Carpal Tunnel Syndrome - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes describes carpal tunnel syndrome.

Carpal tunnel syndrome is compression of the median nerve at the wrist. It is the most common form of nerve entrapment
What is the carpal tunnel? The carpal tunnel is a narrow passage on the palmar side of the wrist made up of bones and ligaments. The carpal tunnel is narrowest at the level of the hook of hamate.
The carpal tunnel is defined by:
•the scaphoid tubercle and trapezium radially
•hook of hamate and pisiform ulnarly
•Proximal carpal row dorsally (floor)
•Transverse carpal ligament palmarly (roof)
The carpal tunnel consists of:
•Nine flexor tendons,with FPL being the most radial tendon. The FDS for the ring and middle fingers lies volar to the index and small fingers.
The recurrent motor branch of the median nerve has multiple variation of the nerve:
•50% are extraligamentous with recurrent innervation.
•30% are subligamentous with recurrent innervation.
•20% are transligamentous with recurrent innervation.
The median nerve also branches into ulnar and radial divisions.
How does carpal tunnel syndrome occur?
Pressure is placed on the median nerve and other structures by the transverse carpal ligament. The normal resting pressure of a hand in the neutral position without carpal tunnel is 2.5 mmHg. In the wrist without carpal tunnel, flexion or extension of the wrist causes pressure on the median nerve of 30 mmHg. The normal resting pressure of a hand in the neutral position with carpal tunnel is 30 mmHg. In the wrist with carpal tunnel, flexion or extension of the wrist causes pressure on the median nerve of between 90-110 mmHg. When using a splint, the CT pressure increases when the wrist is in extension and is the lowest when the wrist is neutral.
Symptoms of CTS:
•Numbness and tingling in the radial 3 ½ digits. Numbness should be less at the thenar area of the palm.
•Clumsiness and weakness
•Pain and paresthesia that wakes the patient up at night and is relieved by shaking the hand away.
Self-administered hand diagram is the most specific test for carpal tunnel syndrome. Thenar atrophy may be present.
For examination:
•Durkan’s test- carpal tunnel compression test is the most sensitive test to diagnose CTS. It is performed by pressing the thumbs over the carpal tunnel and holding pressure for 30 seconds. The onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.
•Phalen test: wrist volar flexion for approximately 60 seconds produces symptoms. Test is performed by tapping on the median nerve over the volar carpal tunnel.
•Semmes-Weinstein testing: most sensitive sensory test for detecting early carpal tunnel syndrome.
•Innervation density test: a- static and moving two point discrimination
Diagnosis of CTS is a clinical diagnosis. Do EMG and nerve conduction studies if surgery is considered. Only subjective evidence of compression neuropathy (routinely used in workmen’s compensation patients). May be negative in about 20% of the patients.
Etiology:
•Repetitive motion and vibration causes thickening of the transverse carpal ligament.
•Pregnancy
•Systemic diseases as diabetes, dialysis, rheumatoid arthritis, obesity, hypothyroidism, amyloidosis and mucopolysaccharidosis.
Risk factors:
•Female •Smoking •Advanced age •Alcoholism •Obesity •Repetitive motion
Comparing surgery with splints, the improvement success rate is 80% with surgery and 54% with splinting at 3 months. 18 months: 90% with surgery and 75% with splint.
Indication for surgery:
•Failure of non-operative management
•Thenar weakness/atrophy
•EMG abnormalities
•Known extrinsic compression from mass lesion.
Open carpal tunnel release results:
•Pillar pain for up to 3-4 months
•Dynamic symptoms resolve rapidly with wrist movement
•Release of the carpal tunnel and duputyren’s contracture at the same time may make the condition worse.
•Static numbness/weakness may take up to a year for improvement plateau.
Outcomes: pinch strength returns in 6 weeks. Grip strength is expected to return to 100% preoperative levels by 12 weeks postoperative. Pinch strength recovers faster than the grip strength. No effect on carpal tunnel release surgery results:
•Internal neurolysis
•Transverse carpal ligament reconstruction
•Tensosynovectomy
•Guyon’s tunnel release.
Causes of carpal tunnel release failure
•Incomplete TCL release
•Incorrect diagnosis
•Double/triple crush
•Peripheral neuropathy
•Space occupying lesion
•Iatrogenic median nerve injury

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Background music provided as a free download from YouTube Audio Library.
Song Title: Every Step

[philland]

This is an extremely well done video. I am going to share it with some of my patients.

[ReuvenMansharoff]

this is by far the best educational video on CTS and related. As one who suffers triple crush and CTS (hands, elbows, TOS and neck) after 30 years of dense computer work, I see docs who confuses matters. Nabil, in this video, demonstrates what should be check and avoid confusion or bad diagnosis. thank you!

[mr]

Best and most comprehensive explanation I have seen so far.

[CrankyPantss]

Excellent presentation. Thanks for sharing this with us.

[windsongshf]

after years of being a waitress I've had CTS and tennis elbow in both arms. I've retired from restaurant work (late 50's) and in the part couple of weeks, the CTS has flared up and I'm getting the tingling right up my arm, and even feel it in my upper arm. I'm not on the computer all day, but I do use it a couple of hours a day, and I can feel it especially when I'm clicking the mouse. What a PITA. Going to the doc this week!

[thackerc]

If you are over the age of 60 and you have carpal tunnel symptoms and you have not started anything new (hobbies, exercises, work) that you think is the cause, please see your doctor and look into a disease called amyloidosis. Carpal tunnel can be an early symptom and it's a very serious disease. My father had carpal tunnel for months and they missed the amyloidosis until he started to have heart arrhythmia problems.

[satadruray]

Absolutely brilliant presentation, sir

[marilynvillanueva]

A great lesson for us . This is to avoid to much heavy work that can damage our carpal tunnel thank you

[joanne_luvsdisney]

This was a great presentation! I am having CT surgery next week so this was very informative. I have Double Crush Syndrome so I am also having an epidural injection soon after

[christopherhickman]

Just had both wrists done. The pain relief is indescribable. I am getting sleep after a couple of years of horrendous night time pain.

[rajeshful]

Thank you very much for giving so much information about carpal tunnel syndrome. I also have been suffering from this problem

[BobWa]

Excellent educational video. Thanks for posting.

[neilday]

I want to thank you for a very clear explanation of what is going to be the scariest operation of my life. Approx. 15 years ago I was recommended to have Carpal Tunnel Release surgery, without (I believe) either a complete diagnosis or exploration of alternatives outlined in this video. I changed many things about what I did and how I did things, and the symptoms mostly dissipated. 2 weeks ago (after 7/8 months of pain), EMG tests confirmed I have a damaged nerve and I am again being told again that I need this surgery. Why am I so terrified of the suggestion? . . . because 36 years ago I paralysed by left arm in a motor bike accident . . and the surgery proposed will be on my right arm . So a very routine operation (so everyone keeps telling me) could change my life catastrophically if something goes wrong. Thank you for helping me to understand and to know what questions to get answers to. Truestokie

[dawnforrespect]

Just had the right surgery done and the left is next. Was told I needed to have carpal tunnel surgery done to rule out carpal tunnel. I've been severely suffering from cipro toxicity yet having to have unnecessary extremely painful surgeries just to rule out other conditions. But on the brighter side for everyone else who needs to surgery I'm sure it would help you immensely

[gokumaster]

There's a typo in the diagram at 3:41. It lists the Thenar muscles as APL, APB and OP. Abductor pollicis longus should be replaces with Flexor Pollicis Brevis.

[sushantakumardas]

Good &
Nice carpal tunnel syndrome video

[ansariurusa]

Thankyou so much.This video is very informative

[alexwonner]

as many have commented alreadty: fantastic presentation. Fantastico!

[soniabaker]

I have had carpal tunnel for weeks and I have done neck stretch exercises, my thumb was solid and is now moving more, all the cracking my neck did when I first started exercising feels free and better, it can be the neck end of the nerves that need freeing.🌹

[arabicboy]

i'm a bit confused, some videos say that the trapezoid and capitate (distal carpals) form the floor, and this video says only the proximal wrist bones form the floor.


so one the former would go:
the latter would go:


and actually, the latter setup has one less wrist bone involved. Can someone help elaborate? thx