In just 20 minutes, orthopedic surgeon Lauren Shapiro, MD, MS, presents what clinicians need to know to identify CTS, from symptoms to simple in-office strength and screening tests, providing criteria for when to pursue electrodiagnostic studies. She also explains the range of treatment options – from splinting to surgery – and which are backed by the evidence. Bonus: a video illustrating how to assess strength in the hand muscle implicated in CTS.
Hey guys, uh, I think I've probably interfaced with some of you guys at some point, but, uh, I'm Lauren Shapiro. Um, I will talk about carpal tunnel, um, for about 20-ish minutes, I believe. Uh, we'll have some time for questions. Um, And we'll go ahead and get started or I can introduce myself. Um, I'm originally from Arizona. Um, I spent, uh, the first part of my life there and then went out to Stanford for undergrad, med school and residency. Uh, so the Bay Area is definitely my home. Um, I was out at Duke for fellowship, um, hand and upper extremity surgery, uh, and then came back and started on a faculty at UCSF in Uh, kind of October 2021. So, I've been here for a couple of years now, uh, and practice is still building. Um, I am logistically at the Orthopedic Institute in Mission Bay on Tuesdays. Um, and then I have a Redwood Shores clinic. On Thursdays. Um, I run a couple of fracture clinics on some Mondays in Redwood Shores, but, um, schedules, I think, in a little bit in flux. But if you guys have any referrals, particularly urgent referrals, just feel free to email, uh, Liz is my practice coordinator, uh, or shoot me an email if you guys have any questions or want stuff to be seen more urgently. You want a little bit of triage for kind of when or if something should be seen, uh, and how quickly. Um, all right, so we will dive right into carpal tunnel. Um, carpal tunnel is essentially median nerve compression within the carpal tunnel. Um, so the carpal tunnel is this canal, um, I can't find my, there it is. Um, can you guys see my mouse? Yeah, sweet. All right. Um, so, the carpal tunnel is essentially composed of about 9, ligaments that run through this carpal tunnel. Um, the median nerve lies right about here, so, one of the more radial structures or closer to the thumb. Um, and essentially, when this, uh, space Uh, when the pressure in that space, uh, becomes great enough such that the blood supply or the nerve gets irritated blood supply gets cut off or the nerve itself gets irritated, that causes symptoms of carpal tunnel syndrome. Um, carpal tunnel syndrome itself, um, is typically, you know, numbness and tingling, primarily in the median nerve distribution. So, primarily the tips of the thumb, index, middle finger, uh, and occasionally the ring finger, and I apologize, some of this is probably review for, uh, a lot of you guys. Um, but this is kind of the, the distribution of the median nerve, uh, and usually the numbness and tingling is kind of at the tips of these fingers here. Um, patients can also present with signs and symptoms of weakness, and I'll, um, show a video of one of the, the strength tests that we do in a little bit. Um, sometimes people will also have pain, usually at the wrist, right about here, um, less frequently associated with pain, more frequently associated with numbness and tingling, um, weakness, oftentimes dexterity issues. Patients feel like they're dropping things, and that can be from Issues with dexterity and or just a lack of their their inability to feel the tips of their fingers, um, those are kind of the primary presenting symptoms. Um, The differential diagnosis here, uh, or what is the cause? I'm sorry, I can't see my, the title part of my slides with the, uh, all of our faces here. Um, the causes of carpal tunnel are, uh, multiple. Um, oftentimes, it's idiopathic and there's not one specific cause, but, uh, these are some things that can lead to increased pressure within the carpal canal, rheumatoid arthritis, gout, amyloidosis, certain types of infections, uh, psoriatic arthritis. Patients can have some arthritis of the carpal bones of the wrist itself that put a little bit more pressure on the carpal canal. Uh, obviously, tumors, ganglion cysts can push on there. Uh, and then patients can have an acute or a subacute, uh, carpal tunnel syndrome with a wrist fracture, dislocation or any type of trauma that causes more swelling, uh, at the carpal tunnel. Um, but notably, these things are not necessary for a patient to have carpal tunnel. Differential diagnosis is vast. Um, the big things that you wanna rule out are any cervical pathology, um, or anything that's emanating from the cervical spine. Um, other things that can cause symptoms of carpal tunnel are things like multiple sclerosis, diabetic neuropathy, um, overuse injuries, um, you know, patients can have brachial plex. Stopathy from a bunch of different things. Patients can have tendonitis, tenosynovitis, um, and thoracic outlet syndrome. And again, these things aren't mutually exclusive. Um, so patients can have carpal tunnel, uh, with one of these things. Um, but these are also things that you should be thinking of when somebody presents with, you know, those symptoms of numbness and tingling in the fingertips. Physical exam usually starts with inspection. Uh, again, this is probably some review for you guys, but, you know, looking at the bulk of the hands, looking to see if there's any APB or abductor paralysis brevis atrophy, and that's just kind of looking at the, the palms of the hands, comparing them to one another. Sometimes people have bilateral carpal tunnel or bilateral atrophy. Um, but you can sometimes pick that up on strength testing, um, and I'll go into that a little bit. You want to look at their range of motion, uh, of the wrists and the fingers. Um, I also will usually ask them to, uh, flex, extend, laterally bend, and rotate, uh, The neck, uh, see if that causes any radicular symptoms, see if that reproduces any of the symptoms in their hand and upper extremity. Sometimes that can be a key to something that's more cervical in nature. Um, and again, just because somebody has cervical issues doesn't necessarily mean they don't have carpal tunnel and vice versa. It just kind of helps us parse out from where the symptoms are emanating primarily. Um, um, other special tests are your Tinel's test. I'm sure you guys are all aware of this, but tapping on that median nerve, um, you know, patients who, uh, have a lot of stuff going on, I try to ask them what that tapping does for them. You know, some people will tap and they'll Uh, kind of jump off the table. Um, I try to elicit exactly what symptoms that, uh, tapping is doing. So asking them if it, you know, does that cause shooting sensation down your fingers? What does this cause when I'm tapping here? Um, sometimes that test can be equivocal, um, in patients who are, uh, I think, harder to kind of diagnose exactly what's going on, but can be a helpful test. Um, I do a combined Phale's and Durkin's test. So, this is a combined, um, flexion of the wrist and compression on that carpal canal. So, I'm pushing on the carpal canal canal, and, um, flexing the wrist at the same time. The sensitivity specificity of a combined phalanx Durkins is a little bit higher than that of each of them done individually. And again, I'll do that usually with both sides, at the same time, hold it for about 30 seconds as I'm talking to them, and I'll ask them if that changes any of their symptoms, uh, and if so, what they're feeling. Um, and usually what I do is just, you know, document exactly what they say. So if they're like, this causes pain, uh, I'll document that, and that doesn't necessarily mean much to me. If they said, this reproduces my symptoms of numbness and tingling in the tips of my fingers, that's a little bit more helpful and diagnostic for me. Um, Sperling's test, uh, you guys are probably also familiar with, but it's essentially a cervical, uh, cervical pathology test for any cervical stenosis. So, essentially having them, I kind of have them look up in the corner, uh, and then push, axi load their neck or head, um, and ask them if that causes any radicular symptoms or if that reproduces any of their symptoms. So I usually document all of these, uh, just to kind of get a better picture of what's going on. And again, we kind of use all of these together, uh, to diagnose what's going on. This is the CTS 6 score. I have a dot phrase for this. I think it's really helpful. Um, this is essentially a screening test for carpal tunnel syndrome. Um, it was developed, uh, by a hand surgeon. Um, and essentially, each of these things gives you a certain number of points. Um, if you're getting a score of over 12, which, you know, isn't that hard to do if you have median nerve distribution, numbness and tingling, wakes you up at night, and a positive Phalans and Tinel's test that a lot of people have, that gets you a score of over 12 pretty easily, um, which, uh, from the literature tells us that patients have a very high likelihood, uh, of having carpal tunnel. In patients who have a score of over 12, uh, I find, and I think the, the literature, the body of literature is growing, uh, to indicate that you don't necessarily need electrodiagnostic studies, uh, to diagnose carpal tunnel syndrome. You know, electrodiagnostic studies, I think, are the gold standard, uh, historically for diagnosing carpal tunnel syndrome, uh, ruling out any cervical pathology, uh, ruling out, um, ulnar nerve pathology or cubital tunnel syndrome. Um, so, you know, if somebody has a pretty straightforward story, uh, uh, and a high CTS score of more than 12, I don't think they need electrodiagnostic studies to formally be treated for carpal tunnel syndrome. And uh we're working on developing the clinical practice guidelines through the American Academy of Orthopedic Surgeons right now, and, uh, that's pretty much what the upcoming uh CPG is going to say. Um, hasn't been finalized yet, but that's what the literature is showing. Um, so, when to get nerve studies. Um, I use nerve studies for when the patient has a low CTS 6 score, but I'm still concerned about carpal tunnel. Um, if patients have a positive Sperlingx test, uh, patients have neck pain with range of motion, or I'm concerned that there's any cervical pathology, um, I'll get a nerve study. Patients that have cubital tunnel pathology are signs and symptoms of cubital tunnel pathology, so numbness and tingling more at the ring and small finger, um, at Tinel's, uh, when you're tapping the elbow or the nerve as it runs around the elbow. Um, those are patients where I think a nerve study is helpful. Um, if patients have had prior surgery, prior carpal tunnel release, um, workers' compensation patients, um, are usually, uh, ones where I'll send, um, them to get an electrodiagnostic study to help me quantify, uh, the level of compression. Um, and then again, if you're unsure, if you think something else is going on, you're not totally sure of the diagnosis, um, this can be helpful. You can also send them to us too, and we can kind of make that final decision. I think at least in the UCSF system, it's taken a couple of months for patients to get electrodiagnostic studies, so, Uh, when it is taking a while, you can feel free to send those patients over, uh, and we can kind of make that final diagnosis, um, and, or, uh, determine if they need a carpal tunnel or an electrodiagnostic study before we pursue any treatment. Advanced imaging, um, there is a growing body of evidence to support ultrasound, um, for the diagnosis of carpal tunnel syndrome. Um, if you're doing this, uh, it usually has to go to a specific ultrasonographer. Um, I would indicate exactly what you're looking for. They have specific thresholds of The size and the cross-sectional area and where they're looking for that, uh, along the carpal canal. So, if you're doing that, it's obviously cheaper and easier to get than an MRI or than an electrodiagnostic study, um, certainly less painful for the patient as well, um, but this is somewhat increasing in practice, so, uh, some of the electrosonographers may not be as trained in this, uh, technique. Um, and then MRIs, there are some studies that look at using MRI for diagnosis of carpal tunnel syndrome. Um, if that's your primary concern, I would not send anybody for an MRI. If you're concerned about something else like scapholunate pathology or any other, you know, carpal instability, carpal injury, an MRI might be helpful, but if you're looking for carpal tunnel, not helpful. Um, treatment options, uh, These are kind of the. Uh, conservative treatment options that we'll run through. Immobilization, um, at night can be helpful. The literature is not very strong to support this, but, uh, you know, it is kind of the dogma for mild carpal tunnel syndrome. Um, I have patients Google carpal tunnel brace. I have them get a couple of them, see which ones they like, and return the other ones. Um, so the idea here is I tell patients we all fall asleep like this, and then we wake up like this, and that puts a lot of pressure on the carpal tunnel. So, nighttime splinting patients to keep that carpal, uh, canal straight and that pressure down can be helpful, particularly in mild symptoms. Um, hand therapy can be beneficial. There's not a ton of literature to support that either. Um, if you're doing this, you wanna put carpal tunnel in the referral, you can put them down for nerve glides or tendon glides, which essentially kind of help mobilize the nerves and the tendons to keep things moving a little bit more smoothly. Um, activity modifications, you know, some of this is just common sense and avoiding the things that cause symptoms. A lot of what causes symptoms, unfortunately, are kind of activities of daily living, talking on the phone, you know, blow drying your hair, driving, um, positions that put the wrist either in extreme extension or extreme flexion. So, you know, when talking with patients about ergonomic modifications, activity modifications, have them think about neutral positions, things that don't put too much stress or strain either on the elbow or the wrist, and the elbow for cubital tunnel and the ulnar nerve, and then at the wrist for carpal tunnel. Medications, um, some people are prescribed prescribing gabapentin, uh, for carpal tunnel. There's no strong evidence to support that. Um, similarly, some people are prescribing opioids. Uh, I would not advocate for that either. Um, I'm sure, uh, you guys probably aren't doing that, but there's not a lot of literature that demonstrates that either of those, um, are helping the symptoms, uh, of carpal tunnel. Um, the other two treatment options that we talked about are an injection. Um, the injection, what I tell patients and what the literature, so traditionally, the literature told us that these are very temporary, um, and that at 6 months, the injection has usually worn off and the symptoms are back. There's some growing evidence that these are lasting a little bit longer. Um, it's hard to get long-term follow-up on a lot of these patients in general, but, you know, the discussion I have with these patients is that one can be diagnostic, you know, if they have carpal cubital, they have carpal and cervical pathology, and we're thinking about, uh, a surgery or trying to quantify what percentage of their symptoms are coming from the wrist. Uh, an injection can be helpful in quantifying that. Um, you know, if we inject them and none of their symptoms go away, we might be barking up the wrong tree, it might be more cervical, we may have the wrong diagnosis, and I'm a little bit more hesitant to undergo a surgery. Um, whereas if, you know, the injection works completely, um, I think we got the right diagnosis, and I think a surgery is probably gonna help that person. The caveat with an injection, we like to wait about 3 months from injection to surgery. So if somebody's pretty eager to get going on the surgical route, um, I won't necessarily inject them, um, unless they want to buy themselves 3 months at a time. Um, and that's on the same hand. So if we inject one and they want the other one operated on, we can do that within 3 months safely. Um, surgical release, uh, is the last treatment option. Um, it's usually a mini incision, uh, on the palm of the hand, right about there. Um, we get patients in pretty quickly for this. It doesn't take us too long. Um, so most of us can get patients scheduled for surgery within a couple of weeks. Um, it's an outpatient surgery, um, that we do with a little bit of local anesthetic, uh, and a little bit of sedative medication. Um, some people are doing this under local only. Um, we're working on trying to set up a procedure room, uh, at Redwood Shores such that we can do this in the office under local anesthesia only. Um, but we are not there yet, but it is something that the literature supports that we are working on. Um, and that is all I have. These are my clinic dates, uh, and these are the clinic dates and locations, and then these are contact information.
