Carpal Tunnel Syndrome: Symptoms, Nerve Conduction Study & Treatment Algorithm

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Below is your **complete, concise-but-exhaustive medical reference** for **Carpal Tunnel Syndrome (CTS)** — following your preferred format.

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# **Carpal Tunnel Syndrome (CTS): Symptoms, Nerve Conduction Study & Treatment Algorithm**

## **Definition**

Carpal Tunnel Syndrome is **median nerve compression** at the level of the wrist within the **carpal tunnel**, leading to sensory and motor dysfunction in the **median nerve distribution**.

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# **Pathophysiology**

* The **carpal tunnel** is a rigid space bordered by carpal bones and the **transverse carpal ligament**.
* Conditions causing tunnel **volume increase** or **nerve vulnerability** → median nerve ischemia + demyelination.
* Chronic compression → **axonal loss** → persistent weakness and atrophy.

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# **Causes / Risk Factors**

### **Local / Mechanical**

* Repetitive wrist flexion/extension
* Vibrating tool use
* Wrist fractures/dislocations
* Ganglion cysts, synovitis

### **Systemic**

* Diabetes mellitus
* Hypothyroidism
* Pregnancy (fluid retention)
* Rheumatoid arthritis
* Obesity
* Amyloidosis

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# **Clinical Features**

### **Symptoms**

**Sensory:**

* Numbness/tingling in **thumb, index, middle, radial half of ring finger**
* Symptoms worse at **night**
* **Shaking hand provides relief** (flick sign)

**Motor:**

* Weak grip, clumsiness
* Difficulty holding objects
* **Thenar muscle weakness** (abductor pollicis brevis)

**Autonomic signs (less common):**

* Dryness of skin over lateral 3½ fingers

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### **Physical Examination**

* **Tinel’s sign:** Tapping over carpal tunnel → tingling in median nerve area
* **Phalen’s test:** Forced wrist flexion for 60 sec → reproduces symptoms
* **Durkan’s test (carpal compression test):** Direct pressure over the tunnel → most sensitive
* Thenar muscle **atrophy** in advanced disease

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# **Nerve Conduction Study (NCS) — Key Findings**

NCS is the **gold standard**.

### **Motor conduction**

* Prolonged **distal motor latency** (> 4.2 ms) of median nerve
* Reduced CMAP amplitude if axonal loss

### **Sensory conduction**

* Slowed sensory velocity
* Prolonged **sensory latency** (> 3.5 ms)
* Reduced SNAP amplitude

### **Comparison tests**

* Median vs ulnar sensory latency to ring finger
* Median–radial latency difference to thumb
* Very sensitive in early disease

### **Grading**

* **Mild:** Sensory slowing only
* **Moderate:** Sensory + motor latency prolongation
* **Severe:** Absent sensory response + low CMAP + thenar atrophy

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# **Diagnosis**

* Clinical examination + NCS
* Ultrasound: Median nerve cross-sectional area > **9–10 mm²** at carpal tunnel inlet
* X-ray only if trauma suspected
* Rule out differentials: cervical radiculopathy (C6), pronator syndrome, diabetic polyneuropathy

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# **Treatment Algorithm (Stepwise)**

## **1. Initial Conservative Management (Mild–Moderate CTS)**

### **a. Wrist Splinting**

* **Night splint** in neutral position
* Best first-line for nocturnal symptoms

### **b. Activity Modification**

* Reduce repetitive wrist flexion
* Ergonomic adjustments

### **c. NSAIDs**

* Provides symptom relief, but **does not alter nerve pathology**

### **d. Corticosteroid Injection**

* Local steroid injection gives **weeks–months of relief**
* Useful in pregnancy
* Avoid frequent injections (>3/year)

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## **2. Consider Further Evaluation**

* Failure of conservative therapy in **6–12 weeks**
* Progression of weakness
* Severe findings on NCS

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## **3. Definitive Treatment — Surgery**

### **Surgical Indication**

* Persistent symptoms despite conservative therapy
* Severe CTS (thenar atrophy or axonal loss on NCS)
* Recurrent symptoms significantly affecting function

### **Procedure**

**Carpal Tunnel Release (CTR)**

* Cut the transverse carpal ligament to decompress the median nerve
* Approaches: **open** or **endoscopic**

### **Outcomes**

* Excellent symptom improvement in majority
* Thenar strength recovery depends on duration of compression
* Recurrence is uncommon

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# **Prognosis**

* Early-stage CTS responds well to conservative therapy
* Long-standing compression with axonal damage → incomplete recovery
* Diabetes: slower improvement
* Pregnancy: symptoms often resolve postpartum

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# **Red Flags (Suggest Alternative Diagnosis)**

* Whole-hand numbness (not median distribution)
* Neck pain + hand paresthesia → cervical radiculopathy
* Symptoms not affected by wrist position
* Marked weakness without sensory loss → motor neuron or peripheral nerve disorder

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