carpal syndrome. Conservative treatments for carpal tunnel syndrome

Carpal tunnel syndrome is a common condition that causes pain, numbness, and weakness in the hands and wrist. The disease occurs when the median nerve is compressed in the carpal tunnel. This nerve supplies the thumb, index and middle fingers, as well as half of the ring finger. The little finger ("little finger") is usually not affected. The median nerve also provides strength to some muscles at the base of the thumb.

What is a carpal canal?

The carpal tunnel is a narrow tunnel in the wrist. The bottom and sides of the tunnel are formed by a semicircle of carpal bones. The transverse ligament forms the upper part of the tunnel.

The median nerve and tendons pass through this narrow space. (Tendons are "rope" structures that connect the muscles of the forearm to the bones of the hand.) Tendons allow the fingers to bend and straighten. Conditions under which contraction occurs carpal tunnel or there is swelling and inflammation of the tendons that go away

through this tunnel, cause carpal tunnel syndrome by compressing the median nerve.

Causes of the disease

The causes of the carpal tunnel syndrome are all conditions in which the tunnel narrows and the nerve is compressed in it. Among them are:

• injuries in the wrist area (fractures and dislocations of bones).
• cysts or tumors in the wrist area that cause compression of the median nerve.
• frequent repetitive movements of the same type in the area of ​​the wrist joint (flexion-extension as well as the impact of vibration on the hand). People of certain professions are subject to this: painters, violinists, cashiers,
  milkmaids, equipment assemblers, artists, dentists, tattoo artists.
  An additional effect is exerted by hypothermia of the brush.
• prolonged incorrect position of the hand in the position of excessive flexion or extension, most often the result of an incorrect position of the hand and computer mouse in office workers - with excessive extension, the median nerve is squashed in the canal.
• risk factors are diseases and conditions of the body in which there is a tendency to tissue edema, as a result of which the carpal canal narrows - this is pregnancy, thyroid disease, diabetes mellitus, obesity, amyloidosis, taking hormonal contraceptives, rheumatism, kidney failure, etc.

Symptoms.

Among the main complaints of patients with carpal tunnel syndrome are tingling, numbness, burning, crawling, pain or shooting in the fingers (all, including thumb but excluding the little finger). Sometimes the pain radiates to the forearm or shoulder.

As a rule, symptoms appear at night or in the morning after waking up. The pain is so pronounced that it can wake the patient. Symptoms decrease after a few minutes after shaking the hand, this forces the person to lower the hand down from the bed, shake the hand. May appear

weakness in the hands, which is manifested by the awkwardness of the hand and the difficulty of holding objects.

In severe cases, there is a disappearance of sensitivity, muscle atrophy, dry skin of the fingers, weakness of the muscles of the thumb. Habitual gestures such as grasping objects, sewing, buttoning shirts become difficult to perform.

Diagnostics

In most cases, a physical examination of the patient, conducting special tests, can diagnose carpal tunnel syndrome.

Phalene's maneuver

This maneuver can be performed as follows:

• Place the backs of your hands on top of each other with your fingers pointing down
• Drop both elbows down.
• Hold this position for 20 seconds.

If you feel pain and the sensation in your arm increases, the test is positive, which could mean narrowing of the carpal tunnel.
Second carpal tunnel syndrome Tinnel test. The test is performed as follows:

• The wrist joint is in the middle position, that is, the arm lies straight
• Now press with two fingers on the carpal tunnel.
• Keep pressing for 20 seconds. If you feel a tingle in your hand, the test is considered positive.

However, studies such as electroneuromyogram, radiography of the wrist joint, CT scan and blood tests. They confirm the diagnosis and more serve to assess the severity of nerve damage and determine the tactics of therapy.

How is carpal tunnel syndrome treated?

Non-surgical treatment

Treatment begins with wearing an orthosis on the wrist at night to give it a neutral position and, accordingly, to reduce nerve compression. Also, non-steroidal anti-inflammatory drugs, such as ibuprofen, nimesil, ketonal, etc., are prescribed to alleviate the pain syndrome. Diuretics are indicated to reduce tissue swelling. In order to improve microcirculation, angioprotectors are used - pentoxifylline or nicotinic acid. To improve the nutrition of the nerve - vitamins of the B-milgamma group, combilipen, etc.

Topical application of NSAIDs is shown, as well as compresses on the wrist joint (with dimexide, artrafik). In some cases, medical blockades with glucocorticoids are used, which allow you to remove local swelling and compression of the nerve, in addition to alleviating

symptoms, they are a diagnostic measure to confirm the diagnosis. As physiotherapy, ultraphonophoresis with hydrocortisone, laser therapy, magnetotherapy, manual therapy, shock wave therapy are indicated. As an auxiliary method, acupuncture can be used.

G56.0 Carpal tunnel syndrome

Epidemiology

As we have said, carpal tunnel syndrome is considered a fairly common pathology. Most of the patients are women, and the proportion of the incidence of men is approximately 10%.

The disease can begin regardless of age characteristics. However, the main number of cases occurs during the period of extinction of hormonal activity, that is, after 45 years. Among the total number of patients, patients under 30 years old can be found. But, as a rule, they are 15 times less than older people.

Causes of carpal tunnel syndrome

Carpal tunnel syndrome begins to develop when there are provoking circumstances in which there is a decrease in its diameter or swelling - something that leads to compression of the nerve. Immediate reasons include:

• injury to the carpal joint, followed by swelling or hematoma;
• violation of the integrity of the wrist bone;
• inflammatory process in the wrist joint;
• neoplasms protruding into the carpal canal;
• inflammatory process in the tendons of the muscle flexors;
• other causes of soft tissue edema of the upper extremities (diabetes mellitus, hypothyroidism, etc.).

The most common cause is considered to be tendosynovitis of the flexor muscles of the wrist, which may be the result of physical overwork of the hand.

Risk factors

Analyzing the above causes of the syndrome, we can identify the appropriate risk factors:

• vascular diseases;
• diseases of the tendons and ligamentous apparatus;
• tendon sheath cysts;
• calcifications;
• arthritis and pseudoarthrosis;
• infectious diseases.

Pathogenesis

Symptoms of carpal tunnel syndrome

The first signs of carpal tunnel syndrome are manifested in the form of loss of sensitivity of the fingers on the hand, more often in the morning. Toward the middle of the day, sensitivity is restored.

A little later, the numbness spreads to all fingers, with the exception of the little finger. In addition, there is soreness, "goosebumps" and a feeling of heat on the fingertips.

The pain is observed throughout the finger, and not just in the joint area.

Sometimes the listed symptoms capture the entire hand, or even reach the elbow bend.

Unpleasant sensations can cause considerable discomfort, especially at night. As a result, insomnia may develop.

If during an attack to do light gymnastics upper extremities, the condition temporarily improves as a result of the restoration of impaired blood circulation.

As carpal tunnel syndrome progresses, more and more symptoms appear. Patients note weakness in the hand and some lack of coordination, they can drop objects, losing the ability to hold them with their fingers.

Every third patient with carpal tunnel syndrome has a change in the shade of the skin: as a rule, the skin on the affected hand has a pale appearance.

In severe cases, with severe compression of the nerve, numbness can capture the entire arm up to the elbow, and even up to shoulder joint or neck. This condition often leads to diagnostic errors, as doctors mistake it for signs of cervical osteochondrosis.

Forms

There are several stages of development tunnel syndrome:

1. Painful stage, when the only sign of compression of the median nerve is pain.
2. The stage of numbness, which is characterized by the appearance of pain and numbness in the fingers.
3. Stage movement disorders when movements in the hand become limited and uncoordinated.
4. The stage of increasing weakness, which develops against the background of soreness, impaired sensitivity and limited movement.
5. The stage of malnutrition, which often represents irreversible changes in tissues.

In addition, various types of carpal tunnel pathology are also identified:

• neuropathy of the radial nerve;
• carpal and cubital canal syndrome.

This classification is adopted for a more accurate description of the disease when making a diagnosis, which makes it as detailed as possible.

Complications and consequences

Carpal tunnel syndrome cannot be attributed to pathologies that are life-threatening for the patient. But a sluggish disease process can gradually lead to a significant limitation of the mobility of the affected limb. Therefore, competent treatment is considered not only desirable, but also necessary for further full-fledged activity. Only after successful qualified therapy, the prognosis of the syndrome can be called favorable.

Diagnosis of carpal tunnel syndrome

Collection of patient complaints, examination and probing of problem areas of the hand. The doctor detects reduced sensitivity of the first 3-4 fingers from the side of the palm. When the process is running, muscle weakness and atrophic changes in the muscle responsible for thumb abduction are detected.

Special testing:

• Tinnel test - simultaneously with tapping in the median nerve projection zone, a tingling sensation appears in the fingers;
• Phalen's test - if you bend your hands in the wrist area and raise your hands up, then for one minute you can feel numbness in your fingers;
• vest test - if you put a pneumocuff on the forearm and pump it up, the patient will feel pain and signs of numbness in the fingers.

Instrumental diagnostics:

• the electroneuromyography method is used to visualize a partial blockade of impulse conduction through the median nerve in the carpal canal;
• x-ray method - helps to exclude diseases skeletal system;
• method ultrasound diagnostics(ultrasonography) - may indicate thickening of Lig. retinaculum and deterioration of nerve mobility;
• magnetic resonance imaging method - allows you to detect the flattening of the median nerve, which indicates its compression.

Differential Diagnosis

Differential diagnosis is carried out with compression neuropathy of other nerve endings, with osteochondrosis cervical(radicular syndrome C6-C7), with transient disorder of cerebral circulation, etc.

Treatment of carpal tunnel syndrome

Patients with uncomplicated carpal tunnel syndrome may be prescribed drug therapy, which consists in the use of anti-inflammatory drugs simultaneously with fixation (immobilization) of the affected hand.

If such treatment was ineffective, then the only option may be surgery. Its essence is the dissection of the transverse carpal ligament involved in the formation of the carpal tunnel. In complicated situations, they resort to excision of modified scar tissue adjacent to the nerve, as well as partial excision of the tendon sheaths.

• Medications that are used to treat carpal tunnel syndrome:

To restore peripheral circulation can be prescribed vascular agents such as Trental, Xanthinol, A nicotinic acid, in combination with anti-inflammatory and diuretic drugs that relieve swelling (Diakarb, Triampur). With loss of sensitivity of the palms, drugs based on carbamazepine, for example, Tegretol, are used in an amount of 200 mg up to 3 times a day.

The early stages of the disease can be successfully treated with the introduction of novocaine into the carpal canal.

• Physiotherapy treatment helps to accelerate the relief of the condition, eliminate soreness, numbness. Often the following procedures are used:
  • UHF - exposure to the affected area of ​​ultra-high frequencies, which helps to increase blood circulation;
  • SMT is a method of amplipulse therapy.

• Treatment of carpal tunnel syndrome at home is possible only at an early stage of the disease. In this case, it is necessary to take anti-inflammatory drugs, and it is also necessary to fix the hand at night with a special bandage - splint, which prevents flexion of the wrist joint. In addition, doctors advise to reduce motor activity limbs, especially with regard to increased grasping movements, arching and tilting of the hand at the wrist.

If the listed actions did not bring results, or the problem reappeared, then you should not hesitate to go to the doctor.

Alternative treatment of carpal tunnel syndrome

Before proceeding to folk treatment syndrome, it is necessary to carefully weigh the pros and cons. If the treatment does not have the expected effective effect, then the disease can be started, and then it will become more difficult to cure it.

• First recipe. Pour boiling water (preferably in a thermos) 1 tbsp. l. powder bay leaf and 3 st. l. fenugreek. After 2 hours, filter the infusion and take 100 ml 3-4 times a day.
• Second recipe. Fill a 0.5 liter container with dried St. John's wort with warm sunflower oil, put in a cool place for three to four weeks. After that, drain the oil through gauze, mix in ginger powder (1 tbsp. Spoon). We have obtained an ointment that should be used to massage the limb and wrist.
• Third recipe. We brew in a thermos an equal amount of string, burdock rhizomes, hop cones, birch leaves, elderberry and verbena. We insist 2-3 hours and take 100-150 ml 4 times a day.
• Fourth recipe. Dilute white clay with warm drinking water to a mushy density. Apply to a cloth or gauze folded in several layers and apply to the affected area. Keep the compress until the clay dries completely.

A compress based on goat's milk also helps well. We moisten a piece of cotton cloth or gauze in fresh goat milk and apply for 2-3 minutes on the affected area. We repeat the procedure several times a day, until the condition is permanently relieved.

• with constant relapses of the disease;
• with a neglected, or so-called "long-standing" disease;
• with atrophic changes in the muscles;
• with a significant blockade of impulse conduction (according to the results of electroneuromyography).

The operation is a dissection of the carpal ligament and, in some cases, excision of scar tissue (neurolysis).

Surgery can be done either open or endoscopically. Both options have the same goal - the elimination of compression of the median nerve.

Endoscopic surgery is considered more gentle, since this method involves minimal damage to external tissues. Accordingly, the scar after the operation will be almost invisible.

The advantages of open surgery are absolute access to the examination of the operation area. The doctor can carefully examine the problem and eliminate it.

As a rule, the operation is considered standard, without any complications, and lasts 30-50 minutes. Hospitalization is not required: the patient is given local anesthesia, and after the intervention, plaster is applied (for about 2 weeks). The operated patient on the same day can go home, where he will independently take the treatment prescribed by the doctor.

Rehabilitation after surgery

The effectiveness of the operation largely depends on the qualifications of the surgeon, on the prescription pathological process. But also important postoperative care for the injured limb. Therefore, after surgery, it is necessary to adhere to the following rules:

• carefully follow all the doctor's instructions;
• visit a doctor regularly for check-ups.

Immediately after the operation, the limb is applied plaster cast, or use a special bandage that allows the fingers to move, but at the same time securely fixes the carpal joint. After about 12-14 days, the patient comes to remove the stitches.

Night and morning pain in the limb should disappear within a few days after surgery. A slight numbness remains temporarily: it may take a little longer to fully restore innervation.

After removing the sutures, the patient can already perform simple hand movements, but significant physical exercise will be banned for at least three more months.

A small scar remains at the site of the incision: as a rule, it is hardly noticeable and does not cause inconvenience to a person.

Gymnastics for carpal tunnel syndrome

With carpal tunnel syndrome, exercise therapy is indicated. The purpose of such gymnastics is to restore the function and mobility of the joint, to strengthen atrophied muscles.

Often, therapeutic exercises are combined with electrical stimulation, when the patient undergoes synchronous stimulation of the muscles, which is performed simultaneously with their contraction.

1. The hand is placed on the surface of the table. Make intense flexion and extension movements with all fingers, and with each individual finger.
2. The hand rests on the surface of the table. The proximal phalanx is fixed with a healthy hand, after which intensive flexion and extension of the interphalangeal joints are performed.
3. Elbows rest on the surface of the table, the brushes are set together, placing them up. Bring and spread fingers, helping with a healthy hand.
4. They reach with the fingertips to various points on the same palm.
5. Grab fingers of various sizes, from small to large.
6. Using fingers, rotate a small ball on the table, in one direction and in the other.

Exercises are carried out slowly, with repetitions from 5 to 8 times.

In addition, practice similar exercises in a warm pool. In this case, the entire limb up to the shoulder should be in the water.

• keep posture;
• avoid sudden movements;
• learn to relax.

To prevent carpal syndrome, you should carefully plan and equip workplace. It should be equipped in such a way that it is possible to periodically relax the hand and carpal joint.

The seat should be comfortable, with an anatomical backrest and handrails located so that the hand rests on elbow joint, but not on the wrist.

Approximately every 45-60 minutes it is advisable to get up from the workplace, stretch, do gymnastic exercises for the arms and hands.

If you follow these simple rules, then it is quite possible to prevent the appearance of carpal tunnel syndrome.

Carpal tunnel syndrome or carpal syndrome - what is it?

If translated into everyday Russian, these are painful inflammatory and cicatricial changes in the carpal canal of the wrist joint. Here passes the median nerve, the tendons of the muscles of the forearm, flexing the fingers, in case of violation of which pains appear in the hand, numbness of the fingers, difficulty in small movements of the hand and fingers. The channel from the side of the palm is covered with a tendon plate - the retainer of the flexor tendons.

Carpal tunnel syndrome is much more common than. Here are the data available on the Internet: 50-150 cases per 1000 population, approximately one in ten people over 30 has signs of carpal syndrome. 10% of patients under the age of 31. Carpal tunnel syndrome is several times more common in women than in men.

Causes of carpal syndrome.

Carpal syndrome is better called compression neuropathy of the median nerve - a large nerve upper limb, responsible for many movements of the forearm, hand, fingers, for sensitivity. But in the carpal canal, a narrow space is allocated to him. Here he can easily get hurt. Constant, monotonous movements with fingers, a brush, such as writing, typing on a computer, doing housework, collecting items from small items, sewing with a needle, can lead to the development of this disease. People involved in sports such as tennis, volleyball, often develop this disease. There is an anatomical version of the structure of the canal, the structure of the median nerve, when a person is initially predisposed to traumatizing the latter. Carpal syndrome is associated with compression of not only the median nerve, but also other nerve fibers accompanying the vessels of the palm.

carpal tunnel syndrome. Symptoms.

What does a person complain about with this disease? On numbness and paresthesia (feeling of "goosebumps", "insect crawling", tingling) in the palm, fingers, pain in the wrist joint, in the fingers, weakness of the fingers. Usually in the large, index, middle and part of the ring. It becomes difficult to perform many small movements and actions with the hand and fingers: holding small objects between the thumb and forefinger; the difficulty of opening a jar, for example. There are patients with complaints of pain and numbness of the whole arm, increased paresthesia at night. When a doctor examines a person with the above complaints, he usually finds a decrease in sensitivity in the first 3 fingers. Flexion or extension of the hand causes increased pain, paresthesia due to additional effects on the median nerve. With severe and prolonged compression of the nerve, not only weakness occurs, but also atrophy of the muscles of the palm, primarily the elevation of the thumb. Right-handers have pain and numbness in the fingers of the right hand. Left-handers have pain and numbness of the fingers of the left hand, respectively. Sometimes the disease develops on both hands.

Carpal syndrome must be differentiated (separated) from polyneuritis of a diabetic, alcoholic nature, from manifestations of osteochondrosis, manifestations of diseases, manifestations, metabolic disorders in the body. Carpal syndrome can be combined with other neurological painful manifestations.

Many people do not consider the symptoms they have described to be serious in order to consult a doctor. And in vain - the prognosis of the disease depends on the timely accurate diagnosis and subsequent treatment.

It is necessary to begin treatment with the creation of functional rest for the hand and fingers. For this purpose, you can use special, sold in orthopedic salons, devices, gloves. Such a device can be quite simply made by yourself. The doctor who treats this pathology will tell you in detail how to do this, how to set the hand in a physiological position in which pressure on the median nerve is minimal. Physiotherapy helps well - exposure to ultrasound, diathermy, inductothermy, microwaves. Massage with rubbing anti-inflammatory, warming ointments gives a good effect. This is a non-specific treatment for inflammation of the tissues surrounding the median nerve. After the removal of acute phenomena, exercises for the hands are advisable - physiotherapy exercises. In a short course for pain, you can use non-steroidal anti-inflammatory drugs - tablets, ointments, injections. Special blockades with an anesthetic and anti-inflammatory agent help well. Some doctors prefer to start treating the patient right away with the blockade. In addition, fixation of the joint for several days is recommended. Usually the effect lasts six months, even more. Conservative treatment helps in 90% of cases. The only question is - for what period of time and is the patient ready to strictly follow and fulfill all the doctor's recommendations? Most experts believe that conservative treatment with little effect should not be delayed for more than a month. It is more expedient to perform a fairly simple operation to decompress the median nerve.

I think that this approach is logical. Surgical treatment with the release of the median nerve under the transverse ligament of the palm eliminates pain, paresthesia.

Who treats carpal syndrome? Neurologists, orthopedic traumatologists, surgeons, and sometimes rehabilitation doctors. With correct and timely diagnosis, many people can be helped.

Definition of carpal tunnel syndrome

Orthopedic doctors talk about carpal tunnel syndrome when there is damage to the median nerve (Nervus Medianus) at the wrist. With tissue edema, pressure on the median nerve (Nervus Medianus) increases, which, as a result, causes it to be pinched.

Carpal tunnel syndrome is one of the most common diseases diagnosed by orthopedists. Approximately every tenth inhabitant of Germany faces this disease during his life.

The carpal canal is located on inside wrist, at the base of the hand and is surrounded by a ligament of connective tissue - the ligament of the wrist. Through the carpal canal pass the tendons and the median nerve (Nervus Medianus), which controls certain muscles of the hand and fingers, and is also responsible for sensitivity in the thumb, index, middle and part of the ring fingers.

Damage to the median nerve is accompanied by the following symptoms:

• decreased sensitivity of the hands
• a feeling of tingling and numbness in the hands, especially in the area of ​​the thumb and middle fingers
• pain with grasping movements
• pain in fingers radiating to hand

Symptoms appear, as a rule, at night, in the morning and are aggravated by additional stress on the hands.

Orthopedists diagnose carpal tunnel syndrome primarily in people over the age of 40. In women, the disease occurs three times more often than in men. In a particularly severe case, numbness can become permanent and lead to atrophy of the muscles of the palmar cavity (at the base of the thumb).

Synonyms: carpal tunnel syndrome (CTS), carpal tunnel syndrome (CTS), median nerve compression syndrome, nerve compression syndrome.
The term in English lang: carpal tunnel syndrome

Description

Carpal tunnel syndrome occurs primarily in people aged 40-70 years. In children, orthopedists diagnose this disease extremely rarely. Patients wake up in the morning because their arm is numb or tingly. If you shake your hand, then, as a rule, complaints disappear. In the future, motor disturbances are added to sensory disorders, for example, a decrease in strength in the thumb.

Carpal tunnel syndrome often develops not on one, but immediately on both hands. At first, complaints appear only periodically. However, prolonged pressure on the median nerve (Nervus Medianus) inevitably leads to its damage. If carpal tunnel syndrome is not monitored by an orthopedic doctor, the muscles at the base of the thumb will atrophy. Damage to the median nerve and severe muscle atrophy cannot be restored. Therefore, it is important to seek the help of an orthopedic doctor in a timely manner.

Causes of Carpal Tunnel Syndrome

Quite often it is impossible to identify any specific cause of the occurrence this disease. In this case, orthopedic doctors speak of idiopathic carpal tunnel syndrome, which mainly occurs in women during menopause due to excessive accumulation of fluid and tissue edema in the carpal tunnel. Also, pregnancy can trigger the development of carpal tunnel syndrome.

In addition to the above, orthopedists name the following causes of the onset of the disease:

• hypothyroidism (hypothyroidism)
• deformities and displacements in the wrist area after previous injuries
• rheumatic diseases
• scar tissue that puts pressure on a nerve
• chronic inflammation of the tendon sheaths (tenosynovitis)
• swelling and inflammatory tissue swelling
• diabetes
• dialysis therapy for kidney failure

It is still not clear whether carpal tunnel syndrome is inherited. However, often orthopedic doctors diagnose the disease in several maternal family members.

In people of certain professions, whose wrist during long period time is subjected to excessive stress, the risk of developing carpal tunnel syndrome is significantly increased.

What can you do about carpal tunnel syndrome?

Orthopedic doctors advise avoiding stress and refusing to perform heavy physical work. Shaking and cooling the hand can provide short-term relief from pain. A good effect is exerted by applying an ice pack wrapped in a towel to the wrist area.

Splinting the wrist at night and during the day helps keep the wrist extended, thereby preventing pressure on the median nerve. For those who work a lot at the computer screen, it is highly recommended to use an ergonomic keyboard.

Help from experts

Depending on the symptomatology, in addition to consulting your doctor, a detailed diagnosis by various specialists may follow. These include:

• orthopedist
• neurologist

What awaits you at the appointment with an orthopedic doctor?

Before the orthopedic doctor starts the examinations, he will start with a conversation (anamnesis) about your current complaints. In addition, he will also ask you about past complaints, as well as the availability possible diseases.
The following questions may await you:

• How long ago did the symptoms start?
• Could you describe the symptoms more precisely and localize them?
• Have you noticed any changes in the process of symptomatology?
• Are you experiencing additional symptoms like shortness of breath, chest pain, dizziness?
• Have you already experienced something similar and performed similar symptoms in family?
• Do you currently have any diseases or hereditary predisposition to the disease and are you under treatment for this?
• Are you currently taking medications?
• Do you suffer from allergies?
• Do you often experience stress at home?

What medications do you take regularly?

Orthopedic doctor needs a review medicines that you regularly take. Please prepare a chart of the medications you are taking before your first appointment with the podiatrist. An example of such a table can be found at the link:.

Examinations (diagnosis) performed by an orthopedist

Based on the characteristics of the symptoms identified during the history and your current state The podiatrist may do the following tests:

• measurement of the speed of propagation of excitation along the fibers of the median nerve (Nervus Medianus) of the wrist
• laboratory tests
• x-ray examination
• Ultrasound (ultrasound examination of the nerve)
• electrophysiological study (EPS)

Treatment (therapy)

With light and moderate An orthopedist may prescribe a nighttime splint to relieve pain and stabilize the wrist. In the event that some other disease is the cause of the development of carpal tunnel syndrome, for example, hypofunction of the thyroid gland (hypothyroidism), the efforts of doctors will be directed primarily to the treatment of the primary disease.

To reduce pain, the podiatrist prescribes pain medications such as paracetamol, diclofenac, or ibuprofen. In addition, injections of glucocorticoids (cortisone) may be prescribed. However, in most cases, after some time, complaints reappear.

If the patient already has a violation of sensitivity (numbness) or paralysis, an operation is necessary. In this case, the ligament of the wrist is excised, reducing the load on the median nerve. Most often, the orthopedist performs the operation under local anesthesia and, as a rule, it leads to good results. After the operation, it is necessary to ensure complete immobilization of the wrist for the next two weeks. However, doctors advise patients to immediately begin active finger movements to avoid stiffness.

Preventive

Since the causes of carpal tunnel syndrome in most cases are not clear, the disease cannot be prevented. It is important to seek the help of an orthopedic doctor in a timely manner, which will avoid subsequent damage.

Forecast

Surgical intervention will help eliminate the patient's complaints about long time. After two to three weeks, the functions of the fingers and hand are restored almost to their full extent. However, surgery is not always necessary.

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

Anatomy

ZK - inelastic fibro-osseous tunnel formed by the bones of the wrist and the flexor retinaculum. Anteriorly, the ZK limits the retinaculum flexor tendons (retinaculum flexorum [syn.: transverse ligament of the wrist]), stretched between the tubercle of the navicular bone and the tubercle of the large trapezoid bone from the lateral side, the hook of the hamate bone and the pisiform bone with the medial. Behind and from the sides, the canal is limited by the bones of the wrist and their ligaments. Eight carpal bones articulate, forming together an arc, facing a slight bulge back to back side, and concavity - to the palm. The concavity of the arch is more significant due to the bony protrusions towards the hand on the scaphoid on one side and the hook on the hamate 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 proper fascia of the palm, which covers the muscles of the eminence of the thumb and little finger with a thin plate, and in the center of the palm it is represented by a dense palmar aponeurosis, which runs in the distal direction between the thenar and hypothenar muscles. The length of the carpal tunnel is on average 2.5 cm. Through the carpal tunnel pass CH and nine tendons of the flexors of the fingers (4 - tendons of the deep flexors of the fingers, 4 - tendons of the superficial flexors of the fingers, 1 - tendon of the long flexor of the thumb), which pass to the palm, surrounded by synovial sheaths. The palmar sections of the synovial sheaths form two synovial bags: the radial one (vagina tendinis m. flexorum pollicis longi), for the tendon of the long flexor of the thumb and the ulna (vagina synovialis communis mm. flexorum), common for proximal departments eight tendons of the superficial and deep flexors of the fingers. Both of these synovial sheaths are located in the carpal tunnel, wrapped in a common fascial sheath. Between the walls of the SC 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 a subsynovial connective tissue through which the vessels pass. CH is the softest and ventrally located structure in the carpal tunnel. It is located directly under the transverse ligament of the wrist (retinaculum flexorum) and between the synovial sheaths of the flexor tendons of the fingers. SN at the wrist level consists on average of 94% of sensory and 6% of motor nerve fibers. The motor fibers of the SN in the SC area are predominantly combined 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 in the dorsal position. However, the motor branch of HF has many anatomical variations that create a great deal of 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 website)

Etiology and pathogenesis

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

Allocate professional and medical risk factors for the development of CTS. In particular, professional (exogenous) factors include a static setting of the hand in a state of excessive extension in the wrist joint, which is typical for people who work at a computer for a long time (the so-called “office syndrome” [those users who, when working, are at greater risk of with a keyboard, the hand is extended ≥ 20° or more in relation to the forearm]). CTS can be caused by prolonged repeated flexion and extension of the hand (eg, pianists, painters, jewelers). In addition, the risk of SZK is increased in people working in low temperature conditions (butchers, fishermen, workers in fresh-frozen food departments), with constant vibrational movements (carpenters, road foremen, etc.). It is also necessary to take into account the genetically determined narrowing of the SC and / or the inferiority of the nerve fibers of the heart failure.

There are four groups of medical risk factors: [ 1 ] factors that increase intratunnel tissue pressure and lead to water imbalance in the body: pregnancy (about 50% of pregnant women have subjective manifestations of CTS), menopause, obesity, renal failure, hypothyroidism, congestive heart failure and oral contraceptives; [2 ] factors that change the anatomy of the carpal tunnel: the consequences of fractures of the bones of the wrist, isolated or in combination with post-traumatic arthritis, deforming osteoarthritis, disimmune diseases, incl. rheumatoid arthritis (note: in rheumatoid arthritis, HF compression occurs early, so every patient with CTS should exclude the development of rheumatoid arthritis); [ 3 ] volumetric formations of the median nerve: neurofibroma, ganglioma; [ 4 ] degenerative-dystrophic changes in the median nerve resulting from diabetes mellitus, alcoholism, hyper- or beriberi, 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. Decreased motor activity in the elderly often contributes to the development of obesity, one of the risk factors for the development of HF compression neuropathy (Evidence A).

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

note! Possible double crush syndrome, first described by A.R. Upton and A.J. McComas (1973), which consists in SN compression in several sections 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 the axon in one place makes it more sensitive to compression in another, located more distally. This phenomenon is explained by a violation of the axoplasmic current 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 than the first three fingers of the hand], daytime and nighttime paresthesias in these areas (relieved by shaking the hand]). Attention should be paid to the fact that in CZK, sensory phenomena are predominantly localized in the first three (partly in the fourth) fingers of the hand, since the sign of the hand to the fingers (palm) receives sensitive innervation from the SN branch that runs outside the ZK. Against the background of sensitivity disorders, there are motor disorders of the type of 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, lace up shoes, etc. Later, patients develop pain in the hand and I, II, III fingers, which at the beginning of the disease can be blunt, aching character, and as the disease progresses, they intensify and acquire a burning character. Pain can occur at different times of the day, but more often it accompanies attacks of nocturnal paresthesias and intensifies with physical (including positional) load on the hands. Due to the fact that HF ​​is a mixed nerve and combines sensory, motor and autonomic fibers, neurological examination in patients with compressive-ischemic HF neuropathy at the wrist level may reveal clinical manifestations corresponding to the defeat of certain fibers. Sensitivity disorders are manifested by hypalgesia, hyperpathia. A combination of hypo- and hyperalgesia is possible, when zones of increased perception of pain stimuli are found on some parts of the fingers, and zones of reduced perception of pain stimuli on others ( note: as with the other most common compression syndromes, the clinical picture may rapidly or slowly worsen or improve over time). Motor disorders in carpal tunnel syndrome are manifested as a decrease in strength in the muscles innervated by the median nerve (abductor abductor muscle of the first finger, superficial head of the short flexor of the first finger), and atrophy of the muscles of the elevation of the first finger. Vegetative disorders are manifested in the form of acrocyanosis, changes in skin trophism, sweating disorders, sensations of coldness of 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 variants of the main symptoms.

note! It is necessary to remember about the possibility of a patient having a Martin-Gruber anastomosis (AMH) - anastomosis from HF to the ulnar nerve [LN] (Martin-Gruber anastomosis, median-to-ulnar anastomosis in the forearm). In the case of the direction of the anastomosis from the FN to the SN, it is called the Marinacci anastomosis (ulnar-to-median anastomosis in the forearm).

AMG renders [ !!! ] significant impact on clinical picture lesions of the peripheral nerves of the upper limb, making it difficult to make a correct diagnosis. In the case of a connection between SN and FN, the classical picture of a certain nerve lesion may become incomplete or, conversely, redundant. So, if heart failure is affected in the forearm distal to the place of AMH discharge, 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 in the composition of the compound, sensitivity disorders can not occur or be expressed insignificantly. In the case of damage to the FN distal to the site of AMH attachment, the clinic may become redundant, since, in addition to the FN's own fibers, the fibers that come through this connection from the heart failure suffer (which may contribute to a false diagnosis of CTS). In this case, in addition to the clinical manifestations of the FN lesion, 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 the HF lesion. Sometimes the anastomosis itself can be an additional potential lesion site due to compression from the adjacent muscles.

read also the post: Anastomosis Martin-Gruber(to the website)

Characterizing the course of the disease, many authors distinguish two phases: irritative (initial) and the phase of loss of sensory and motor disorders. R. Krishzh, 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 day) paresthesias and pains, 4th - persistent disturbance of sensitivity; 5th - motor disorders. Later, Yu.E. Berzinysh et al. (1982) somewhat simplified this classification and proposed to distinguish 4 stages: 1st - episodic subjective sensations; 2nd - regular subjective symptoms; 3rd - violations of sensitivity; 4th - persistent movement disorders. In addition to the above classifications, 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: I degree (mild) - intraneural edema, in which transient paresthesias are observed, an increase in vibration sensitivity threshold; movement disorders are absent or slight muscle weakness is observed, the symptoms are inconsistent, transient (during sleep, after work, during provocative tests); II degree (moderate) - demyelination, intraneural fibrosis, increased vibration and tactile sensitivity, muscle weakness without atrophy, symptoms are transient, there are no permanent paresthesias; III degree (pronounced) - axonopathy, Wallerian degeneration of thick fibers, decreased skin innervation up to anesthesia, atrophy of the muscles of the eminence of the thumb, paresthesias are 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, with a remitting course - exacerbation or remission).

Diagnostics

Diagnosis of CTS includes: [ 1 ] medical history, including any medical problems, illnesses, injuries that the patient has had, current symptoms, and an analysis of daily activities that may cause these symptoms; [ 2 ] hand diagrams (the patient fills in the diagram of his hand: in what places he feels numbness, tingling or pain); [ 3 ] neurological examination and provocation tests: [ 3.1 ] Tinel test: tapping with a neurological hammer on the wrist (above the site of passage of CH) causes a tingling sensation in the fingers or irradiation of pain (electric lumbago) in the fingers (pain can also be felt in the area of ​​tapping); [ 3.2 ] Durkan's test: compression of the wrist in the area of ​​CH passage causes numbness and/or pain in fingers I-III, half of the IV fingers (as in Tinel's symptom); [ 3.3 ] Phalen test: 90° flexion (or extension) of the hand results in numbness, tingling, or pain in less than 60 seconds (in healthy person similar sensations may also develop, but not earlier than after 1 minute); [ 3.4 ] Gillett 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 ] Goloborodko test: the patient is opposite the doctor, the patient’s hand is held palm up, the doctor’s thumb is placed on the eminence of the thenar muscles, the doctor’s 2nd finger rests on the patient’s 2nd metacarpal bone, the thumb of the doctor’s other hand rests on the elevation of the hypothenar muscles, 2 the th finger of the doctor's hand rests on the 4th metacarpal bone of the patient; a “disintegrating” movement is made at the same time, stretching the transverse ligament of the wrist and briefly increasing the cross-sectional area of ​​the SC, while a decrease in the intensity of manifestations of HF neuropathy is observed for several minutes.

If CTS is suspected, [ !!! ] carefully study the sensitivity (pain, temperature, vibration, discrimination) in fingers I - III, then evaluate the motor activity of the hand. Basically, they examine the long flexor of the thumb, the short muscle that abducts the thumb of the hand, and the muscle that opposes it. An oppositional test is carried out: with pronounced tenar weakness (which occurs more than late stage) the patient cannot connect the thumb and little finger; or the doctor (researcher) can easily separate the closed thumb and little finger of the patient. It is important to pay attention to possible vegetative disorders.

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

The "gold standard" of instrumental diagnostics is electroneuromyography (ENMG), which allows not only to objectively examine the 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 differential diagnosis in cases with doubtful symptoms, as well as for the diagnosis of volumetric formations of the hand. MRI allows you to visualize the ligamentous, muscular apparatus, fascia, subcutaneous tissue.

One of the methods to visualize the structure of the nerve in CTS is ultrasonography (ultrasound), which allows visualization of SN and surrounding structures, which helps to identify the causes of compression. For the diagnosis of HF lesions at the level of the SC, the following indicators are significant (Senel S. et al., 2010): [ 1 ] increase in the cross-sectional area of ​​the CH in the proximal part of the SC (≥0.12 cm²); [ 2 ] decrease in the cross-sectional area of ​​CH in the middle third of the SC; [ 3 ] change in the echostructure of the SN (disappearance of internal division into bundles), visualization of the SN before entering the SC during longitudinal scanning in the form of a strand with uneven contour, reduced echogenicity, homogeneous echostructure; [ 4 ] identification using color-coded techniques of the vasculature within the nerve trunk and additional arteries along the course of heart failure; [ 5 ] thickening of the ligament - tendon retainer (≥1.2 mm) and an increase in its echogenicity. Thus, when scanning CH, the main ultrasound signs The presence of compression-ischemic SZK are: thickening of SN proximal to the carpal canal, flattening or decrease in thickness of SN in the distal part of the SC, decreased echogenicity of SN before entering the SC, thickening and increased echogenicity of the ligament - flexor retinaculum.

X-ray examination of the hands in CTS carries [ !!! ] limited information content. It acquires its main significance in traumas, systemic connective tissue diseases, osteoarthritis.

Treatment

Conservative and surgical treatment of CTS is possible. Conservative treatment is recommended for patients with mild degree disease, mainly in the first six months from the onset of symptoms. This includes splinting and wearing a brace (with the hand in a neutral position; it is usually recommended to immobilize the hand during the night's sleep for 6 weeks, but some studies have shown high efficiency splint/orthosis and during the daytime), as well as injections of glucocorticoids (GC) into the GC, which reduce inflammation and swelling of the tendons (however, GC has a detrimental effect on tenocytes: it reduces 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 made between 2 and 7 weeks from the onset of the disease. Due to the risk of developing adhesive process in the canal, many specialists do no more than 3 injections with an interval of 3-5 days. If there is no improvement in clinical and instrumental data, surgical treatment is recommended. The effectiveness of NSAIDs, diuretics and B vitamins, physiotherapy, manual therapy and reflexology has not been proven (Evidence B).

The operation for CTS consists in decompression (reducing the pressure in the area of ​​the SC) and reducing the compression of the HF by dissection transverse ligament wrist. There are three main methods of heart failure decompression: classical open approach, minimally invasive open approach (with minimal tissue dissection - about 1.5 - 3.0 cm) and endoscopic surgery. All of them are aimed at effective decompression of CH in the canal by complete dissection of the carpal ligament. Endoscopic decompression is as effective as open technique surgical intervention on the SC. The advantages of endoscopic HF decompression over open decompression methods are the smaller size postoperative scar and less pronounced pain syndrome, however, due to access restrictions, the risk of injury to the nerve or artery increases. Factors affecting the outcome of the operation are: older age of patients, permanent 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 median nerve decompression in carpal tunnel syndrome” Gilveg A.S., Parfenov V.A., Evzikov G.Yu.; Federal State Autonomous Educational Institution of Higher Education “First Moscow State Medical University named after I.I. THEM. Sechenov" Ministry of Health of the Russian Federation, Moscow (journal "Neurology, neuropsychiatry, psychosomatics" No. 3, 2018) [read]

More about SZK in the following sources:

article "Carpal Tunnel Syndrome: Anatomical and Physiological Basis for Manual Therapy" by A.V. Stephanidi, 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 "Diagnosis 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" 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 (Privolzhsky) Federal University, Kazan; Kazan State Medical University, Kazan (Practical Medicine magazine No. 4, 2014) [read];

article "Carpal tunnel syndrome (literature review)" Khalimova A.A., medical Center"Rakhat", Almaty, Kazakhstan (magazine "Herald of the AGIUV" special issue, 2013) [read];

article "Carpal Tunnel Syndrome in the Elderly" by A.S. Gilveg, V.A. Parfenov; First Moscow State Medical University. THEM. Sechenov (magazine "Doctor Ru" No. 1, 2017) [read];

article "Carpal Tunnel Syndrome in postpartum period» 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. Evzikov, Z.A. Suslin, N.N. Yakhno; Department of Nervous Diseases First Moscow State Medical University them. THEM. Sechenov; Centre radiodiagnosis Federal State Budgetary Institution "Treatment and Rehabilitation Center" of the Ministry of Health of the Russian Federation; Federal State Budgetary Institution "Scientific Center of Neurology" RAMS, Moscow (Neurological Journal, No. 3, 2013) [read];

article "Carpal Tunnel Syndrome in rheumatic diseases» E.S. Filatov; Federal State Budgetary Institution "Research Institute of Rheumatology named after N.N. V.A. Nasonova" RAMS, Moscow (journal "Neuromuscular Diseases" No. 2, 2014) [read];

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

article "Change 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 VPO North-Western State Medical University. I.I. Mechnikov, St. Petersburg (Medical Visualization magazine No. 1, 2014) [read];

article "The 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 health institution of the Yaroslavl region " Clinical Hospital No. 8, Yaroslavl; SBEI HPE "Yaroslavl State Medical Academy" of the Ministry of Health of the Russian Federation (journal "Neuromocular Diseases" No. 2, 2014) [read];

article " Modern methods diagnosis of carpal tunnel syndrome” N.V. Zabolotskikh, E.S. Brileva, A.N. Kurzanov, Yu.V. Kostina, E.N. Ninenko, V.K. Bazoyan; FPC and teaching staff of GBOU VPO KubGMU Ministry of Health of the Russian Federation, Krasnodar; Research Institute-KKB No. 1 im. 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" N.G. Savitskaya, E.V. Pavlov, N.I. Shcherbakova, D.S. Yankevich; Scientific Center of Neurology of the Russian Academy of Medical Sciences, Moscow (magazine "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 damage to the median nerve" A.V. Stephanidi, I.M. Dukhovnikov; Irkutsk State Medical Academy of Postgraduate Education, Irkutsk (Journal "Manual Therapy No. 2, 2016) [read];

article "The use of local administration of corticosteroids in the treatment of carpal tunnel syndrome" V.N. Kiselev, N.Yu. Aleksandrov, M.M. Korotkevich; FSBI All-Russian Center for Emergency and Radiation Medicine named after V.I. A.M. Nikiforov" Ministry of Emergency Situations of Russia, St. Petersburg; FGBOU DPO "North-Western State Medical University named after N.N. I.I. Mechnikov, Ministry of Health of the Russian Federation, St. Petersburg; Russian Research Neurosurgical Institute. 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 (journal "Neuromuscular Diseases" No. 1, 2018) [read];

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

article "Carpal Tunnel Syndrome: state of the art question” A.V. Baitinger, D.V. Cherdantsev; Federal State Budgetary Educational Institution of Higher Education "Krasnoyarsk State Medical University. professor V.F. Voyno-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" Gilveg A.S., Parfenov V.A., Evzikov G.Yu.; Federal State Autonomous Educational Institution of Higher Education “First Moscow State Medical University named after I.I. THEM. Sechenov" Ministry of Health of the Russian Federation, Moscow (journal "Neurology, neuropsychiatry, psychosomatics" 2019, App. 2) [read]