الفهرس 
Anatomy of carpal tunnelOnly 14 pages are availabe for public view
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Abstract
CTS is the most frequently diagnosed, best understood, and most easily treated entrapment neuropathy in which the median nerve is compressed under the TCL.
The carpal tunnel is a fibro-osseous tunnel on the palmar aspect of the wrist. The concave flexor surface of the carpal bones form a bony gutter which is converted into a tunnel by a TCL, with the median nerve, tendons of the long flexor of the fingers and thumb, with their synovial sheath passing through the tunnel.
Over the years, there has been controversy regarding the pathophysiology of CTS and the relative roles of mechanical versus ischemic factors. It has been concluded that there is a difference between chronic and acute entrapment, yet mechanical deformation is the initial insult in both cases and vascular factors follow in the cascade. The pathophysiologic changes following nerve compression also depend on the degree and duration of the compression. In the majority of patients with CTS a specific etiologic factor may not be identified, and thus most cases are idiopathic, yet a secondary cause may be sought, as endocrinal disorders or fracture of the carpal bones. A common predisposing factor in most patients seems to be repetitive wrist motion.
CTS affect 1% of the general population and 5% of the working population who must undergo repetitive use of their hands and wrists in daily living. The highest incidence is among middle-aged and elderly women. The mean age of patients is in the 45-50 year old group, yet it may occur in any age group. CTS is more common in females than males, with a ratio of 2.2:1.The dominant hand is most often involved, but the non-dominant may be affected alone, and the condition is bilateral in at least 10% of patients.
The most common symptoms is burning pain, dull aching pain or
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numbness and tingling in the distribution of median nerve distal to wrist. Patients are often awoken by pain in the middle of the night and report hanging their hand out of bed or shaking it vigorously in order to relieve their pain. Less common symptoms include a feeling of clumsiness and weakness in the affected hand that is often made worse by activity or work. Patients may also complain of pain radiating to the forearm, elbow or even the shoulder.
Examination will usually fail to reveal objective findings. Tinel’s sign, Phalen’s test, compression flexion test and other special tests, are provocative tests which help to confirm the diagnosis. Thenar atrophy is a late sign and signifies significant functional loss.
Median nerve conduction studies are the gold standard diagnostic tests. NCSs measure the sensory and motor nerve conduction velocity in the median nerve at the level of the wrist. The sensory component of the median nerve is affected much earlier than the motor component. Needle EMG of the thenar muscles is sometimes useful for detecting motor axon loss in thenar muscles. Denervation is usually seen in more severe cases of entrapment or in traumatic median neuropathy at the wrist. MRI and ultrasonography may be used to diagnose CTS by measuring the median nerve cross sectional area.
Conservative treatments are effective in patients with mild to moderate CTS. They are indicated in patients with no muscle weakness or atrophy, absent denervation, and with only a mild abnormality on nerve conduction studies. Pregnant women with CTS rarely require surgical treatment. Conservative treatments likes adjusting the work environment, wrist splinting, NSAIDs, local injection of corticosteroids, ultrasound therapy.
CTR surgery should be considered in patients with symptoms that does not respond to conservative measures and in patients with severe nerve entrapment, thenar atrophy, or motor weakness. CTR surgeries include classic OCTR, mini open CTR and ECTR. Double-mini incision release was performed with the
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patients under local or general anesthesia. A 1-cm incision was outlined longitudinally proximally from the wrist flexion crease adjacent to the ulnar border of the palmaris longus tendon, blunt elevator was inserted beneath the transverse carpal ligament. A second 1-cm incision was made in the ulnar palm where the elevator was felt to exit. The transverse carpal ligament was cut off through the distal and proximal incisions under direct vision. Later, the wound is irrigated and haemostasis achieved. Incision is closed with single layer using interrupted non absorbable material.
Incomplete sectioning of the TCL is the most common complication in CTR. Other complications include injury of the palmar cutaneous branch of the median nerve, injury of the ulnar nerve or its branches, severance of the thenar motor branch of the median nerve, hypertrophy scar, wound infection, loss of grip strength and others.
In this study, 60 patients with CTS were studied. All patients were clinically examined for symptoms and signs of CTS and were investigated by EDSs. DMIR was done and the transvers carpal ligament was released under vision.
The average of occurrences was 38 years ranged between 20-59 years. Females more affected than males. The dominant hand was affected in 50% of patients, with 20% of patients complaining of bilateral manifestation. All cases were idiopathic with no specific cause found. No recurrent cases were founded. Patients complained numbness in 73.3%, burning sensation in 20% and electric like pain in 6.7% of patients.
A provocative test, as Tinel’s sign and Phalen’s test were positive in 100% of patients. With NCSs, 20% of patients showed mild entrapment, 53.3% of patients showed moderate entrapment and 26.7% of patients showed severe entrapment of the median nerve at the wrist.
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DMIR was done for all patients and 48 patients (80%) were markedly improved, while other 12 patients (20%) had mild improvement of pain due to late presentation. Complications were only seen in 13.3% of patients, 8.3% of patients complained of poor hand grip although they had marked improvement of numbness, 5% of patients had tender scar.