You're not the only one, it's the most common neuropathy in the world.
-Dr. Revels
At the bottom of this blog is a small "Definitions" section for reference.
Disclaimer: In no way, shape, or form am I looking to create a diagnosis or counter a rendered diagnosis in your case. Please keep in mind that all information presented is only a small amount of accessible information to creating the true clinical picture for your unique case. You should always consult with your attending physician about your condition.
-Dr. Ryan Revels
Carpal tunnel syndrome (CTS) is recognized as the most common entrapment neuropathy and is defined as a clinical condition [1-6] involving the median nerve when it either becomes entrapped by thickening of the tendinous sheathes, increased pressure or inflammation occurs. This entrapment typically occurs as it passes through the carpal tunnel which is formed by the small bones of the hand known as the "carpal bones" (Figure 1), and the median nerve travels underneath the transverse carpal ligament (Figure 2) of the wrist [1].
More so, CTS is believed to affect up to 1-in-10 people over their lifetime [6]. Electrophysiological evidence has been considered the gold-standard in the classification and identification of carpal tunnel syndrome [1,2,5,6].
Anatomy of The Carpal Tunnel
Figure 1. The bones of the hand/wrist are called the "carpal bones." These eight bones are responsible for the formation of the "floor of the carpal tunnel" when viewed from the anatomical orientation.
The carpal tunnel is formed by the foundational carpal bones of the hand/wrist, these bones from medial-to-lateral (inside-to-outside) starting at the closest region to the elbow are the schaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate (Figure 1). It's important to recognize, or at least reference these bones as some play a physical role in the cause to CTS symptoms [1-3,5,9].
The roof of the carpal tunnel is formed by a side-to-side passing ligament recognized as the transverse carpal ligament visualized in Figure 2. Inflammation of this ligament is thought to be a primary reason to the precipitation of CTS and is the ligament which is cut during surgical intervention.
It isn't just the thought of these bones and ligament as the only cause, but other causes may include:
· Obesity [5]
· Increased pressure [5]
· High force [5]
· Repetitive work [5]
· Vibrating tools [5]
Other causes of CTS include:
· Thoracic outlet syndrome
· Tight inflamed cervical muscles
· Radiculopathy
Lesser-known causes by nutritional deficiencies; particularly if someone is suffering from CTS in both wrists:
· Thiamine (B1)
· B12 deficiencies
The wrist isn't the only location for entrapment, inflammation or insult to the median nerve, but it may occur from the neck at the spinal column, the shoulder-effected by very tight muscles of the biceps, and the forearm. One lesser-known cause to CTS may be the Ligament of Struther's or from the pronator teres. There is consideration to the other 9-tendons which pass through the carpal tunnel with the median nerve from the forearm and finger flexors.
It's easy to see why this is the number one diagnosed neuropathy.
Surely, you're wondering "but why, or how?" Let's take a deeper look into the origin of the median nerve and explore its course through the shoulder and arm before it arrives at the wrist to better understand why all of these causes play a role.
If this doesn't interest you, you can just skip ahead to the Signs and Symptoms section of this blog.
A Journey of The Median Nerve
The median nerve is undoubtedly the most discussed and recognized upper extremity nerve, though there are five primary upper extremity nerves in total, the other four are the musculocutaneous, radial, axillary and ulnar nerves. Together these 5-nerves make up the 5-branches of the brachial plexus (BP)(Figure 3 & Video 1).
The BP is a grouping of spinal nerves which exit the spinal column where the spinal cord is housed (Figures 3 & 4, Video 1). These nerves then coalesce to form the BP. Notice the bundling of the BP as it is anatomically located deep to the collar bone and just before the armpit (Figure 3).
Where the spinal nerves leave the spinal column they are flanked by lateral neck muscles (cervical muscles) called the scalene muscles. The BP passes deep to the pectoralis minor muscle who's origin is of a small projection (corachoid process), and it lies deep to the pectoralis major muscle. These points are important to note, as they are primary locations for the entrapment causes of Thoracic Outlet Syndrome (TOS) (Figure 4).
Figure 3. The brachial plexus and its respective branches: axillary, musculocutaneous, radial, median and ulnar nerves. https://www.aboutkidshealth.ca/Article?contentid=1033&language=English
The BP is a grouping of spinal nerves which exit the spinal column where the spinal cord is housed (Figures 3 & 4, Video 1). These nerves then coalesce to form the BP. Notice the bundling of the BP as it is anatomically located deep to the collar bone and just before the armpit (Figure 3).
Where the spinal nerves leave the spinal column they are flanked by lateral neck muscles (cervical muscles) called the scalene muscles. The BP passes deep to the pectoralis minor muscle who's origin is of a small projection (corachoid process), and it lies deep to the pectoralis major muscle. These points are important to note, as they are primary locations for the entrapment causes of Thoracic Outlet Syndrome (TOS) (Figure 4).
It's at this point the axillary nerve immediately branches from the BP and deep into the axilla (armpit) to innervate the muscles of the shoulder and the teres minor muscle of the shoulder blade.
The median nerve, musculocutanous, radial and ulnar nerves continue down the arms to innervate their respective muscles and skin contributions.
The median nerve is formed by the contributions of the medial and lateral cords within the brachial plexus (Figure 5 & Video 1). As it leaves the brachial plexus it courses deep in the upper arm beneath the biceps muscle and very close to the humerus bone. Keep this in mind as to possible causes to nerve compression and aggravation.
Figure 4. Primary locations for Thoracic Outlet Syndrome and it's
production of median nerve symptoms. https://www.thoracicoutlet
syndrome.com/what-is-the-cause-of-the-compression-of-your
-thoracic-outlet/
The median has no role with the muscles or skin innervation of the upper arm.
The course of the median nerve and the cord contributions which coalesce to form it. (6) https://reader.elsevier.com/reader/sd/pii/S2468122919303640token=65E9A57374271794E25ABF1A58049E8E79DECB621DEECAA89A46D60FAFE398E740206E605AA302611B0A589D90D632C6
Pronator Teres Syndrome
The median nerve then proceeds down the arm as it dives beneath the bicipital aponeurosis and through two heads of the pronator teres muscle. This is another known area of nerve entrapment as median nerve proceeds beneath the sublimis bridge after it passes the space produced at the heads of the pronator teres heads [7] (Figure 6).
Figure 6. The median nerve is shown descending beneath the sublimis bridge after traversing the space between the two heads of the pronator teres. The nerve is compressed at the sublimis bridge. [7] From Kopell HP, Thompson WA. Pronator syndrome: a confirmed case and its diagnosis. N Engl J Med. 1958; 259:713–715. https://musculoskeletalkey.com/median-neuropathy/
After this point the median nerve provides innervation to muscles of the forearm:
· Flexor digitorum superficialis
· Flexor digitorum profundus*
· Palmaris
· Flexor carpi radialis
· Flexor pollicis longus
. . . and the four muscles of the hand:
· Opponens pollicis
· Flexor pollicis brevis
· 1st & 2nd lumbricals
· Abductor pollicis brevis
*The lateral division of this muscle, as the ulnar/medial division muscle innervation is provided by the ulnar nerve.
Figure 7. Palmar view of the median nerve distribution for skin sensory innervation by the median nerve. Transverse slices at the carpal tunnel with corresponding ultrasonography. [6] https://reader.elsevier.com/reader/sd/pii/S2468122919303640?token=319FA399E10A8D31FFF86A127C03D59DBBADF8A0E1C551CDF04517116854A7A39F57C6BDB68E0CD29C33DDECB0D1C9FD
The skin sensory innervation provided by the median nerve include the thumb, pointer finger, middle finger and the lateral region of the ring finger (1st, 2nd, 3rd and 4th digits, respectively) of the palmar side of the hand (Figure 7). This is critical to know!
· As this play a valuable role in the proper differentiation to which nerve is compromised and use of symptoms as a patient trying to explain their pain or a doctor trying to properly diagnose their patient.
Patients, your attending physician should ask you a series of questions which will empower him/her to further understand your reason for visit. The more you know, the more you can correctly articulate your complaint, hopefully, producing a better clinical picture and working diagnosis for your physician. This could be the difference between receiving case appropriate care.
In its full course, the median nerve originates at spinal roots of the cervical spine from cervical levels C5/6/7/8/T1, proceeds though multiple spaces of the neck and shoulder to become a part of the brachial plexus, it traces along the brachium, under the bicipital aponeurosis, through the two-heads of the pronator teres then deep in the forearm (antebrachium) alongside deep wrist and finger flexors to pass through the carpal tunnel (Figures 8 & 9). Bringing us to the primary reason of this blog.
If you've made it this far then you're without a doubt more knowledgeable about the median nerve, and its many associated causes of median nerve entrapment and carpal tunnel syndrome.
It's important to recognize these causes as you may suffer from carpal tunnel-like syndrome, yet the true cause has nothing to do with the carpal tunnel!
The purpose of this blog isn't about other entrapment sites like the Ligament of Struther's, the thoracic outlet or the pronator teres-these conditions will be addressed in other blogs.
We now segue into the Signs & Symptoms associated with carpal tunnel syndrome.
Signs & Symptoms of Carpal Tunnel Syndrome
Signs
To any doctors reading this: of the number of orthopedic exams extenuating your MRS exam-CTS is typically examined using Phalen's and Tinel's Tap test (Videos 2 & 3) [3]. If you've become rusty on the in's-and-out's of these examinations I've linked tutorial videos in the "videos section" below.
The sensitivity of Phalen's test ranges from 42% - 85%, with a specificity of 54% - 98%, as Tinel's sensitivity and specificity ranges are 38% - 100% and 55% - 100%, respectively [6]. There are multiple conflicting sensitivity and specificity values in current research [2], I'll leave your clinical appreciation for these values to the rendering physician.
With this much fluctuation within the orthopedic values it's easy to observe a chance of misdiagnosis in your patient's symptoms. Hence, the addition of electrodiagnosis in your protocol could greatly reduce the amount of guessing in your patient's diagnosis, treatment and prognosis.
For understanding the clinical value and the meaning of sensitivity and specificity see the embedded video (Video 4).
Symptoms
· Dull aching discomfort in the hand, forearm, or upper arm [2]
· Paresthesia in the hand [2,5]
· Numbness [5]
· Burning [5]
· Weakness or clumsiness of the hand [2]
· Dry skin, swelling, or color changes in the hand [2]
· Occurrence of any of the above in the median distribution [2]
· Provocation of symptoms by sleep [2]
· Provocation of symptoms by sustained hand or arm positions [2]
· Provocation of symptoms by repetitive actions of the hand or wrist [2]
· Mitigation of symptoms by changing hand posture or shaking the wrist [2]
· According to the American Academy of Neurology's Guidelines. *
Journal Studies & Research
The purpose of these following studies is to provide depth to the understanding of how CTS neuropathy manifests, treatment and diagnostic processes and therapeutics used in case management.
Article 1: Surgical versus non-surgical treatment for carpal tunnel syndrome (Review).[1]
Summary: Carpal tunnel syndrome is the most prevalent mononeuropathy resulting from entrapment of the median nerve as it passes beneath the transverse carpal ligament of the wrist. The thickening of ligaments, and increased pressure are thought to be the etiology of this pathology. There is a significant prevalence in the female population (9.2%), vice the male population (0.6%) seen in one study of the Netherlands population.
Though there isn't a universally accepted diagnostic clinical and laboratory criteria, it is agreed that the certain electrophysiological abnormalities support diagnosis. More so, there isn't a universally accepted therapy for CTS.
The objective of this systematic review is to discover whether the evidence supports the assumed therapeutic benefit of surgery over non-surgical treatment.
There is a good response from people who received surgical treatment when compared to splinting. There were adverse effects in both groups of conservative and surgical groups, yet it's important to note that a significant number of the adverse effects experienced by the conservative care patients were a result from later receiving surgical intervention.
Although the better results in the surgical group are statistically significant, the lower limit of the CI is close to the non-significant threshold.
The authors of this article state that surgical intervention may yield better symptom relief when compared to splinting.
Article 2: Chiropractic manipulative therapy of carpal tunnel syndrome.[3]
Summary: Conservative treatment of CTS may include physical therapies, nutritional recommendations and manual chiropractic manipulation as a non-surgical management to CTS.
Carpal tunnel syndrome is caused by compression of the median nerve between the longitudinal tendons of the wrist and the median nerve as it passes below the transverse carpal ligament.
The patient discussed here developed CTS at his workplace due to repetitive and stressful motions of his wrist.
Chiropractic manipulative therapy (CMT) involves manipulation of the joints and soft tissue extending from the wrist to the cervical spine. The carpal bones, wrist, elbow, shoulder and the articulations of the cervical and thoracic spine are the bony structures treated.
Non-conservative medical treatments include steroidal therapy and the release of the flexor retinaculum, or transverse carpal ligament, located over the carpal tunnel.
A 58-year-old male suffered from right-handed burning pain ranging from the right elbow downward the right hand and fingers, especially the middle finger. He was a cashier for approximately one year, eight hours a day, five days a week.
Treatment included: CMT, ultrasound, cryotherapy, muscle stim, deep tissue massage, wrist supports and vitamin/mineral supplements-2 visits/week for 4-weeks. No restrictions in activities or limitations at work.
Author states conservative treatment for CTS via CMT, physical therapy and nutrition can reduce patient discomfort and hand dysfunction significantly. However, referral to other providers of conservative medical or non-medical treatment, or to non-conservative surgical treatment, should also remain options.
Article 3: Evaluation of fascial manipulation in carpal tunnel syndrome: a pilot randomized clinical trial.[8]
Summary: Fascial manipulation (FM) involves deep friction over specific (see image in article). In this article the authors aimed to assess that FM had better effects compared to sham intervention.
Patients of the FM group received 5-sessions of 30-45 minutes, 1 session/week for 5-weeks, post target points, friction was applied for 2-4 minutes. The sham group received the exact protocol with the exception that the friction was applied outside of the target zones.
EMG median nerve conduction velocity and latency were recorded at T0 and T1.
There were no reported side effects from the control or experimental in this study. as considering the platform of this pilot study, the authors identified a significant effect of FM in patients with CTS after 5-weeks of treatment. The continue that this technique had no side-effects and was safe; however, the effects were not long lasting.
Article 4: Steroid injection or wrist splint for first-time carpal tunnel syndrome.[10]
Summary: The two treatments that constitute standard care for most patients with first-time carpal tunnel syndrome are night splinting and local steroid injections. In a large-sample , US national database (2009-13), 71% of patients with carpal tunnel syndrome were treated with immediate surgery without precious steroid injection.
In The Lancet, Linda S Chesterton and colleagues report the results of a randomized trial done in 25 UK primary care centers, which compared a single steroid injection (20 mg methylprednisolone acetate) with 6 weeks’ night splinting in patients with mild or moderate carpal tunnel syndrome. Among the 212 patients who completed the questionnaire, the overall Boston Carpal Tunnel Questionnaire score (combined symptom severity and functional status scores, 1–5 scale) at 6 weeks was significantly better in the injection group than in the night splint group by an adjusted mean difference of –0·32 (95% CI –0·48 to –0·16), corresponding to an effect size of 0·41. At 6 weeks, mean symptom severity score improvement was 0·84 in the injection and 0·48 in the splint group.
Nerve conduction tests were not used, which is a limitation because they reflect diagnostic accuracy and disease severity.
Access to splints is easier whereas steroid injections are often prescribed and given by a doctor; costs would increase depending on the extent to which patients are referred for injections. A small treatment benefit in favor of steroid injection should be sufficient to consider injection as a first-line treatment, provided that it can be given safely in primary care without referral and the patient accepts possible transient post-injection pain.
This trial might justify a change in clinical practice in that patients with mild or moderate carpal tunnel syndrome can choose a single steroid injection in primary care instead of night splinting. A policy of initial treatment with steroid injection and considering surgery in case of inadequate improvement or recurrence of symptoms is reasonable and supported by evidence.
Article 5: Local corticosteroid injection for carpal tunnel syndrome (Review).[11]
Summary: Local corticosteroid injection for carpal tunnel syndrome provides greater clinical improvement in symptoms one month after injection compared to placebo. Significant symptom relief beyond one month has not been demonstrated. Local corticosteroid injection provides significantly greater clinical improvement than oral corticosteroid for up to three months.
Local corticosteroid injection does not significantly improve clinical outcome compared to either anti-inflammatory treatment and splinting after eight weeks or Helium-Neon laser treatment after six months. Two local corticosteroid injections do not provide significant added clinical benefit compared to one injection.
Article 6: Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome (Review).[12]
Summary: Carpal tunnel syndrome is caused by compression of the median nerve at the wrist, leading to mild to severe pain and pins and needles in the hand. Other Cochrane reviews show benefit from nerve decompression surgery and steroids. This review of other non-surgical treatments found some evidence of short-term benefit from oral steroids, splinting/hand braces, ultrasound, yoga and carpal bone mobilization (movement of the bones and tissues in the wrist), and insulin and steroid injections for people who also had diabetes.
Evidence on ergonomic keyboards and vitamin B6 is unclear, while trials so far have not shown benefit from diuretics, non-steroidal anti-inflammatory drugs, magnets, laser acupuncture, exercise or chiropractic.
Article 7: Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial. [13]
Summary: Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. The gradual ischemia resulting from high pressure with accompanying compression of the median nerve (MN) within the carpal tunnel is thought to contribute to the pathophysiology of CTS1 . Moreover, CTS can cause inflammation of the intracarpal tendon including the flexor pollicis longus, deep and superficial flexor tendons. The inflammation of the tendon frequently produces a cycle of intracarpal swelling causing further compression of MN2 . Typical symptoms and signs include numbness, tingling, pain, or burning sensation in the digits controlled by the MN, and/or nocturnal paresthesia. Thenar muscle wasting might also occur during the chronic stages.
Despite the availability of conservative therapies, their efficacy is usually unfavorable or short-lived3 . A report revealed that approximately 60 to 70% patients with CTS who underwent conservative treatment still had symptoms after 18 months’ follow-up . Moreover, a recent study has shown that the treatment failure rate of the wrist splint was reported as 69% after 12 months’ follow-up . Although surgical intervention is more effective than conservative treatment, conservative therapies are advocated for mild-to-moderate CTS. Surgical therapy is suggested for severe CTS or patients with poor response to conservative treatments, since the failure rate of surgery ranges from 7–75% . Therefore, it is important to explore and develop a novel non-surgical intervention for CTS.
Platelet-rich plasma (PRP) is a biologic product of concentrated platelets and contains several growth factors that promote wound healing/growth, angiogenesis, and axon regeneration. PRP has been widely used as a safe and novel treatment in dentistry, orthopedics, ophthalmology, neurosurgery, and cosmetic surgery for three decades. Recently, increasing evidence has revealed the beneficial effects of PRP on axon regeneration and neurological recovery in animal or vitro studies
We demonstrated that PRP significantly reduced pain severity, ameliorated disability, and improved CSA of MN 6 months post-treatment.
PRP is considered as a safe treatment and practiced in many disciplines of medicine. It is an autologous preparation utilizing the patient’s own blood. Increasing evidence has highlighted the positive effects of PRP on peripheral nerve regeneration with acceptable safety profiles in experimental studies9–16. Farrag et al. 9 demonstrated beneficial effects of PRP compared with platelet poor plasma (PPP) for facial nerve regeneration in a rat model. Sariguney et al. 10 showed that PRP enhanced the remyelination of the sciatic nerve in an end-to-end neurorrhaphy rat model. Ding et al. 11 applied PRP to the site of bilateral nerve-crush rat model and the findings revealed a significant effect on cavernous regeneration and functional recovery.
Although the mechanism of PRP in CTS in the present study are uncertain and probably multifactorial, we could hypothesize possible causes based on the significantly reduced CSA of the MN and improved electrophysiological studies. First, the PRP could promote angiogenesis, neurogenesis, and regeneration via direct effects on the MN itself based on previous experimental studies9–16. Second, PRP could reduce the inflammation and swelling of the flexor tenosynovitis52 since we performed perineural injection without intraneural injection to prevent direct nerve trauma. Therefore, the PRP could diffusely encase the MN and surrounding soft tissues. The decreased swelling of the flexor tendon would result in reduction of intracarpal pressure exerted on the MN23. Finally, the hydrodissection could also contribute some benefits. A CTS animal model with histological studies is needed to explore and differentiate the above mechanism in the future.
In conclusion, this study shows that ultrasound guided PRP injection is safe and effective for treating CTS. The efficacy of PRP for CTS seems to be a potentially worthwhile area for further study in peripheral neuropathy.
Article 7: Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome. [14]
Summary: Carpal tunnel syndrome (CTS) can be treated by both conservative (Klauser et al., 2009) and surgical interventions. Surgical decompression of the median nerve through the incision of the transverse carpal ligament (either open or mini-open or under ultrasound guidance) is the most cost-effective therapeutic option (Hui et al., 2005). However, mild to moderate CTS can be treated by conservative interventions, like functional braces and local infiltrations (Prime et al., 2010) in the carpal tunnel, mainly with corticosteroids. Local infiltration of corticosteroids easily leads to atrophy of the median nerve, subcutaneous fat, and systematic complications, such as hair loss and Cushing syndrome (Lambru et al., 2012). This treatment option is clearly inferior to surgical intervention despite the fact that it can improve clinical condition. There is evidence that local infiltration of corticosteroids is not superior to local injection of anesthetic (Karadas et al., 2012). To the best of our knowledgement, use of corticosteroids in the clinical practice has not been studied.
To conclude, our study showed very encouraging mid-term results (12 weeks) regarding use of PRP for treatment of CTS. Based on our results, we recommend the planning and performance of a randomized double-blind controlled clinical trial to confirm the possible favorable use of PRP in patients with mild to moderate CTS.
Discussion
Carpal tunnel syndrome plagues humans with a multitude of symptoms which we've discussed, being the number one mononeuropathy, it's clear why there is so much focus on it's pathology and therapies. Despite this focus, there seems to be an increasing amount of relief being offered through pharmaceutical and surgical intervention. The research also demonstrates the struggle with conservative care as a sole source of relief. It seems the answer may lie somewhere in-between the two methods of care.
The patients are receiving a respectable amount of relief from steroid injections (more than oral) and local injections more than systemic injections. Patients are also only receiving temporary relief seemingly only lasting up to 3-months, and in some personal cases as little as 2-weeks. An aforementioned study correlates corticosteroid dangers with Local infiltration of corticosteroids easily leads to atrophy of the median nerve, subcutaneous fat, and systematic complications, such as hair loss and Cushing syndrome (Lambru et al., 2012). [14] This is a point of consideration given the long-term effect associated with steroid injections (a topic for another blog).
Surgical intervention demonstrates a positive outlook for severe cases of CTS, after exhausting all conservative care manners. It's important to remember that most physicians will consider surgery for moderate-to-severe cases of CTS, and of these cases the failure rate for symptom relief ranges from 7-75% (that's a 97-25% success rate). This rate has a large degree of variability. This being said, one alternative care options include platelet-rich protein injections (PRP).
The RCT study included in this blog is the first of its kind to suggest the use of PRP for CTS symptoms producing significant reduction in symptoms, to decrease the degree of disability out to 6-months post-treatment. [13] PRP has even been shown to enhance remyelination of sciatica and bilateral crush neuropathy in rat-model. [14]
The idea behind caring for neurological disorders like CTS, like any ailment, it's best to address the complaints soonest they're recognized, as delay may result in more intense symptoms or a permanence in the condition. We need to consider that, depending on the type of neurological lesion, nerve lesion (injury) when present for 18-24 months (depending on which resource you search) the damage will be permanent. This is unlike muscle atrophy from not working out at the gym, the change is not reversible with today's understanding. At this point, it's not just the lack of feeling, the burning pain, pins and needles, but muscle atrophy will occur thus weakening the body's/limb's function. This may lead to a debilitating cascade in daily function and other detriment to life.
Therapies
Conservative Care other than Pharmaceuticals
· Ultra Sound
· Laser Acupuncture
· NSAID's
· Chiropractic
· Magnets
· Exercise
· Platelet-rich Plasma (PRP)
Pharmaceuticals
· Steroid Injections
· Local
· Systemic
· Oral
Surgical Intervention
Consult with your physician
Conclusions
The complexity of cause and treatments offered for CTS should be more understood at this point. If you feel you may be suffering from CTS, this blog provides some insight to your options in the progression in your care. It is in my deepest wishes you find the proper care regimen with the best possible results for yourself. If you have any comment or questions, I'd love to hear from you!
Definitions
Demyelination
·A demyelinating disease is any condition that results in damage to the protective covering (myelin sheath) that surrounds nerve fibers in your brain, optic nerves and spinal cord. When the myelin sheath is damaged, nerve impulses slow or even stop, causing neurological problems.
Neuropathy
·Disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness.
Radiculopathy
·Irritation of or injury to a nerve root (as from being compressed) that typically causes pain, numbness, or weakness in the part of the body which is supplied with nerves from that root.
Videos
N/A
References
1. Verdugo RJ., Salinas RS., Castillo J. and Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No. CD001552. DOI 10.1002/14651858.CD001552.
2. Bland Jeremy DP. Carpal Tunnel Syndrome. Clinical Review 2007, Vol. 335. https://img1.wsimg.com/blobby/go/8d08e653-62d4-4ae5-b57e-bfa671044840/downloads/Carpal%20Tunnel%20Syndrome-Clinical%20Review.pdf?ver=1597579054208
3. DeLeon RP D.C., Auyong S D.C. Chiropractic manipulative therapy of carpal tunnel syndrome. Journal of Chiropractic Medicine 2002, Issue 1. Pgs: 75-78, https://img1.wsimg.com/blobby/go/8d08e653-62d4-4ae5-b57e-bfa671044840/downloads/Chiropractic%20manipulative%20therapy%20of%20carpal.pdf?ver=1597579054208
4. Kasius KM., Claes F., Verhagen WIM and Meulstee J. Motor Nerve Conduction Tests in Carpal Tunnel Syndrome. 2019. Front. Neurol. 10:149. https://img1.wsimg.com/blobby/go/8d08e653-62d4-4ae5-b57e-bfa671044840/downloads/Motor%20Nerve%20Conduction%20Tests%20in%20Carpal%20Tunnel%20.pdf?ver=1597579054208
5. Aroori S and Spence Roy AJ. Carpal tunnel syndrome. Elster Med J 2008; 77 (1) 6-17. https://img1.wsimg.com/blobby/go/8d08e653-62d4-4ae5-b57e-bfa671044840/downloads/Carpal%20Tunnel%20Syndrome.pdf?ver=1597579054208
6. Soubeyranda M., Melhemb R., Protaisc M., Artusoc M., Anatomy of the median nerve and its clinical applications. 2019. Hand Surgery and Rehabilitation; (30) Pgs. 2-18 https://reader.elsevier.com/reader/sd/pii/S2468122919303640?token=65E9A57374271794E25ABF1A58049E8E79DECB621DEECAA89A46D60FAFE398E740206E605AA302611B0A589D90D632C6
7. Harris HH., Peters BH. Pronator syndrome: clinical and electrophysiological features in seven cases. 1976, Journal of Neurology, Neurosurgery, and Psychiatry, 39. Pgs: 461-464. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC492308/pdf/jnnpsyc00167-0051.pdf
8. Pintucci M., Imamura M., Thibaut A., et. al. Evaluation of fascial manipulation in carpal tunnel syndrome: a pilot randomized clinical trial. 2017. European Journal of Physical and Rehabilitation Medicine. 53 (4): 630-632. https://orbi.uliege.be/bitstream/2268/247701/1/R33Y2017N04A0630.pdf
9. Preston DC, M.D. and Shapiro B. M.D., PhD. Electromyography and Neuromuscular Disorders: Clinical-Electophysiologic Correlations. 2013, Elsevier Saundsers, Third Edition. https://www.sciencedirect.com/book/9781455726721/electromyography-and-neuromuscular-disorders
10. Paul C Adamson, *Jeffrey D Klausner Steroid injection or wrist splint for first-time carpal tunnel syndrome? Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA 90025, USA https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2931929-9
11. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database of Systematic Reviews2007, Issue 2. Art. No.: CD001554. DOI: 10.1002/14651858.CD001554.pub2. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001554.pub2/epdf/abstract?cookiesEnabled
12. O’Connor D, Marshall SC, Massy-Westropp N, Pitt V. Non-surgical treatment (other than steroid injection) for carpal-tunnel syndrome. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003219. DOI: 10.1002/14651858.CD003219. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003219/epdf/abstract
13. Yung-Tsan Wu1,2, Tsung-Yen Ho1, Yu-Ching Chou3, Ming-Jen Ke1, Tsung-Ying Li1,2, Guo-Shu Huang4 & Liang-Cheng Chen1. Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial https://www.nature.com/articles/s41598-017-00224-6.pdf
14. Michael Alexander Malahias, Elizabeth O. Johnson, [...], and Vasileios S. Nikolaou, M.D., Ph.D. Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4705801/
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