Lg complex after carpal tunnel surgery. Carpal syndrome - treatment

carpal tunnel syndrome- these are changes of a traumatic nature, caused by constant tension, when the median nerve is compressed. The disease usually resolves against the background of an inflamed tendon.

The result may be:

• Numbness and soreness of the wrist or entire arm;
• Sensation of weakness in the fingers and in the arm, chiefly during nocturnal rest.

It is believed that given state associated with the performance of professional duties.

Causes of the disease

The cause of the disease can be a narrowing of the carpal tunnel of the wrist or an increase in the tissues inside. In a wrist fracture, carpal tunnel involvement can cause bone loss.

The risk group also includes people performing professional duties related to:

• The application of effort;
• Uncomfortable position of the wrist;
• vibrating instruments;
• Monotonous repetition of monotonous movements.

With a combination of risks, the likelihood of developing the disease increases.

The cause of the disease can be inflammation of the synovial membrane. As the pressure increases, the nerve stops functioning normally.

What happens when a nerve is compressed?

The blood supply to the outer sheath of the nerve slows down, the blood stops flowing. This condition is called ischemia. At first, the outer sheath of the nerve is affected, but with an increase in its pressure inner part becomes thicker, as new cells are formed - fibroblasts and scar tissue.

As a result, the patient feels pain, the hand becomes numb. When the pressure normalizes, the symptoms quickly recede. In the absence of timely treatment, the chances of recovery are reduced or lost.

Diagnostics

Diagnosis can be made by questioning and examining the patient based on characteristic areas of numbness and pain symptoms. A characteristic indicator is night pain and numbness of the hand.

Important information for diagnosis is the absence of damage to the little finger. To check, the patient is recommended to pinch his little finger.

The next group of complaints is numbness during certain activities - driving a car or sweeping.

If symptoms occur after injury, they are performed to exclude a fracture.

To obtain additional data, electrical stimulation is also prescribed, with the help of which the performance of the nerves of the hand and the speed of passage of impulses through the nerve are checked.

It is important to exclude problems of a different kind that provoke an increase in the symptom - pain in the shoulder, elbow or neck,.

How is the treatment carried out?

Several types of treatment for carpal tunnel syndrome are used, which the doctor prescribes depending on the individual characteristics of the clinical picture.

conservative

It is necessary to exclude or change the activity that caused the existing symptoms:

• Do not perform repetitive brush strokes;
• Do not hold vibrating instruments;
• Do not perform activities that require arching of the wrist.
• It is recommended to stop smoking, get rid of excess weight.
• In the early stages, the position will make it easier to wear a brace that keeps the wrist in the correct position.

Medical

Prescribe anti-inflammatory drugs and vitamin B-6.

Relieve swelling and temporarily relieve symptoms of cortisone injections.

Physiotherapy

Specific exercises help prevent or control symptoms.

The goal is to get rid of excess pressure in the carpal tunnel.

The physiotherapist will analyze the performance of duties for risks and advise how to normalize the situation.

Surgical treatment

In case of unsuccessful attempts to restore by conservative methods, an operation using local anesthesia is recommended:

• An incision is made in the palm (≤ 5 cm) to see connective tissue;
• The transverse ligament is cut;
• The skin is stitched.

Over time, the free space between the ends of the ligaments is scarred.

Rehabilitation after surgery

At successful treatment relief is felt after 1.5-2 months.

A physiotherapist will advise you on how to avoid a reoccurrence of the problem in the future.

Treatment of carpal tunnel syndrome is carried out in Moscow, at the clinic of the Central Clinical Hospital of the Russian Academy of Sciences. You can make an appointment online. The price of treatment and other information can be found by phone.

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

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

Most researchers are of the opinion that the root cause of the disease is many hours of work with monotonously repetitive movements of the hands. Such work has a permanent, mechanically traumatic effect on the area of ​​the wrist joint and carpal tunnel. For example, Liu et al. based on their own research, they came to the conclusion that carpal tunnel syndrome occurred in every sixth of the examined workers working on a computer.

Today, work on a computer is considered as one of the main factors provoking the development of CTS. The information field is replete with accusations against the keyboard and mouse, serious research is being carried out in this direction. An alternative, not official name for the problem appeared - "Computer Mouse Syndrome" or "Mouse Disease". By analogy, smartphones are also considered risk factors. Apparently, next in line is a new name for the disease - "Smartphone Syndrome".

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

According to Hanrahan, there are between 400,000 and 500,000 CTS surgeries per year in the United States of America, and economic costs exceed $2 billion. According to other sources, it costs about $30,000 to treat one CTS patient in US A.

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

From the above data, it can be seen that the disease has an unclear prognosis in relation to the restoration of impaired functions. upper limbs, often leads to a decrease in household adaptation, unsuitability, and sometimes disability. Therefore, it is very important to continue to develop effective methods for early detection of the disease and its pathogenetically substantiated treatment.

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

Definition (common version)

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

Anatomy

Carpal Canal (Anatomical and physiological features)

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

Median nerve (anatomical and physiological features)

Median nerve (lat. Nervus medianus), comes from the fibers of the lower cervical and first thoracic (C5 - T1) roots spinal cord and is formed as a result of the fusion of the lateral and medial bundles of the brachial plexus. The brachial plexus itself is located, as in the sphincter, between the anterior and middle scalene muscles, as well as 1 rib from below. On the forearm, the nerve exits between the superficial and deep muscles of the flexors of the fingers and gives them its branches. After that, through the opening of the carpal tunnel, it penetrates the palmar surface of the hand, along with the tendons of the flexor muscles. In the canal, the nerve is located most superficially, directly under the transverse carpal ligament. Then, it divides into branches and innervates the region of the thumb, middle and part of the ring fingers. The median nerve is mixed, it consists of sensory (sensory), motor and autonomic fibers. The latter carry out metabolism and regulate the tone of the walls of the blood and lymphatic vessels of the hand. To function properly, a nerve must be able to glide freely over surrounding tissues and structures. When moving the limbs, the nerve is capable of sliding in the longitudinal direction within a few millimeters, which protects it from overstretching (Kalmin O.V., 1988; Sunderland S., 1990; Lundborg G., 1996). Normally, the median nerve is not compressed in the carpal tunnel and hand movements do not impair its function.

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

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

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

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

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

Atrophy of the muscles of group I of the finger with compression of the fibers of the median nerve

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

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

In confirmation of our point of view, we present photographs of patient N., 41 years old. Diagnosis: Cervical osteochondrosis. Radicular compression syndrome C5-T1 with a primary lesion of the median nerve.

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

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

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

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

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

Not infrequently, CTS is observed on both hands. At first, the disease manifests itself on one hand, then the second hand is also involved in the process. It is logical to assume that the symmetrical spread of the disease process has one genesis - and this is cervical osteochondrosis.

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

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

MRI patient with KTS

TREATMENT

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

There are people who, by occupation, are at risk of a disease called "carpal tunnel syndrome." Programmers, system administrators, machinists, drivers, hairdressers, as well as those who are engaged in knitting and embroidery, playing the cello, violin or piano, often complain of pain in the wrist of the “working” hand. However, anyone can get sick, regardless of their occupation. Women are more likely to get sick, as their wrists are thinner.

Carpal tunnel syndrome (carpalis - from Latin means carpal tunnel) is a set of symptoms that are caused by compression of the median nerve in the carpal tunnel. After monotonous work with a brush, a person feels numbness, weakness of the hand, pain in it.

Causes

In order for the wrist to be sufficiently mobile and at the same time stable, its bones are connected by many strong ligaments. Inside the wrist there is a fibrous rim through which the tendons and nerves of the hand pass - the carpal tunnel.

A large number of the same type of movements (including when working with a computer mouse) or an uncomfortable position of the hands, which leads to the fact that the wrist is constantly in tension, can cause swelling of the tendons and ligaments that form this narrow tunnel, and hence the pinched nerves. This is the root cause of the syndrome.

However, factors such as:

• Heredity.
• Age after 50 years.
• Fractures, injuries, bone outgrowths, cysts, tumors in the wrist area.
• Obesity.
• Infections.
• Hormonal changes in pregnant or menopausal women leading to a delay excess fluid in the synovial membranes (the inner layer of the joints).
• Smoking and alcohol, which cause a decrease in blood flow to the median nerve.

Clinical manifestations of the disease can occur not only when a person works with a brush, but even in a dream. Helps reduce symptoms by changing the position of the hand or shaking the hand.

Initially, they can come and go, but over time they inevitably turn into constant companions of the disease. It can get to the point that it becomes difficult to perform any movement associated with finger work: buttoning a shirt or tying shoelaces.

What does a person feel?

• Tingling (including at night).
• Numbness and swelling of the fingers.
• Weakness in the muscles of the hand.
• Pain in the fingers or in the entire hand (often resembling a backache or a sharp electric shock).

A neurologist examines such a patient. He can determine:

With the help of effleurage over the area of ​​the carpal tunnel, the patient's reaction in the form of "lumbago" in the fingers (the so-called Tinel's symptom);

With the help of maximum flexion of the wrist in the wrist joint for 1 minute, the patient's reaction in the form of weakness, numbness or tingling (the so-called Phalen test).

The history of the disease, its additional factors (indirect causes) are studied.

As additional methods diagnostics apply:

1. Electroneuromyography (the degree of damage to the muscles of the forearm is established).
2. Nerve conduction velocity (is it normal).
3. X-ray of the wrist joint (its goal is to exclude other diseases of the hands).

Treatment

The main methods of treatment of carpal tunnel syndrome are conservative and surgical.

The first is used when the disease is diagnosed in the early stages. The more pronounced the symptoms and the more often they disturb the patient, the more severe the form of the disease and the less likely that conservative treatment will be effective. In such cases, it is preferable surgical intervention.

Conservative treatment involves:

• Fixation of the wrist joint (an orthosis is put on at night - a special orthopedic apparatus; it fixes the hand in a physiological (natural) position; during the day, while working, you can wear splints).
• Taking medication to reduce pain and reduce inflammation (for example, treatment with Nimesil or Nurofen).
• shift professional conditions if the work is associated with an active load on the hands.
• Steroid injections (such as prednisolone or dexamethasone) that are given into the carpal tunnel to reduce symptoms.

If treatment with conservative methods for six months has not yielded results, then surgical intervention is inevitable.

This operation is usually performed on an outpatient basis. local anesthesia. The carpal ligament (in other words, the transverse carpal ligament) is surgically dissected.

The recovery period lasts a couple of months and suggests the possibility of minor pain, swelling, stiffness in the hand. In order to exclude such consequences, a rehabilitation program is individually developed for the patient with a whole range of measures for effective recovery brush functions.

The hand will completely return to normal within a year: the more neglected the disease was, the longer it will take.

Eat well during treatment. If you provide the body with all the vital biologically active substances, then recovery will be accelerated, and the period of rehabilitation and restoration of working capacity will be reduced.

First of all, you need to make your workplace convenient. When working with the keyboard, strictly follow the angle of the bend of the arm at the elbow - 90 °. When working with the mouse, keep an eye on the brush - straight and lies on the table away from the edge (the elbow should also be on the surface of the table). Use a special wrist support (the same mouse pad). The chair or work chair must have armrests.

Secondly, during the work, take breaks and do preventive exercises that will improve blood circulation in the muscles of the wrist and help stretch them:

• Shake your hands.
• Clench your fingers into fists (5-10 times).
• Rotate your fists around your axis.
• Press the left hand on the fingers of the right (as if turning the palm and wrist outward) and vice versa.

And finally, adjust your diet, eliminate smoking, be friends with sports and stick to normal weight body.

Forecast

As for the prognosis for carpal tunnel syndrome, timely diagnosis and comprehensive, adequate treatment will make it favorable. It is absolutely impossible to start the disease: irreversible damage to the nerve is fraught with loss of working capacity of the hand.

Below is a video - an excerpt from E. Malysheva's program about carpal tunnel syndrome:

Carpal tunnel syndrome is a condition in which the median nerve is compressed at the wrist. It can be said that tunnel syndrome is a disease of the century, which is currently widespread, especially among IT people who work at a computer for a long time. The disease belongs to neurological diseases and is included in the group of tunnel neuropathies.

The syndrome is manifested by very unpleasant symptoms: prolonged numbness of the fingers and acute pain in the wrist. Long pastime at the computer, constant monotonous loads on the hand when using a robot with a mouse lead to a narrowing of the anatomical canal, which infringes and squeezes peripheral nerve in the carpal tunnel.

What is carpal tunnel syndrome

Tunnel syndromes are not an independent disease, but a complex clinical symptoms caused by pinching and compression of the nerve in narrow spaces, the so-called anatomical tunnels. The walls of such tunnels are natural channels that normally allow peripheral vessels and nerves to pass freely. At various pathologies their narrowing occurs, which leads to compression of the vessels and nerves passing through it.

Pathology at all times occurred in women much more often than in men. This is due to the fact that women are more likely to perform monotonous monotonous work, which puts a strain on the muscles of the hand. Among men, the disease affects programmers working at a computer. Compression of the carpal nerve can be caused by thickening of the tendons that are close to the median nerve, as well as damage to the nerve itself: its thickening and swelling.

Carpal tunnel syndrome develops as a result of repetitive movements that involve the same wrist muscles. The first symptoms appear when using a computer mouse, when the hand is in a permanent wrong position. This puts a lot of pressure on the wrist and can be complicated by cubital tunnel syndrome. It is the computer mouse that is responsible for the spread of the disease around the world. And since computers are in every home and young people sit online for many hours, the disease takes on the character of a pandemic.

Causes of the syndrome

Above we have already written about the causes of the development of the pathological process. Any pathological processes that reduce the size anatomical canals and contributing to the compaction of tissues inside it, can cause the development of carpal tunnel syndrome. There are many additional factors that can provoke the development of the syndrome. These include:

1. Wrist injuries (sprains, fractures, bruises);
2. Pregnancy. In this period female body subject to many phenomena, such as edema. When the body accumulates significant amount fluid, then there are problems with the nerve fibers, since the edema has high blood pressure on the wrist, resulting in a pinched nerve.
3. metabolic disorders ( diabetes).
4. Rheumatoid arthritis.
5. Hormonal disruptions. During the period of hormonal changes, mainly in women, there are problems with the joints, which are often accompanied by tunnel neuropathies.

The above problems can cause unpleasant symptoms when you do the following:

• monotonous monotonous actions with hands;
• with an uncomfortable position of the hands;
• while talking on a mobile phone;
• while doing exercise with emphasis on the wrist;
• with prolonged vibration (working with the keyboard);
• with prolonged use of the mouse (the brush is in a suspended state).

In addition, the situation can be aggravated bad habits: smoking, alcohol, obesity.

Symptoms

Primary symptoms that appear on early stage ailments, characterized by tingling in the fingers, severe but short-lived pain at the site of the median nerve. As the disease progresses, the symptoms get worse and worse. Most clearly, the symptoms make themselves felt at night, which prevents a person from having a good rest. At the same time, a person cannot fall asleep until the morning due to extremely unpleasant numbness of the hand and severe pain, he develops insomnia and chronic fatigue.

The syndrome has its characteristics. For example, not the whole hand becomes numb, but only three of its fingers: the thumb, index, middle and half of the ring finger, the little finger is never affected in this pathology. In very advanced cases, the functionality of the hand is disrupted, it cannot be clenched into a fist, there are pain when trying to connect the thumb and little finger, a person is not able to take an object in his hand, and then hold it. In other words, fine motor skills are disturbed and the hands stop obeying, which can lead to muscle atrophy and disability.

A person becomes helpless and vulnerable, he cannot drive a car, talk on the phone, work at a computer, perform household activities, and take care of himself.

All symptoms for initial stage diseases are reversible and are safely eliminated. In advanced cases, surgical treatment may be required, in which the canal is widened and excess tendons are removed.

Timeline of symptoms:

1. During monotonous and monotonous movements (for example, at the computer, or when knitting), there is a strong dull pain in the area where the nerve passes, which radiates to the thumb, index and middle fingers. To eliminate the pain, it is enough to stop and shake your hands several times, and also take a half-hour break. The problem occurs due to poor patency of the nerve and circulatory disorders. On the this stage all symptoms are reversible.
2. If the problem was ignored for a long time, then after a certain time, the tingling and burning sensation in the hand no longer goes away on its own, but haunts a person even after hours for several hours, turning into a constant dull pain. Cause constant pain are the compaction of the tendon located around the nerve. It begins to put pressure on the nerve and there are pains on the inside brushes that give into the fingers.
3. The body tries to compensate for unfavorable factors, therefore, an accumulation of lymphatic fluid is observed between the cartilages, which carries away fragments of the affected tissue and cells with the lymph flow. In its natural state, this process is great at troubleshooting, and the fluid is self-absorbing. At constant loads inflammatory process unable to regress and its self-repair is impossible. Therefore, prolonged swelling and stagnation of lymph are irreversible without additional treatment. Edema and numbness are significant at night, and if they are accompanied by severe pain, then the disease has reached its climax. And soon the only way out will be surgery.

Diagnostics

Diagnosis is carried out by an experienced neurologist or neurosurgeon, since a doctor of another specialization will not be able to distinguish short-term nighttime numbness of the hand from a pathological process. The main diagnostic method is to determine the speed of nerve conduction of impulses. For this purpose, electromyography (EMG) or electroneuromyography (ENG) is performed. The latter allows you to differentiate carpal tunnel syndrome from spinal hernia and osteochondrosis.

How is electromyography performed? The patient, who is sitting in a comfortable chair, is placed on the hand with electrodes, having previously processed them antiseptic. The electrodes are connected to a special electromyograph apparatus. Electrical impulses are passed through the electrodes, and the nerve conduction. The result is displayed on a computer monitor and simultaneously recorded on paper in the form of waves. The result of electromyography is very similar to an electrocardiogram and is performed on the basis of the same principles. The specialist studies and evaluates the result to reach a verdict.

It is also possible to diagnose the disease on the basis of some tests.

Testa Fallen. To perform the test, it is necessary to bend and unbend the brushes by 90 degrees (see figure). A feeling of numbness or tingling occurs immediately within 20 seconds. At healthy person numbness and pain can also be observed, but not earlier than after 1 minute.

Tinel test. When tapping with a neurological hammer, tingling and irradiation of pain in three fingers are felt. Sometimes tapping causes acute pain.

Durkan test. Mechanical compression of the wrist in the area of ​​the nerve causes numbness of the thumb, index, middle and sometimes half of the ring finger.

An oppositional test is also carried out, which consists in the impossibility of connecting the thumb and little finger. This phenomenon develops as a result of thenar weakness (elevation at the base of the thumb).

Treatment of carpal tunnel syndrome

Treatment of the disease is carried out in three directions:

• drug treatment;
• physiotherapy;
• gymnastic exercises;
• surgery.

Medical treatment

At an early stage of the disease, the patient's condition can be improved with the help of medicines. Such treatment is carried out on an outpatient basis. Prescribe drugs of the NSAID group (non-steroidal anti-inflammatory drugs), which quickly relieve inflammation, pain and swelling:

• diclofenac;
• ibuprofen;
• nimesulide;
• analgin.

Use to relieve pressure in the area of ​​a pinched nerve hormonal preparations corticosteroids injected directly into the carpal tunnel. Injections are very effective in dealing with pain, swelling and inflammation.

Vitamin B is good therapeutic effect since the vitamin itself has an anti-inflammatory effect.

It should be noted that symptomatic treatment with help medications does not lead to complete healing, but only alleviates the patient's condition. Therefore, along with medicines, it is recommended to wear an orthosis. Wearing an orthosis allows you to remove nighttime symptoms, which are especially exhausting for the patient.

Physiotherapy

As a physiotherapy treatment use:

1. Paraffin baths. A sick hand is lowered into a bath with molten paraffin. Then the procedure is repeated 3-4 more times until the so-called paraffin glove is formed on the hand. Then a special glove is put on the hand with paraffin or the hand is wrapped in a warm towel. Joints and tendons under the influence of hot paraffin warm up, which relieves inflammation, swelling and pain.
2. Ultraviolet therapy. In this treatment, tendons and joints are heated by short-wave electromagnetic waves in the range of several gigahertz.
3. Ultrasonic treatment. Exposure to high frequency sound waves leads to an increase in temperature in the treated area, which improves the conductivity of the channel, relieves swelling and pain. A two-week course of ultrasound treatment can significantly reduce the manifestation of symptoms.
4. Manual therapy. During the treatment with this method, improvements in the blood circulation of the hand were noticed.

Gymnastic exercises

Exercises can be performed independently at home, so their advantage is obvious.

Exercise number 1. Dip your hand in a bath of hot water, clench it into a fist and rotate it in the water. Hot water should be the right temperature to keep your hand warm. The duration of the procedure is no more than 15 minutes. After finishing, put on a winter glove or wrap your hand in a warm cloth or scarf.

Exercise number 2. Night warming compress, which is made on the basis of diluted alcohol or vodka. Do not take pure medical alcohol, it can burn the skin on your hand.

Exercise number 3. Massage. It is necessary to massage the entire arm, and not just the brush, starting from the outside of the palm, rising up to outside forearm. Massage should be performed by a professional massage therapist.

Exercise No. 4 Hydromassage. You can do it yourself twice a day. Cool and warm water is used in the morning, and warm in the evening. Massage should affect the collar part, shoulder blades, shoulders, forearms, hands.

Surgery

Carried out in severe neglected cases, when all other methods are ineffective. aim surgical intervention is the excision of the ligament that puts pressure on the median nerve.

There are two types of operations:

• endoscopic;
• classic open intervention.

An endoscopic procedure involves the use of an endoscope that is inserted into the carpal tunnel through a pinpoint incision. This is a minimally invasive operation that leaves a small dot on the patient's skin. The recovery period after such a procedure is short and almost painless.

The classic open procedure involves a larger incision on the inside of the palm. After this type of intervention, the scar remains larger and recovery period longer.

radial tunnel syndrome

It is an increase in pressure on the radial nerve, which is located in the muscles and bones of the elbow, as well as the forearm. The causes of this disease can be:

• injury;
• lipomas (benign tumors);
• inflammation of surrounding tissues;
• osteochondrosis;
• spinal hernia.

Symptoms of the disease are acute pains that have a burning character on back side brushes and in the upper part of the forearm, appearing when trying to straighten the fingers and wrist. Unlike carpal syndrome, radial tunnel syndrome does not cause numbness or tingling because the radial nerve is responsible for muscle contraction.

Compression-ischemic lesion of the median nerve in the carpal (carpal) canal. It is manifested by pain, decreased sensitivity and paresthesia in the area of ​​the palmar surface of the I-IV fingers, some weakness and awkwardness when moving the brush, especially if you need a gripping movement with your thumb. Diagnostic algorithm includes examination by a neurologist, electrophysiological testing, biochemical blood tests, radiography, ultrasound, CT or MRI of the wrist area. Treatment is mainly conservative - anti-inflammatory, anti-edematous, analgesic, physiotherapy. If it fails, an operative dissection of the carpal ligament is shown. The prognosis is favorable, subject to the timeliness of therapeutic measures.

ICD-10

G56.0

General information

Carpal tunnel syndrome (carpal tunnel syndrome) - compression and ischemia of the median nerve with a decrease in the volume of the carpal tunnel in which it passes, passing from the forearm to the hand. In neurology, it belongs to the so-called. tunnel syndromes. The carpal canal is located at the base of the hand from its palmar surface, is formed by the bones of the wrist and the transverse ligament stretched over them. Passing through it, the median nerve enters the palm. In the canal under the trunk of the median nerve, the tendons of the flexor muscles of the fingers also pass. On the hand, the median nerve innervates the muscles responsible for abduction and opposition of the thumb, flexion of the proximal phalanges of the index and middle fingers, and extension of the middle and distal phalanges of the same fingers. Sensitive branches provide superficial sensitivity of the skin of the tenor (elevation of the thumb), the palmar surface of the first three and half of the 4th finger, the rear of the distal and middle phalanges of the 2nd and 3rd fingers. In addition, the median nerve provides autonomic innervation to the hand.

Causes of Carpal Tunnel Syndrome

Carpal tunnel syndrome occurs in any pathological process that leads to a decrease in the volume of the canal. A tendency to disease may be due to congenital narrowness or structural features of the canal. Thus, women have a narrower carpal tunnel, and carpal tunnel syndrome occurs in them much more often than in men.

One of the reasons for the narrowing of the carpal tunnel is a wrist injury: bruise, fracture of the bones of the wrist, dislocation in the wrist joint. In this case, the volume of the canal can decrease not only due to displacement of the bones, but also due to post-traumatic edema. A change in the ratio of the anatomical structures that form the carpal canal due to excessive bone growth is observed in the case of acromegaly. Carpal tunnel syndrome can develop against the background of inflammatory diseases (synovitis, tendovaginitis, rheumatoid arthritis, deforming osteoarthritis, acute and chronic arthritis, joint tuberculosis, gout) and tumors (lipomas, hygromas, chondromas, synoviomas) of the wrist area. The cause of carpal syndrome may be excessive swelling of tissues, which is noted during pregnancy, kidney failure, endocrine pathology(hypothyroidism, menopause, condition after oophorectomy, diabetes mellitus), taking oral contraception.

A chronic inflammatory process in the area of ​​the carpal tunnel is possible with constant trauma associated with professional activities involving repeated flexion-extension of the hand, for example, in pianists, cellists, packers, carpenters. A number of authors suggest that prolonged daily work on a computer keyboard can also provoke carpal tunnel syndrome. However, statistical studies have not revealed significant differences between the incidence among keyboard workers and the average incidence of the population.

Compression of the median nerve primarily leads to a disorder of its blood supply, i.e., to ischemia. At the beginning, only the sheath of the nerve trunk suffers, as the pressure increases, pathological changes affect the deeper layers of the nerve. First, the function of sensory fibers is disturbed, then motor and autonomic. Long-term ischemia leads to degenerative changes in nerve fibers, substitution nervous tissue connective tissue elements and, as a result, persistent loss of median nerve function.

Symptoms of Carpal Tunnel Syndrome

Carpal tunnel syndrome manifests with pain and paresthesia. Patients note numbness, tingling, "shooting" in the palm area and in the first 3-4 fingers of the hand. Pain often radiates up the inside of the forearm, but may radiate down from the wrist to the fingers. Nocturnal pain attacks are characteristic, forcing patients to wake up. The intensity of pain and the severity of numbness decrease when rubbing the palms, lowering the brushes down, shaking or waving them in the lowered state. Carpal syndrome can be bilateral, but the dominant hand is more often and more severely affected.

Over time, along with sensory disturbances, there are difficulties with movements of the brush, especially those that require the exciting participation of the thumb. It is difficult for patients with an affected hand to hold a book, draw, hold on to the upper handrail in transport, hold mobile phone near the ear, drive a car steering wheel for a long time, etc. There is inaccuracy and discoordination of movements with a brush, which is described by patients, as if “everything falls out of their hands”. A disorder of the autonomic function of the median nerve is manifested by a sensation of “swelling of the hand”, its cooling or, conversely, a feeling of an increase in temperature in it, increased sensitivity to cold, blanching or hyperemia of the skin of the hand.

Diagnosis of carpal tunnel syndrome

A neurological examination reveals an area of ​​hypesthesia corresponding to the zone of innervation of the median nerve, a slight decrease in strength in the muscles innervated by the median nerve, vegetative changes in the skin of the hand (color and temperature of the skin, its marbling). Additional tests are carried out that reveal: Phalen's symptom - the occurrence of paresthesia or numbness in the hand during its passive flexion-extension for a minute, Tinel's symptom - tingling in the hand that occurs when tapping in the area of ​​the carpal canal. Accurate data on the topic of the lesion can be obtained using electromyography and electroneurography.

In order to study the genesis of the carpal syndrome, a blood test is performed for the RF, blood biochemistry, radiography of the wrist joint and hand, ultrasound of the wrist joint, CT scan of the wrist joint or MRI, if indicated, its puncture. It is possible to consult an orthopedist or traumatologist, endocrinologist, oncologist. It is necessary to differentiate carpal tunnel syndrome from radial nerve neuropathy, ulnar nerve neuropathy, upper limb polyneuropathy, vertebrogenic syndromes caused by cervical spondylarthrosis and osteochondrosis.

Treatment of carpal tunnel syndrome

basis medical tactics is the elimination of the causes of the narrowing of the carpal canal. These include reduction of dislocations, immobilization of the hand, correction of endocrine and metabolic disorders, relief of inflammation and reduction of tissue swelling. Conservative therapy is carried out by a neurologist, if necessary, together with other specialists. The issue of surgical treatment is decided with a neurosurgeon.

conservative methods therapies are reduced to immobilization of the affected hand with a splint for a period of about 2 weeks, anti-inflammatory, analgesic, decongestant pharmacotherapy. NSAIDs are used (ibuprofen, indomethacin, diclofenac, naproxen, etc.), in severe cases, they resort to prescribing glucocorticosteroids (hydrocortisone, prednisolone), with severe pain syndrome conduct therapeutic blockade of the wrist area with the introduction local anesthetics(lidocaine). Decongestant therapy is carried out with the help of diuretics, mainly furosemide. A positive effect is provided by vitamin therapy with drugs gr. B, mud therapy, electrophoresis, ultraphonophoresis, compresses with dimethyl sulfoxide. Vascular therapy with pentoxifylline, nicotinic acid allows to reduce ischemia of the median nerve. After achieving clinical improvement, to restore the function of the nerve and strength in the muscles of the hand, physiotherapy exercises, hand massage, myofascial massage of the hand are recommended.

With the ineffectiveness of conservative measures, carpal syndrome requires surgical treatment. The operation is to cut transverse ligament wrist. It is performed on an outpatient basis using endoscopic techniques. With significant structural changes in the area of ​​the carpal canal due to the impossibility of using endoscopic technique the operation is carried out in an open way. The result of the intervention is an increase in the volume of the carpal tunnel and the removal of compression of the median nerve. 2 weeks after the operation, the patient can already perform hand movements that do not require a significant load. However, it takes several months for the brush to fully recover.

Forecast and prevention of carpal tunnel syndrome

With timely complex treatment carpal tunnel syndrome usually has a favorable prognosis. However, about 10% of cases of compression do not lend themselves to even the most optimal conservative treatment and require surgery. The best postoperative prognosis are cases that are not accompanied by a complete loss of sensitivity and atrophy of the muscles of the hand. In most cases, a month after the operation, the function of the hand is restored by about 70%. However, awkwardness and weakness can be noted after a few months. In some cases, there is a recurrence of carpal tunnel syndrome.

Prevention consists in the normalization of working conditions: adequate equipment of the workplace, ergonomic organization of the work process, changing activities, the presence of breaks. To preventive measures also include a warning and timely treatment injuries and diseases of the wrist area.