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 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 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 handed up her extremities surgery uh and then came back and started on faculty at U CS F 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 and 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 nine 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, bloods, like 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. So 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 ting is kind of at the tips of these fingers here. Um, patients can also present with sides 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 inability, the 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 to 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 and 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 overused injuries. Um You know, patients can have racial opathy from a bunch of different things. Patients can have tendonitis tus inviti 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, the 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 a PB or abductor poly for 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 wanna 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. So 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 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 pins 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. Durkin 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, actually load their neck or head um and ask them if that causes any Ridic 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 six 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 pence in tel'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 electro diagnostic studies uh to diagnose carpal tunnel syndrome. You know, electro diagnostic 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 electro diagnostic 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 six score, but I'm still concerned about carpal tunnel. Um If patients have a positive sperling 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 or 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 electro diagnostic 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 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 U CS F system, it's taken a couple of months for patients to get electro diagnostic studies. So uh when it is taking a while you can feel free to send those patients over. Uh And we can kinda make that final diagnosis um and or uh determine if they need a carpal tunnel or uh electro diagnostic 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 electro diagnostic study, um certainly less painful for the patient as well. Um But this is somewhat increasing in practice. So, uh some of the electro Anders may not be as trained in this uh technique. Um And then MRI S, 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, and 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 will 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 nerve 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 activity 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 talk 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 six 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 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 a caveat with an injection. We like to wait about three 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 wanna buy themselves three months of 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 three 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.