, obesity.

With a combination of these factors and constantly repeated stress on the hand, chronic inflammation of the connective tissue develops, it swells and thickens. At the same time, the amount of fluid produced by the synovial membranes decreases.


Constant friction of the connective tissues of the tendons during hand movements increases their swelling and leads to compression of the median nerve. This nerve contains fibers that provide sensitivity to the fingers and motor activity of the thumb.

Increased pressure between the tendon sheaths leads to venous stagnation. As a result of the action of these factors, the blood supply to the nerve is disrupted, and this disease develops.

Manifestations of carpal syndrome

One of the first signs of the disease is numbness in the hand area. Symptoms can appear at any time, and it does not matter where the person is. You can sit at the computer or lie on the sofa, hold an object in your hands or not - it doesn’t matter.

At any moment the following may appear:

  • Painful sensations in the hand;
  • Tingling in one or both wrists of varying intensity;
  • Feeling of swelling of fingers;
  • Numbness of hands;
  • Periodic “shots” in the fingers.

Moving your arms or changing their position reduces symptoms. At first, the manifestations of the syndrome are not clearly expressed; they appear and then disappear.

Over time, especially if a person does not seek help from doctors and does not take any measures, muscle atrophy may develop.

As the disease progresses, symptoms will be constant. Sleep disturbances, including insomnia, may occur.

Weakness and awkwardness provoke restrictions in performing the simplest daily manipulations. It is difficult for a person to tie his shoelaces or button his jacket. This will be reflected in your work in the future.

Video

Diagnosis of median nerve compression

To quickly eliminate the pathology, you need to consult a doctor.
A neurologist will conduct a survey and examination.

Additional examination methods include:

  • Electroneuromyography;
  • X-ray of the wrist joint;
  • Magnetic resonance imaging.

Seeing a doctor at the first signs of the syndrome helps to quickly identify the disease and recover.

Drug treatment of the disease

It will take a long time to treat this disease.

To eliminate the causes of carpal tunnel syndrome, the following groups of drugs are prescribed:

  • Anti-inflammatory;
  • Decongestants;
  • Painkillers;
  • Corticosteroids.
  • Diuretics to reduce swelling.

Medicines may be sufficient for a complete recovery, but only if contacting a specialist was timely. To get rid of carpal tunnel syndrome, in addition to treatment, you will need to change your occupation.

How to treat a disease with folk remedies

Traditional medicine methods will be effective and efficient only if they complement traditional drug treatment.
Without medications, folk remedies will bring temporary relief.

There is no need to self-medicate.
Before using a non-official medicine, consult your doctor.

Healing tincture will help eliminate pathology

You will need several pickles and vodka or medical alcohol. Chop the cucumbers, combine them with chopped red pepper, mix well. Fill the mixture with 500 milliliters of vodka. Refrigerate the container for fourteen days.

Filter the product and rub it into the affected area. This medicine helps normalize blood circulation and eliminate swelling.

Ledum

Pour apple cider vinegar over the dried, crushed branches of the plant. Seal the container tightly and leave for seven days in a cool, dry place. Rub this medicine onto your fingers.

Pumpkin will help in healing

Cut the pumpkin into small pieces, pour the raw materials into an enamel pan, add water and put on fire. Bring to a boil, cool slightly and grind the raw material to a pasty state.

Apply the prepared paste to the affected area, wrap it with compression paper on top and secure with a bandage. These warming procedures must be done once a day. The duration of treatment is seven days.

The use of salt and ammonia

Dilute a spoonful of table salt in two hundred milliliters of boiled, slightly cooled water. Combine this solution with ammonia and camphor alcohol.

Mix all the ingredients well and treat the affected joint with this remedy before going to bed. The medicine helps eliminate pain and numbness.

Black pepper and vegetable oil

Pour 100 grams of ground black pepper with a liter of vegetable oil. Place the mixture on the fire and wait until it boils.

Simmer over low heat for thirty minutes. Cool the product and rub it into sore fingers 2 times a day.

Parsley will relieve puffiness

Chop the parsley rhizomes and brew 20g of raw material in three hundred milliliters of boiled water. Place the container with the composition in the cold for ten hours. Take a sip of the medicine every 2 hours.

Preparation of a diuretic

Brew dry and crushed birch leaves, approximately 15 grams, in two hundred milliliters of boiled water. Leave the product in a dark, cool room for 4 hours. Drink 1/3 cup of infusion four times a day.

Surgical intervention for pathology

When all attempts to control and reduce symptoms have proven futile, surgery is performed to relieve pressure on the median nerve.

There are several different methods to reduce blood pressure.

But they have one thing in common - restoring the blood supply to the nerve and improving the patient’s condition.

Open surgery is one of the most common and effective. During surgery, an anesthetic is used, which causes a nerve block in a certain area of ​​the limb. A small incision is made in the palm of the affected limb, usually no more than five centimeters.


The surgeon's incision shows palmar fixation. The transverse carpal ligament is cut.

Only the skin is stitched, and the ends of the ligament remain free. This results in less pressure on the nerve. The space between the two ends of the ligament gradually fills with scar tissue.

This type of surgery is performed on an outpatient basis, and after its completion the patient can go home. The operation is effective and after 3-4 weeks the patient feels a noticeable improvement.

After surgery, it is important not to put stress on your arm and limit activities that require repetitive movements.

If you suddenly feel a slight ache or numbness in your limb, you may be developing carpal syndrome. Contacting a specialist at an early stage will eliminate the disease without resorting to surgery. If left untreated, the consequences will be disastrous, up to and including complete loss of function of the limb.

Nutritional Features

It is possible to get rid of the pathology only through drug treatment or surgery. But in order for treatment and postoperative rehabilitation to produce results, you still need to choose the right nutrition.

The carpal tunnel is located on the wrist, which is surrounded by a large number of bundles of fibrous tissue. These same bundles perform a supporting function for the joint. And most of all, calcium helps for healthy joints and tendons. The daily diet for carpal tunnel syndrome should include calcium-fortified foods, fresh vegetables and fruits.

Here's a sample list of such products:

  • Fermented milk products (cottage cheese, kefir, yogurt, cheese, etc.);
  • Pumpkin dishes;
  • Lean fish;
  • Legumes, cereals, pasta.

In addition to these products, it will be useful for such pathology to consume more ice cream; 100 grams of it contain up to 200 mg of calcium.

And it will be useful for such patients to often eat pizza with cheese and tomatoes, because with such ingredients, up to 800 mg of a substance necessary for joints was found in its composition.

Meals should be 4 or 5 times a day, that is, food should be consumed in small quantities and often so as not to overload the stomach. Now, let's talk about an approximate diet:

  1. Breakfast - pumpkin porridge, sandwich with cheese and sausage, tea with lemon.
  2. Second breakfast - kefir, oatmeal cookies and some fruit.
  3. Lunch - cabbage soup made from fresh white cabbage, boiled pasta with any lean fish, fresh vegetable salad, dried fruit compote, 1 orange.
  4. Afternoon snack - medium-fat cottage cheese, kefir.
  5. Dinner - boiled potatoes with fish cutlet, cheesecake with pumpkin, fresh berry compote and any fruit.

And remember that with such a problem, food should contain less salt. Highly salty foods retain water in the body, which leads to swelling of the limbs and wrists.

Gymnastics, massage, physiotherapy

If a person has a problem with the wrist, the doctor, in addition to drug treatment or surgery, may prescribe courses of exercise therapy, massage or physical therapy.

The goal of such treatment methods is to restore the function of joint mobility and give strength to atrophied muscles.

It happens that therapeutic exercises are prescribed together with electrical stimulation. Let's talk about some gymnastic exercises of 2 recovery stages.

First stage:

  1. We place our hand on the table. We make quick flexion and extension movements with all fingers, and then the same thing, only with each finger.
  2. We place our hand on the table surface. We hold the proximal phalanx in one position with the healthy hand, then quickly bend and straighten the interphalangeal joints.
  3. We place our elbows on the surface of the table, pressing our hands together and pointing upward. We bring our fingers together and spread them apart, but help with the non-sick hand.
  4. Using the pads of our fingers we reach different points of the same palm.
  5. In the next exercise, you need to try to grab objects of different sizes with the fingers of your affected hand.
  6. Using the fingers of your affected hand, roll a small ball on the table in different directions.

All these exercises should be done slowly and repeated up to 8 times.

This gymnastics can be done in the pool; the arm should be completely immersed in water up to the shoulder.

The second stage of gymnastics classes:

  1. We click our fingers on different objects, for example, on a soft pad, wood, ball, and so on.
  2. Pull the elastic bands onto your fingers.
  3. Throw or catch a small ball with the fingers of the affected hand.
  4. Throw the balls up.

And for such exercises to give the best results, you need to bandage your hand before going to bed. This ensures a quick recovery, facilitating the work process until the joint is fully functional.

And hand massage helps a lot during carpal tunnel syndrome.

It is carried out:

  1. First, place your hand in a relaxed position on the table, with the inside facing up. We touch with two fingers of our healthy hand the place where the pulse is felt and slowly tap, and then we grab this place with our healthy hand and make small turns.
  2. We place our hand on the table up to the elbow and stroke it with gentle movements, first from the outside, and then from the inside.
  3. Then you need to hang your sore arm slightly off the table, grab it with your healthy one and make quick circular movements in different directions.
  4. We place the hand on the table with the outer side up and use the index and middle fingers of the healthy hand.
  5. Then we hold the hand in the same position and do small pinching over the entire surface of the hand.
  6. At the end of the massage, gently stroke the hand on both sides.

And in addition to massage and gymnastic exercises, the attending physician sometimes prescribes physical treatment, which is selected for each individual patient, taking into account the advanced state of the disease and the nature of the nerve damage.

Such treatment can be carried out by magnetic therapy, laser therapy, interference pulse currents, ultrasound, and manual therapy. Physiotherapy, of course, is a good way to get rid of this problem, but it is not suitable for all people; due to the effects of different devices on the skin, some patients often experience allergies.

Consequences and complications

The disease does not pose a great danger to human life. But, if a person has pain in the wrist for a long time, this leads to a complete loss of strength and sensitivity in it.

And only proper treatment and daily exercises can improve the functioning of the hand.

And the consequences of this disease can only be severe damage to the median nerve and disruption of the hand.

Prevention of pathology

  1. Make a suitable desktop height. The normal height of the table should coincide with the level of the armrests of the chair; while working, the forearms should lie on the armrests and not hang.
  2. Create the desired monitor height so that the text you read or write is at eye level. If the monitor is very low, then you will constantly lower your head, and if the monitor is very raised, on the contrary, you will raise your head. This will excessively strain the neck muscles, which will worsen blood circulation in the cervical spine and worsen blood circulation in the arms.
  3. When working at a computer, sit so that your back fully touches the back of a chair or armchair and your shoulders are relaxed. Sit relaxed, do not pull your head into your shoulders.
  4. Work only with a comfortable mouse and keyboard. Choose a small computer mouse so that it can be completely covered by your hand. And the keyboard should have a stand so that the keys on it are slightly raised. Joystick-style computer mice are available for sale and are great for people with this wrist problem. Mice don't put any strain on your hand at all.

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The carpal canal is limited in depth by the volar surface of the radius, on the ulnar side by the hook of the hamate, on the radial side by the scaphoid bone, and superficially by the connection of a fairly dense transverse carpal ligament, the palmar aponeurosis and the fascia of the forearm.

IN carpal tunnel pass through nine tendons (the deep and superficial flexors of the four fingers and the long flexor of the first digit) and the median nerve.

Carpal tunnel syndrome refers to compression neuropathy of the median nerve at the wrist. Thus, the syndrome can develop against the background of any pathological conditions leading to increased pressure in the carpal tunnel, which include: mechanical irritation and swelling of any of the nine flexor tendons, the development of their tenosynovitis, swelling of the median nerve itself, anatomical changes and scarring in the tissues surrounding carpal tunnel, anomalies in the development of the lumbrical muscles, pathological formations of the carpal tunnel (deep ganglion cysts), compaction and contraction of the transverse carpal ligament.

Sir James Paget first described compression of the median nerve secondary to a fracture of the distal radius in 1854. Later, in 1880, James Putman, a neurologist from Boston, described similar symptoms in a group of patients.

Patient complaints

Patients with this pathology often have such characteristic symptoms as night pain and paresthesia, numbness in the area of ​​innervation of the median nerve distal to the wrist, and weakness of the muscles of the eminence of the first finger.

The doctor must have information about the family history and general somatic condition of the patient. The presence of congenital diseases or anomalies, connective tissue diseases, systemic and metabolic disorders and previous injuries should be taken into account distal forearm And wrist joint.

Diagnostics

Clinical examination is critical for accurate diagnosis. In acute cases, pain is detected along the carpal tunnel. Light percussion in the projection of the median nerve in the wrist area causes “electrical shootings” that spread into the zone of innervation of the median nerve, known as Tinel's sign(Tinel).

Phalen test(Phalen) is performed by bending the hands to the maximum and bringing them into full contact with the back surfaces in the so-called position “reverse to the position of the praying hands.” Carpal canal at the same time, it narrows and the test is considered positive if paresthesia appears in the fingers within 60 seconds. As the pathology progresses, the time to induce this symptom decreases.

Other studies include monofilament test, two-point discrimination test, reverse Phalen test And tourniquet test. In later stages, atrophy of the muscles of the eminence of the first finger can be observed. Muscle strength is determined subjectively by adducting the abducted first finger, overcoming the resistance provided by the examiner's second finger and comparing the result with the opposite side.

A carefully collected history and thorough examination help the doctor differentiate between isolated compression neuropathy at the wrist level and double crash syndrome. The clinical correlation of the double crash phenomenon is confirmed by the high incidence of carpal syndrome in patients with cervical radiculopathy. A high incidence of carpal tunnel syndrome has also been described in association with more proximal median nerve entrapment. Therefore, it is necessary to exclude syndromes of the superior thoracic outlet, pronator teres and pathology of the central nervous system.

Electromyography and electroneurography (ENG) help diagnose carpal tunnel syndrome. Indications for surgical treatment should not be set or changed based on the results of ENG, especially if its indicators are normal, but there are clinical signs of the syndrome. A slowing of the distal latency of the median nerve to 7.0 milliseconds or more indicates severe nerve compression. In this case, it is necessary to immediately decide on surgical intervention.

The most important diagnostic aspects carpal tunnel syndrome are a thorough history taking and clinical examination. Electrophysiological examination of the median nerve is an additional diagnostic method that allows one to confirm the presence of pathology and has prognostic significance for the results of surgical treatment.

X-ray of the wrist joint allows you to exclude possible congenital or acquired bone anomalies. Previous distal bone fractures should be taken into account forearms and bones wrists. Malunion of distal radius fractures, previous wrist procedures, and a hypo- or aplastic hamate hook may complicate the surgeon's work when using a slit cannula. Standard radiography is recommended wrist joint in anteroposterior, lateral and carpal projections.

If an extensive examination is indicated, MRI, CT, ultrasound scintigraphy or arthrography may be necessary.

Treatment

Conservative treatment consists of day or night splinting of the wrist joint, changes in daily physical activity, physical therapy, and oral nonsteroidal anti-inflammatory drugs. The effectiveness of intercarpal steroid injections varies according to the literature.

Surgical decompression was first introduced as a treatment option in 1933, followed by a classic paper published by Phalen in 1950. Since then, open carpal tunnel release has been established as the “gold standard” for surgical treatment of carpal tunnel syndrome.

Indications for surgical release of the transverse carpal ligament are well substantiated, and the intervention in most cases is endoscopic.

The advantages of endoscopic carpal tunnel release over open surgery include:

  • No massive scars or pain when standing
  • Less pronounced inhibition of grasping function
  • Shorter recovery period

Rehabilitation

Active movements begin immediately after the local anesthesia wears off. The patient is advised to avoid heavy lifting or pressure on the hand until the discomfort subsides, usually within 2-3 weeks.

Active finger movements reduce the formation of scar tissue in the wrist area, and thus prevent the adhesive process affecting the nerve and tendons in the intervention area. The stitches are removed after a week. If a patient begins strenuous physical activity, such as lifting weights, too early, this can lead to swelling and prolonged pain in the palmar area of ​​the hand. In such cases, myofascial release and infusion therapy help to cope with the problem.

Carpal tunnel syndrome(CTS [syn.: carpal tunnel syndrome, English. carpal tunnel syndrome]) - a complex of sensory, motor, vegetative symptoms that occurs when there is a malnutrition of the trunk (SN) in the area of ​​the carpal tunnel (CT) due to its compression and (or) overstretching, as well as violations of longitudinal and transverse sliding of the CH. According to Russian and foreign data, in 18 - 25% of cases of tunnel [in the occlusion] neuropathy, HF develops [ !!! ], which is characterized by positive (spontaneous pain, allodynia, hyperalgesia, dysesthesia, paresthesia) and negative (hypoesthesia, hypalgesia) symptoms in the zone of sensitive innervation of the median nerve. Untimely detection and treatment of CTS leads to irreversible loss of hand function and decreased quality of life, which determines the need for early diagnosis and treatment of CTS.

Anatomy
The ZK is an inelastic fibro-osseous tunnel formed by the carpal bones and the flexor retinaculum. In front, the ZC is limited by the retinaculum of the flexor tendons (retinaculum flexorum [syn.: transverse carpal ligament]), stretched between the tubercle of the scaphoid bone and the tubercle of the large trapezoid bone on the lateral side, the hook of the hamate bone and the pisiform bone on the medial side. The canal is limited at the back and sides by the carpal bones and their ligaments. The eight carpal bones articulate, forming together an arch, with a slight convexity facing back towards the back, and a concavity towards the palm. The concavity of the arch is more significant due to the bony projections towards the hand on the scaphoid bone on one side and the hook on the hamate bone on the other. The proximal part of the retinaculum flexorum is a direct continuation of the deep fascia of the forearm. Distally, the retinaculum flexorum passes into the fascia of the palm, which with a thin plate covers the muscles of the eminence of the thumb and little finger, and in the center of the palm is represented by a dense palmar aponeurosis, which passes distally between the thenar and hypothenar muscles. The average length of the carpal tunnel is 2.5 cm. The SN and nine digital flexor tendons pass through the carpal tunnel (4 - deep digital flexor tendons, 4 - superficial digital flexor tendons, 1 - flexor pollicis longus tendon), which pass to the palm, surrounded by synovial vaginas. The palmar sections of the synovial sheaths form two synovial bursae: the radial bursa (vagina tendinis m. flexorum pollicis longi), for the long flexor pollicis tendon, and the ulnar bursa (vagina synovialis communis mm. flexorum), common for the proximal sections of the eight tendons of the superficial and deep flexor digitorum. Both of these synovial sheaths are located in the carpal tunnel, enveloped in a common fascial sheath. Between the walls of the SG and the common fascial sheath of the tendons, as well as between the common fascial sheath of the tendons, the synovial sheaths of the flexor tendons of the fingers and the SN, there is subsynovial connective tissue through which the vessels pass. The SN is the softest and most ventrally located structure in the carpal tunnel. It is located directly under the transverse carpal ligament (retinaculum flexorum) and between the synovial sheaths of the flexor tendons of the fingers. The SN at the wrist level consists on average of 94% sensory and 6% motor nerve fibers. The motor fibers of the SN in the ZC region are predominantly united into one nerve bundle, which is located in most cases on the radial side, and in 15–20% of people, on the palmar side of the median nerve. Mackinnon S.E. and Dellon A.L. (1988) believe that if the motor bundle is located on the palmar side, it will be more prone to compression than if it is dorsal. However, the motor branch of HF has many anatomical variations that create great variability in the symptoms of carpal tunnel syndrome.


Before reading the rest of the post, I recommend reading the post: Innervation of the hand by the median nerve(to the site)

Etiology and pathogenesis

Please note! CTS is one of the most common peripheral nerve tunnel syndromes and the most common neurological disorder in the hands. The incidence of CTS is 150: 100,000 population; CTS most often occurs in women (5-6 times more often than in men) of middle and old age.

There are occupational and medical risk factors for the development of CTS. In particular, professional (exogenous) factors include a static position of the hand in a state of excessive extension in the wrist joint, characteristic of people who work at a computer for a long time (the so-called “office syndrome” [those users who, while working, are at greater risk with the keyboard, the hand is extended ≥ 20° or more relative to the forearm]). CTS can be caused by prolonged repetitive flexion and extension of the hand (for example, pianists, artists, jewelers). In addition, the risk of CTS is increased in people who work in low temperatures (butchers, fishermen, workers in fresh frozen food departments), with constant vibration movements (carpenters, road workers, etc.). It is also necessary to take into account genetically determined narrowing of the cerebral cortex and/or inferiority of the nerve fibers of the SN.

There are four groups of medical risk factors: [ 1 ] factors that increase intratunnel tissue pressure and lead to disruption of the water balance in the body: pregnancy (about 50% of pregnant women have subjective manifestations of CTS), menopause, obesity, renal failure, hypothyroidism, congestive heart failure and taking oral contraceptives; [ 2 ] factors that change the anatomy of the carpal tunnel: consequences of fractures of the wrist bones, isolated or in combination with post-traumatic arthritis, deforming osteoarthritis, dysimmune diseases, incl. rheumatoid arthritis (note: with rheumatoid arthritis, compression of the HF is observed early, so the development of rheumatoid arthritis should be excluded in every patient with CTS); [ 3 ] space-occupying formations of the median nerve: neurofibroma, ganglioma; [ 4 ] degenerative-dystrophic changes in the median nerve that occur as a result of diabetes mellitus, alcoholism, hyper- or vitamin deficiency, contact with toxic substances. [ !!! ] Elderly patients are often characterized by a combination of the above factors: heart and kidney failure, diabetes mellitus, deforming osteoarthritis of the hands. A decrease in physical activity in old age often contributes to the development of obesity, one of the risk factors for the development of compressive neuropathy HF (Evidence Level A).

Please note! Despite the fact that there are several dozen local and general factors contributing to the development of the syndrome, the majority of researchers come to the conclusion that the primary cause of provocation of CTS is chronic trauma to the wrist joint and its structures. All this contributes to the development of aseptic inflammation of the neurovascular bundle in a narrow canal, leading to local swelling of the fatty tissue. Edema, in turn, provokes even greater compression of anatomical structures. Thus, a vicious circle is completed, which leads to progression and chronicity of the process (Chronic or repeated compression of the HF causes local demyelination, and sometimes degeneration of HF axons).

Please note! Possible double crush syndrome, first described by A.R. Upton and A.J. McComas (1973), which consists in compression of the SN in several areas of its length. According to the authors, in most patients with CTS, the nerve is affected not only at the level of the wrist, but also at the level of the cervical nerve roots (spinal nerves). Presumably, compression of an axon at one location makes it more sensitive to compression at another, more distal location. This phenomenon is explained by a violation of the axoplasmic flow in both the afferent and efferent directions.

Clinic

In the initial stages of CTS, patients complain of morning numbness of the hand(s) [more pronounced in the first three fingers of the hand], daytime and nighttime paresthesia in these areas (decreased by shaking the hand)). It should be noted that in STS, sensory phenomena are predominantly localized in the first three (partially in the fourth) fingers of the hand, since the sign of the hand up to the fingers (palm) receives sensitive innervation from the branch of the SN, which passes outside the STS. Against the background of sensitivity disorders, there are motor disorders such as sensitive apraxia, especially pronounced in the morning after waking up, in the form of disorders of fine purposeful movements, for example, it is difficult to unbutton and fasten buttons, lacing shoes, etc. Subsequently, patients develop pain in the hand and fingers I, II, III, which at the beginning of the disease can be dull, aching in nature, and as the disease progresses they intensify and acquire a burning character. Pain can occur at different times of the day, but more often accompanies attacks of nocturnal paresthesia and intensifies with physical (including positional) stress on the hands. Due to the fact that the HF is a mixed nerve and combines sensory, motor and autonomic fibers, a neurological examination in patients with compression-ischemic neuropathy of the HF at the wrist level may reveal clinical manifestations corresponding to damage to certain fibers. Sensitivity disorders are manifested by hypalgesia and hyperpathy. A combination of hypo- and hyperalgesia is possible, when in some areas of the fingers zones of increased, and in others - zones of decreased perception of pain stimuli are found ( please note: As with the other most common compression syndromes, the clinical picture may rapidly or slowly worsen or improve over time). Movement disorders in carpal tunnel syndrome manifest themselves as decreased strength in the muscles innervated by the median nerve (abductor brevis of the first finger, superficial head of the flexor brevis of the first finger), and atrophy of the muscles of the eminence of the first finger. Autonomic disorders manifest themselves in the form of acrocyanosis, changes in skin trophism, impaired sweating, a feeling of coldness in the hand during attacks of paresthesia, etc. Of course, the clinical picture in each patient may have some differences, which, as a rule, are only variations of the main symptoms.
Please note! It is necessary to remember about the possibility of the patient having a Martin-Gruber anastomosis (AMG) - anastomosis from the SN to the ulnar nerve [UL] (Martin-Gruber anastomosis, median-to-ulnar anastomosis in the forearm). If the anastomosis is directed from the FN to the SN, it is called Marinacci anastomosis, ulnar-to-median anastomosis in the forearm.


AMG provides [ !!! ] significant impact on the clinical picture of lesions of the peripheral nerves of the upper limb, making it difficult to make a correct diagnosis. If there is a connection between the SN and LN, the classic picture of damage to a particular nerve may become incomplete or, conversely, redundant. Thus, when the SN is affected in the forearm distal to the origin of the AMH, for example with CTS, the symptoms may be incomplete - the strength of the muscles that are innervated by the fibers passing as part of the anastomosis does not suffer, in addition, in the case of the presence of sensory fibers as part of the connection, sensitivity disorders may do not occur or be expressed insignificantly. In the case of damage to the FN distal to the site of attachment of the AMH, the clinic may become redundant, since in addition to the own fibers of the FN, the fibers that come through this connection from the SN are affected (which can contribute to a false diagnosis of CTS). In this case, in addition to the clinical manifestations of FN damage, weakness of the muscles innervated through the HF anastomosis may additionally occur, as well as in the case of the presence of sensory fibers in the anastomosis - sensitivity disorders characteristic of HF damage. Sometimes the anastomosis itself can be an additional potential site of injury due to compression from adjacent muscles.

read also the post: Martin-Gruber anastomosis(to the site)

Characterizing the course of the disease, many authors distinguish two phases: irritative (initial) and the phase of loss of sensory and motor disorders. R. Kriszh, J. Pehan (1960) distinguish 5 stages of the disease: 1st - morning numbness of the hands; 2nd - night attacks of paresthesia and pain; 3rd - mixed (night and daytime) paresthesia and pain, 4th - persistent sensory impairment; 5th - motor disorders. Subsequently, Yu.E. Berziniš et al. (1982) somewhat simplified this classification and proposed to distinguish 4 stages: 1st - episodic subjective sensations; 2nd - regular subjective symptoms; 3rd - sensitivity disorders; 4th - persistent motor disorders. In addition to the classifications presented above, which are based only on clinical manifestations and objective examination data, a classification has been developed that reflects the degree of damage to the nerve trunks and the nature of the manifestation of neuropathies.

Based on the International Classification of the degree of damage to the nerve trunk (according to Mackinnon, Dellon, 1988, with additions by A.I. Krupatkina, 2003), neuropathies are divided according to the severity of compression: degree I (mild) - intraneural edema, in which transient paresthesia is observed, an increase in vibration sensitivity threshold; there are no movement disorders or mild muscle weakness is observed, symptoms are inconsistent, transient (during sleep, after work, during provocative tests); II degree (moderate) - demyelination, intraneural fibrosis, increased threshold of vibration and tactile sensitivity, muscle weakness without atrophy, transient symptoms, no permanent paresthesias; III degree (severe) - axonopathy, Wallerian degeneration of thick fibers, decreased innervation of the skin up to anesthesia, atrophy of the muscles of the eminence of the thumb, paresthesia is permanent. When formulating a clinical diagnosis, V.N. Stock and O.S. Levin (2006) recommend indicating the degree of motor and sensory defects, the severity of the pain syndrome, the phase (progression, stabilization, recovery, residual, in case of remitting course - exacerbation or remission).

Diagnostics

Diagnosis of STS includes: [ 1 ] medical history, including any medical problems, illnesses, injuries the patient has had, current symptoms, and an analysis of daily activities that may cause these symptoms; [ 2 ] hand diagrams (the patient fills out a diagram of his hand: in which places does he feel numbness, tingling or pain); [ 3 ] neurological examination and provocation tests: [ 3.1 ] Tinel test: tapping the wrist with a neurological hammer (above the site of passage of the heart failure) causes a tingling sensation in the fingers or pain radiating (electrical shooting) to the fingers (pain can also be felt in the area of ​​tapping); [ 3.2 ] Durkan test: compression of the wrist in the area where the HF passes causes numbness and/or pain in the 1st - 3rd, half of the 4th fingers (as with Tinel’s symptom); [ 3.3 ] Phalen test: flexion (or extension) of the hand 90° leads to numbness, tingling or pain in less than 60 seconds (a healthy person can also develop similar sensations, but not earlier than after 1 minute); [ 3.4 ] Gillett's test: when the shoulder is compressed with a pneumatic cuff, pain and numbness occur in the fingers (note: in 30 - 50% of cases, the described tests give a false positive result); [ 3.5 ] Holoborodko test: the patient is opposite the doctor, the patient’s hand is held palm up, the thumb of the doctor’s hand is placed on the eminence of the thenar muscles, the 2nd finger of the doctor rests on the 2nd metacarpal bone of the patient, the thumb of the doctor’s other hand rests on the eminence of the hypothenar muscles, 2 The doctor’s 4th finger rests on the patient’s 4th metacarpal bone; At the same time, a “collapsing” movement is performed, stretching the transverse carpal ligament and briefly increasing the cross-sectional area of ​​the wrist, while a decrease in the intensity of the manifestations of SN neuropathy is observed for several minutes.

If CTS is suspected, it is necessary [ !!! ] carefully study the sensitivity (pain, temperature, vibration, discrimination) in fingers I - III, then evaluate the motor activity of the hand. They mainly examine the flexor pollicis longus, the abductor pollicis brevis muscle, and the opponensus muscle. An opposition test is performed: with severe thenar weakness (which occurs at a later stage), the patient cannot connect the thumb and little finger; or the doctor (researcher) can easily separate the patient’s closed thumb and little finger. It is important to pay attention to possible autonomic disorders.

read also: article “Validation of the Boston Carpal Tunnel Questionnaire in Russia” by D.G. Yusupova et al. (magazine “Neuromuscular Diseases” No. 1, 2018) [read]

The “gold standard” for instrumental diagnostics is electroneuromyography (ENMG), which allows not only to objectively examine nerves, but also to assess the prognosis of the disease and the severity of CTS. MRI is usually used to determine the location of nerve compression after unsuccessful surgical interventions on the carpal tunnel and as a method of differential diagnosis in cases with questionable symptoms, as well as to diagnose space-occupying formations of the hand. MRI allows visualization of the ligamentous, muscular apparatus, fascia, and subcutaneous tissue.

One of the methods that allows you to visualize the structure of the nerve in CTS is ultrasound, which allows you to visualize the SN and surrounding structures, which helps to identify the causes of compression. For diagnosing HF lesions at the GC level, the following indicators are reliably significant (Senel S. et al., 2010): [ 1 ] increase in the cross-sectional area of ​​the SN in the proximal part of the CC (≥0.12 cm²); [ 2 ] reduction in the cross-sectional area of ​​the SN in the middle third of the GC; [ 3 ] change in the echostructure of the SN (disappearance of internal division into bundles), visualization of the SN before entering the SG during longitudinal scanning in the form of a cord with an uneven contour, reduced echogenicity, homogeneous echostructure; [ 4 ] identification, using color-coded techniques, of the vascular network inside the nerve trunk and additional arteries along the SN; [ 5 ] thickening of the tendon retinaculum ligament (≥1.2 mm) and increasing its echogenicity. Thus, when scanning the SN, the main ultrasound signs of the presence of compression-ischemic CVS ​​are: thickening of the SN proximal to the carpal tunnel, flattening or reduction in the thickness of the SN in the distal part of the CS, a decrease in the echogenicity of the SN before entering the CS, thickening and increased echogenicity of the flexor retinaculum ligament.


X-ray examination of the hands with CTS carries [ !!! ] limited information content. It acquires primary importance in cases of injuries, systemic connective tissue diseases, and osteoarthritis.

Treatment

Conservative and surgical treatment of CTS is possible. Conservative treatment is recommended for patients with mild disease, mainly in the first six months from the onset of symptoms. It includes splinting and wearing an orthosis (in a neutral position of the hand; it is usually recommended to immobilize the hand during night sleep for 6 weeks, but some studies have demonstrated the high effectiveness of wearing a splint/orthosis during the day), as well as injections of glucocorticoids (GC) into the GCs, which reduce inflammation and swelling of the tendons (however, GCs have a detrimental effect on tenocytes: they reduce the intensity of collagen and proteogligan synthesis, which leads to tendon degeneration). According to the recommendation of the American Association of Orthopedic Surgeons (2011), HA injections are performed between 2 and 7 weeks from the onset of the disease. Due to the risk of developing an adhesive process in the canal, many specialists do no more than 3 injections with an interval of 3 to 5 days. If there is no improvement according to clinical and instrumental data, surgical treatment is recommended. The effectiveness of the use of NSAIDs, diuretics and B vitamins, physiotherapeutic treatment, manual therapy and reflexology has not been proven (level of evidence B).

Surgery for CTS involves decompression (reducing pressure in the CTS area) and reducing compression of the CTS by cutting the transverse carpal ligament. There are three main methods of HF decompression: classic open access, minimally invasive open access technique (with minimal tissue dissection - about 1.5 - 3.0 cm) and endoscopic surgery. All of them are aimed at effective decompression of the HF in the canal by completely cutting the carpal ligament. Endoscopic decompression is as effective as the open technique of cervical surgery. The advantages of endoscopic HF decompression over open decompression methods are a smaller postoperative scar and less severe pain, however, due to limited access, the risk of injury to a nerve or artery increases. Factors influencing the outcome of the operation are: older age of patients, constant numbness, the presence of subjective weakness of the hand, thenar muscle atrophy, the presence of diabetes mellitus, stage III CTS.

read also the article “Immediate and long-term results of decompression of the median nerve in carpal tunnel syndrome” Gilweg A.S., Parfenov V.A., Evzikov G.Yu.; Federal State Autonomous Educational Institution of Higher Education “First Moscow State Medical University named after. THEM. Sechenov" Ministry of Health of the Russian Federation, Moscow (magazine "Neurology, neuropsychiatry, psychosomatics" No. 3, 2018) [read]

Read more about SZK in the following sources:

article “Carpal tunnel syndrome: anatomical and physiological basis for manual therapy” by A.V. Stefanidi, I.M. Dukhovnikova, Zh.N. Balabanova, N.V. Balabanova; Irkutsk State Medical Academy of Postgraduate Education, Irkutsk (magazine “Manual Therapy” No. 1, 2015) [read];

article “Diagnostics and treatment of carpal tunnel syndrome” Pilgun A.S., Shernevich Yu.I., Bespalchuk P.I.; Belarusian State Medical University, Department of Traumatology and Orthopedics, Minsk (magazine “Innovations in Medicine and Pharmacy” 2015) [read];

article “Carpal (carpal) tunnel syndrome” by A.A. Bogov (Jr.), R.F. Masgutov, I.G. Khannanova, A.R. Gallyamov, R.I. Mullin, V.G. Topyrkin, I.F. Akhtyamov, A.A. Gods; Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan; Kazan (Volga Region) Federal University, Kazan; Kazan State Medical University, Kazan (magazine “Practical Medicine” No. 4, 2014) [read];

article “Carpal Tunnel Syndrome (Literature Review)” Khalimova A.A., Rakhat Medical Center, Almaty, Kazakhstan (magazine “Bulletin of AGIUV” special issue, 2013) [read];

article “Carpal tunnel syndrome in old age” by A.S. Gilweg, V.A. Parfenov; First Moscow State Medical University named after. THEM. Sechenov (Doctor Ru magazine No. 1, 2017) [read];

article “Carpal tunnel syndrome in the postpartum period” by I.A. Strokov, V.A. Golovacheva, N.B. Vuytsik, E.A. Mershina, A.V. Farafontov, I.B. Filippova, V.E.Sinitsyn, G.I.Kuntsevich, G.Yu.Ezikov, Z.A. Suslina, N.N. Yakhno; Department of Nervous Diseases of the First Moscow State Medical University named after. THEM. Sechenov; Center for Radiation Diagnostics of the Federal State Budgetary Institution "Treatment and Rehabilitation Center" of the Ministry of Health of the Russian Federation; FSBI "Scientific Center of Neurology" RAMS, Moscow (Neurological Journal, No. 3, 2013) [read];

article “Carpal tunnel syndrome in rheumatic diseases” E.S. Filatova; FSBI "Research Institute of Rheumatology named after. V.A. Nasonova" RAMS, Moscow (magazine "Neuromuscular diseases" No. 2, 2014) [read];

article “Possibilities of ultrasound examination in the diagnosis of carpal tunnel syndrome” by E.R. Kirillova, Kazan State Medical University of the Ministry of Health of the Russian Federation, Kazan (magazine “Practical Medicine” No. 8, 2017) [read] (additional literature);

article “Changes in the cross-sectional area of ​​the median nerve at various stages of carpal tunnel syndrome” Maletsky E.Yu., Aleksandrov N.Yu., Itskovich I.E., Lobzin S.V., Villar Flores F.R.; GBOU HPE North-Western State Medical University named after. I.I. Mechnikova, St. Petersburg (magazine “Medical Visualization” No. 1, 2014) [read];

article “Study of tactile sensitivity using Semmes-Weinstein monofilaments in patients with carpal tunnel syndrome and healthy individuals” I.G. Mikhailyuk, N.N. Spirin, E.V. Salnikov; State Healthcare Institution of the Yaroslavl Region “Clinical Hospital No. 8”, Yaroslavl; State Budgetary Educational Institution of Higher Professional Education "Yaroslavl State Medical Academy" of the Ministry of Health of the Russian Federation (magazine "Neuromuscular Diseases" No. 2, 2014) [read];

article “Modern methods for diagnosing carpal tunnel syndrome” by N.V. Zabolotskikh, E.S. Brileva, A.N. Kurzanov, Yu.V. Kostina, E.N. Ninenko, V.K. Bazoyan; FPC and teaching staff of the State Budgetary Educational Institution of Higher Professional Education of the Kuban State Medical University of the Ministry of Health of the Russian Federation, Krasnodar; Research Institute-KKB No. 1 named after. prof. S.V. Ochapovsky MZ KK, Krasnodar (magazine “Kuban Scientific Medical Bulletin” No. 5, 2015) [read];

article “Electroneuromyography in the diagnosis of carpal tunnel syndrome” by N.G. Savitskaya, E.V. Pavlov, N.I. Shcherbakova, D.S. Yankevich; Scientific Center of Neurology of the Russian Academy of Medical Sciences, Moscow (journal “Annals of Clinical and Experimental Neurology” No. 2, 2011) [read];

article “Dynamic carpal tunnel syndrome: manual muscle testing to determine the level and cause of median nerve damage” by A.V. Stefanidi, I.M. Dukhovnikova; Irkutsk State Medical Academy of Postgraduate Education, Irkutsk (magazine “Manual Therapy No. 2, 2016) [read];

article “Use of local administration of corticosteroids in the treatment of carpal tunnel syndrome” by V.N. Kiselev, N.Yu. Alexandrov, M.M. Korotkevich; FSBI All-Russian Center for Emergency and Radiation Medicine named after. A.M. Nikiforova" EMERCOM of Russia, St. Petersburg; Federal State Budgetary Educational Institution of Further Professional Education "North-Western State Medical University named after. I.I. Mechnikov" Ministry of Health of the Russian Federation, St. Petersburg; Russian Research Neurosurgical Institute named after. prof. A.L. Polenova (branch of the Federal State Budgetary Institution "National Medical Research Center named after V.A. Almazov" of the Ministry of Health of the Russian Federation), St. Petersburg (magazine "Nerve-muscular diseases" No. 1, 2018) [read];

article “Treatment of carpal tunnel syndrome (tunnel compression mononeuropathy of the median nerve)” by M.G. Bondarenko, teacher of massage and physical therapy, GBOU SPO Kislovodsk Medical College of the Ministry of Health of the Russian Federation (magazine “Massage. Body Aesthetics” No. 1, 2016, con-med.ru) [read];

article “Carpal tunnel syndrome: current state of the issue” by A.V. Baitinger, D.V. Cherdantsev; Federal State Budgetary Educational Institution of Higher Education "Krasnoyarsk State Medical University named after. Professor V.F. Voino-Yasenetsky" Ministry of Health of the Russian Federation, Krasnoyarsk; ANO "Research Institute of Microsurgery", Tomsk (magazine "Issues of Reconstructive and Plastic Surgery" No. 2, 2018) [read];

article “Issues of diagnosis and treatment of carpal tunnel syndrome” Gilweg A.S., Parfenov V.A., Evzikov G.Yu.; Federal State Autonomous Educational Institution of Higher Education “First Moscow State Medical University named after. THEM. Sechenov" Ministry of Health of the Russian Federation, Moscow (journal "Neurology, neuropsychiatry, psychosomatics" 2019, Appendix 2) [read]

Carpal tunnel syndrome (CTS) is caused by nerve compression and irritation in the wrist, resulting in pain, numbness, tingling and/or weakness in the wrist and hand. Repeated sprains and fractures, unusual wrist anatomy, arthritis, and certain other conditions can reduce the space in the carpal tunnel, thereby increasing the risk of CTS. Associated symptoms can often be treated at home, but sometimes medical attention is required for complete recovery.

Steps

Part 1

Treatment of CTS at home

    Try not to pinch the median nerve. The carpal tunnel is a narrow tunnel made up of small bones in the wrist, connected by ligaments. This channel protects nerves, blood vessels and tendons. The main nerve responsible for the movements of the palm and its sensitivity is called the median nerve. Therefore, you should avoid activities that lead to pinching and irritation of the median nerve, such as frequent bending of the hand at the wrist, lifting heavy objects, sleeping with curved wrists, and punching hard surfaces.

    • Make sure your watches and bracelets fit loosely on your wrist; if they are too tight, they can irritate the median nerve.
    • In most cases of CTS, it is difficult to identify a single cause. Typically, CTS is caused by a combination of factors, such as frequent wrist strain coupled with arthritis or diabetes.
    • The anatomy of the wrist can also contribute - in some people the bones of the carpal tunnel at or do not have the correct shape.

  1. Stretch your wrists regularly. Daily wrist stretching can help reduce the symptoms of CTS or get rid of them altogether. In particular, wrist stretches help expand the space available for the median nerve within the carpal tunnel because it stretches the ligaments surrounding the tunnel. The best way to stretch both wrists at the same time is to assume a “praying pose.” Place your palms together about 6 inches from your chest and lift your elbows until you feel a stretch in both wrists. Hold this position for 30 seconds, then lower your elbows again. Repeat the exercise 3-5 times a day.

    Shake your palms. If you feel numbness or aching pain in one or both palms (or wrists), shake them thoroughly for 10-15 seconds, as if shaking water from them. By doing this, you will achieve quick, albeit temporary, improvement. This shaking will stimulate circulation and improve blood flow to the median nerve, causing symptoms to temporarily disappear. You can do this type of exercise, which helps combat the symptoms of CTS, many times a day, just taking a few seconds off from your work.

    • Symptoms of CTS most often appear (and first appear) in the thumb, index and middle fingers, as well as part of the ring finger. This is why people with CTS seem clumsy and often drop things.
    • Only the little finger is not affected by CTS symptoms because it is not connected to the median nerve.

  2. Wear a special wrist support bandage. This semi-rigid brace or splint will help you avoid the symptoms of CTS throughout the day by keeping your wrist in a natural position and preventing it from bending too much. A wrist splint or brace should also be worn during activities that may aggravate CTS symptoms, such as computer work, carrying heavy bags, driving, or bowling. Wearing a support bandage while you sleep can help prevent nighttime symptoms, especially if you have a habit of tucking your hands under your body while you sleep.

    • You may need a support bandage for several weeks (day and night) to noticeably reduce the symptoms of CTS. However, in some cases, the support bandage has a negative effect.
    • Wearing wrist splints is also helpful if you have CTS and are pregnant, since your palms (and feet) are more likely to swell during pregnancy.
    • Wrist supports and splints can be purchased at a pharmacy or medical supply store.

  3. Consider changing the position in which you sleep. Some postures can significantly worsen the symptoms of CTS, which reduces sleep duration and quality. The worst posture is one in which your fists are tightly clenched and/or your palms (with curved wrists) are tucked under your body; The posture in which the arms are above the head is also unfavorable. Instead, try sleeping on your back or side with your arms close to your body, wrists straight, and palms open. This position will ensure normal blood circulation in the wrists and blood supply to the median nerve.

    • As noted above, using support bands while sleeping can help prevent hand and wrist misalignment, but it will take some getting used to.
    • Avoid sleeping on your stomach with your arms under the pillow, as this will cause your wrists to become pinched. People sleeping in this position often experience numbness and tingling in their palms upon awakening.
    • Most wrist supports are made of nylon and have Velcro fastening, which can irritate your skin. In this case, place a sock or piece of thin cloth under the bandage to reduce skin irritation.

  4. Take a closer look at your workplace. In addition to poor sleep posture, symptoms of CTS can be caused or exacerbated by poor workplace design. If your computer keyboard, mouse, desk, or chair is positioned poorly and without consideration for your height and body type, it can cause tension in your wrists, shoulders, and mid-back. Make sure the keyboard is positioned in such a way that you don't have to bend your wrists all the time when typing. Buy an ergonomic keyboard and mouse designed to reduce stress on your hands and wrists. Your employer may cover the costs.

    Take over-the-counter medications. Symptoms of CTS are often associated with inflammation and swelling in the wrist, which further irritates the median nerve and adjacent blood vessels. Therefore, non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin, Advil) or naproxen (Aleve) are often helpful in reducing the symptoms of CTS, at least in the short term. You can also take painkillers such as paracetamol (Tylenol, Panadol) to relieve pain caused by CTS, but they do not reduce inflammation and swelling.

    Part 2

    Medical care for CTS

    1. Make an appointment with your doctor. If you experience the symptoms listed above in your wrist/hand for several weeks or more, you should see a doctor. Your doctor will examine you and likely order x-rays and blood tests to rule out possible diseases and injuries that have symptoms similar to CTS, such as rheumatoid arthritis, osteoarthritis, diabetes, a stress fracture in the wrist, or blood vessel problems.

      Visit a physical therapist or massage therapist.

      Try corticosteroid injections. To relieve pain, inflammation, and other symptoms of CTS, your doctor may recommend injections of a corticosteroid drug (such as cortisone) into your wrist or heel of your hand. Corticosteroids are a powerful, fast-acting medication that can relieve swelling in the wrist and relieve pressure on the median nerve. They can also be taken orally, but this is considered much less effective than injections and also causes more severe side effects.

      • Other steroid medications such as prednisolone, dexamethasone, and triamcinolone are also used in the treatment of CTS.
      • Corticosteroid injections can lead to complications such as local infection, excessive bleeding, weakening of tendons, muscle wasting, and nerve damage. Therefore, they are usually done no more than twice a year.
      • If steroid injections do not significantly improve the condition, surgery should be considered.

    2. Carpal tunnel surgery should be considered as a last resort. If other treatments have failed to relieve the symptoms of CTS, your doctor may recommend surgery. Surgery is only used as a last resort because there is a risk of making the situation worse, although for many patients surgery helps to completely relieve the symptoms of CTS. The purpose of this surgery is to relieve pressure on the median nerve by cutting the main ligament that is pressing on it.

V.V. Tolkachev, V.S. Tolkachev (Point of View)

The most common disease of the hands, which can lead to partial or complete disability, is carpal tunnel syndrome (CTS), or, as it is often called, carpal tunnel syndrome. More than 75 million people worldwide suffer from this disease, mostly in industrialized countries. (Karjalainen A., Niederlaender E. 2004). The peak incidence rate occurs in people 35-60 years old, i.e. in the risk group, people of working age (Popelyansky Ya.Yu. 2003). The problem is 3-5 times more common among women than among men (Berzins Yu. E., 1989). The cause of CTS has not yet been established.

Most researchers are of the opinion that the root cause of the disease is long hours of work with monotonously repeated movements of the hands. Such work has a constant, mechanically traumatic effect on the area of ​​the wrist joint and carpal tunnel. Thus, Liu et al. Based on their own research, they came to the conclusion that carpal tunnel syndrome occurred in every sixth computer worker they examined.

Today, working on a computer is considered one of the main factors provoking the development of CTS. The information field is replete with accusations against the keyboard and mouse; serious research is being conducted in this direction. An alternative, non-official name for the problem has appeared - “Computer Mouse Syndrome” or “Mouse Disease”. By analogy, smartphones are also considered risk factors. Apparently, a new name for the disease is on the way - “Smartphone syndrome”.


Let us make a reservation right away that we do not think the point of view of the authors who consider CTS as only local damage to the contents of the carpal tunnel to be convincing. For example, how can one explain the fact, based on the dominant “mouse theory”, which is not at all rare, that another hand is also involved in the process, which did not hold this same “mouse” by the “tail”?

According to Hanrahan, between 400,000 and 500,000 TSC surgeries are performed annually in the United States, with economic costs exceeding $2 billion. According to other sources, about $30,000 is spent on the treatment of one patient with CTS in the US.

The problem of treating patients in this category is far from resolved, since, despite the use of modern techniques using microsurgical techniques, the number of unsatisfactory results and relapses in the long-term postoperative period ranges from 10 to 20% or more. The main complications after surgery in the wrist area for decompression of the carpal tunnel are: the formation of scar contractures, damage to the median nerve, and wound infection (Mackinnon SE. 1991).

From the above data it is clear that the disease has an unclear prognosis regarding the restoration of impaired functions of the upper extremities, often leading to a decrease in everyday adaptation, professional incompetence, and sometimes disability. Therefore, it is very important to continue to develop effective methods for early detection of the disease and its pathogenetically based treatment.

Carpal tunnel syndrome has numerous synonyms: ischemic neuropathy, trap syndrome, trap neuropathy, carpal tunnel syndrome, tunnel neuropathy, carpal tunnel syndrome.

Definition (common version)

CTS is considered as one of the types of compression neuropathies, which is based on local entrapment of the median nerve, in the place where it passes through a narrow anatomical tunnel, under the transverse carpal ligament. The disease manifests itself as a complex of pain, sensory, motor, autonomic and trophic disorders.

Anatomy

Carpal tunnel (Anatomical and physiological features)

Carpal tunnel (canalis carpi). It is a narrow tunnel on the palmar side of the wrist, up to 2 cm in diameter. It is formed by the bones, tendons and muscles of the wrist. Normally, the flexor tendons of the hand and fingers freely pass through the canal, as well as blood vessels and the largest nerve of the upper limb, the median nerve. The canal is covered from above by a wide transverse carpal ligament or flexor retinaculum (lat. retinaculum flexorum). The ligament is stretched between the radial and ulnar eminences of the wrist and is a strip of strong connective tissue. Places of attachment of the transverse or carpal ligament: on the ulnar side there is the pisiform bone and the hook of the hamate bone, on the radial side there is the tubercle of the scaphoid and the crest of the trapezoid bone. The following muscles are attached to the ligament: along the ulnar muscle, the flexor of the little finger, and along the radialis, the flexor pollicis brevis muscle, the abductor pollicis brevis muscle, and the opponens pollicis muscle. The purpose of the ligament follows from its name (flexor retinaculum), i.e. it serves to hold and protect the contents of the carpal tunnel: the tendons of the muscles that flex the fingers and hand, blood vessels and the median nerve. In addition, the ligament holds the small bones of the wrist in the position necessary for the normal functioning of the hand and is the attachment point for the muscles that provide certain movements of the thumb and little finger. When a ligament is cut, its functions are partially or completely lost.

Median nerve (anatomical and physiological features)

Median nerve (lat. nervus medianus), originates from the fibers of the lower cervical and first thoracic (C5 - T1) roots of the spinal cord and is formed as a result of the fusion of the lateral and medial bundles of the brachial plexus. The brachial plexus itself is located, as in the sphincter, between the anterior and middle scalene muscles, as well as 1 rib below. On the forearm, the nerve emerges between the superficial and deep muscles of the flexor muscles of the fingers and gives them its branches. After this, through the opening of the carpal tunnel, it penetrates the palmar surface of the hand, along with the tendons of the flexor muscles. In the canal, the nerve is located most superficially, directly under the transverse carpal ligament. Then, it divides into branches and innervates the area of ​​the large index, middle and part of the ring finger. The median nerve is mixed, it includes sensory (sensitive), motor and autonomic fibers. The latter carry out metabolism and regulate the tone of the walls of the blood and lymphatic vessels of the hand. To function normally, the nerve must have freedom to glide through surrounding tissues and structures. When the limbs move, the nerve is capable of sliding in the longitudinal direction within a few millimeters, which protects it from overstretching (Kalmin O.V., 1988; Sunderland S., 1990; Lundborg G., 1996). Normally, the median nerve is not subject to compression in the carpal tunnel and hand movements do not interfere with its function.

As already noted, CTS is considered as a consequence of narrowing of the anatomical carpal tunnel with the development of nerve-canal conflict. [Al-Zamil M.H., 2008]. At the same time, it is known that degenerative changes develop in the most mobile parts of the spine, therefore, in the cervical region, the C4-C8 roots of the spinal cord are most often affected. When the C4-C5 roots are affected, proximal, and for C5-C8, distal paresis of the hand is characteristic, with weakness and numbness in the fingers. That is, pinched roots can be accompanied not only by local, but also by distal (remote) clinical manifestations. At the same time, local painful manifestations in the area of ​​compression of the spinal nerve may be mild or obscured by distant ones.

According to Moskvitin A.V. 2011) during an X-ray study of patients with tunnel syndromes, signs of degenerative-dystrophic processes in the cervical spine were identified in 90.8% of those examined. On MRI, 95% had signs of dystrophic intervertebral disc damage. According to the author, one of the predisposing factors for the development of tunnel syndromes is cervical osteochondrosis.

Works (Evdokimov S.I. 1982) showed that with compression of the root and its membranes, a pathological change in the relationship between the sympathetic and parasympathetic parts of the autonomic nervous system is observed. This leads to disruption of blood supply (microcirculation) in areas of their innervation, including muscles, nerve and connective tissue formations, often accompanied by edematous-dystrophic changes. Sympathetic innervation of the upper extremities; carried out at the level of T4-T7 (Petrukhin A.S. 2009). When the lateral horns of the spinal cord are damaged, which is observed in osteochondrosis, vasomotor, trophic and secretory disorders occur in the zone of autonomic segmental innervation.

The photograph below shows the hands of a patient suffering Cervical osteochondrosis. Degenerative-dystrophic changes in the joints and muscles of the hands are clearly visible. However, there are no clinical manifestations of CTS.

Compression and damage to the fibers that form the median nerve can be caused by muscles. According to (Vein A.M., 2003; Popelyansky Y.Yu. 2003, Chutko L.S., 2010). the neck muscles easily come into a state of tonic tension. Factors of muscle tension are: stress, emotional tension, anxiety, depression (McComas A., 2001). Prolonged tonic tension of the paravertebral muscles can cause compression of the roots in the cervicothoracic spine, and pathologically altered scalene muscles cause compression of the large nerves of the brachial plexus and, at the same time, compress the vessels (subclavian artery and vein) in the sphincter formed between the anterior and middle scalenes muscles, as well as the first rib from below (Moskvitin A.V. 2011). Clinically significant compression of the branches of the brachial plexus can occur at two levels: in the interscalene and subclavian spaces. It has been established that when the infraclavicular part of the brachial plexus is damaged, motor disturbances are observed in the muscles of the upper limb. Thus, when the ulnar nerve is involved in the process, weakness and atrophy of the muscle group of the fifth finger and the palmar surface of the forearm along the ulnar edge is observed; when the fibers of the median nerve are involved, weakness and atrophy of the muscles of the first finger group and the muscles of the palmar cavity are observed.

Atrophy of the muscles of the first finger group due to compression of the fibers of the median nerve

There is an opinion (A.R. Upton and A.J. McComas 1973) that the disease can be classified as multilevel neuropathies (double crush syndrome) and is considered as a combination of nerve compression at several levels of its length.

Based on the above, we can assume that CTS is not only a local problem in the wrist area. The components of CTS are: osteochondrosis of the cervicothoracic spine, muscular-tonic condition of the muscles of the neck and shoulder girdle, as well as compression of the roots (C5-Th7) with the development of an edematous-dystrophic process in the hand area.

To confirm our point of view, we present photographs of patient N., 41 years old. Diagnosis: Cervical osteochondrosis. Radicular compression syndrome C5-T1 with predominant damage to the median nerve.

The presence of edema on the left hand (picture on the left) as a manifestation of a violation of autonomic innervation, which can contribute to the development of CTS. Compression of the motor fibers of the median nerve of the left hand (photo on the right) makes it impossible to clench the fingers into a fist.

In the following photographs taken during the therapy: A - swelling on the fingers of the left hand has decreased, B - the ability to clench the left hand into a fist and fully bend the index finger has been restored.

The most commonly described complaints and clinical manifestations of CTS: for weakness of the hand, numbness of the fingers, the presence of paresthesia (tingling or crawling sensation). Pain also accompanies this disease; it can be periodic or constant, aching, burning, shooting. Painful manifestations usually intensify at night; a person is forced to get out of bed several times and stretch his arms, which brings temporary relief. Any physical activity can also cause increased pain. As the disease progresses, the hand becomes poorly controlled and awkward, fine motor skills are lost, and the patient experiences difficulty performing even simple everyday activities. The development of vascular disorders is possible, which is manifested by pale or marbling of the skin, swelling of the hand. In advanced cases, atrophy of the muscles of the eminence of the thumb (thenar) develops, and the hand takes on the appearance of a “monkey’s paw.” Chronic pain, long and frequent sleep interruptions lead to exhaustion of the nervous system and the development of neurotic disorders.

Analysis of individual complaints and clinical manifestations in CTS.
Most authors point to such manifestations of the disease as weakness of the hand and loss of grip strength. However, the function of clenching the hand into a fist and the strength in it are carried out not due to the muscles of the hand itself (there are simply no such muscles on the hand), but due to the contraction of the muscles of the forearm, the tendons of which are attached to the phalanges of the fingers. The innervation of the forearm muscles is indeed carried out by the median nerve, but much higher than the carpal tunnel. To do this, just look at the anatomy textbook. Thus, diagnostic tests of CTS based on determining hand strength (ergonomics) are not very informative.

Increased pain at night, in a lying position, is regarded as one of the characteristic signs of CTS. Rydevik B., (1981), and others explain the appearance of night pain by the fact that at rest the work of the muscle pump stops, the outflow of fluid from the vessels of the limb slows down. As a result, there is an increase in interstitial pressure and compression of the nervi nervorum. The same factor explains the appearance of nocturnal paresthesias. At the same time, the authors of this hypothesis do not take into account that the configuration of the spine changes significantly depending on the position of the body (lying or standing), especially in its most mobile parts. In a lying position, displaced vertebrae increase pressure on nerve formations and soft tissues, which already suffer from osteochondrosis. There is also no intelligible explanation why, in a lying position, at rest, the muscle pump does NOT work (stops working) only on one arm.

It is not uncommon for CTS to be observed on both hands. Initially, the disease manifests itself on one hand, then the second hand is also involved in the process. It is logical to assume that the symmetrical distribution of the disease process has one genesis - and this is cervical osteochondrosis.

DIAGNOSTICS
Generally recognized diagnostic methods KTS are: clinical manifestations, electromyography and MRI.

Muscle atrophy in the thenar region, more on the left, in a patient with CTS

MRI patient with KTS


TREATMENT

When carrying out treatment, we proceed from the fact that the occurrence of CTS is based on a pathological process in the cervical and upper thoracic spine. Changes in the carpal tunnel are secondary. At the same time, treatment is carried out at two levels: in the interval (C4-T7), which is justified by the anatomical and pathophysiological features of the innervation of the arm and hand, as well as in the wrist area, to eliminate local manifestations of the disease. To eliminate changes in the designated parts of the spine, we use: manual therapy (the sliding-pressure method is preferable), mesotherapy and physiotherapeutic methods. Locally, in the carpal canal area: massage, mesotherapy and physiotherapy. The result depends on the duration of the process and the presence of concomitant diseases. Our treatment shows high efficiency, which confirms the correctness of the chosen approach.