Unraveling Carpal Tunnel Syndrome: Causes, Diagnosis, and Treatment Options with Dr. Edward Lin

What if you could unlock the mysteries of that persistent numbness in your fingers? Would you be eager to learn about the common culprit, Carpal Tunnel Syndrome, and the many factors that contribute to it? Dr. Edward Lin, our esteemed Chief of Hand Surgery at the Kayal Orthopaedic Center, is joining us to unravel the complexities of this condition. We'll first delve into understanding Carpal Tunnel Syndrome and its association with the median nerve in the hand. We also tackle how conditions such as diabetes, rheumatoid arthritis, and even your job could be leading to the syndrome.

Often, Carpal Tunnel Syndrome gets confused with other conditions due to the numerous sites where the median nerve can experience compression. Hence, Dr. Lin enlightens us on the importance of accurate diagnosis and the role of diagnostic imaging in the process. We highlight the benefits of an EMG nerve conduction study and how it can depict the severity of the condition. We'll then navigate through a sea of treatment options—ranging from immobilizing the wrist joint, modifying activities, to exercises like tendon gliding, and even medications that can manage the symptoms.

We don't stop at conventional treatments. Dr. Lin walks us through fascinating alternative modalities like acupuncture and physical therapy. Hear about promising natural remedies like omega-3 fatty acids and Vitamin B6 complex antioxidants. We explore how early intervention leads to better results, and the potential risks of severe Carpal Tunnel Syndrome secondary to delayed treatment. Post-surgery recovery and the chances of recurrence are also discussed. All in all, we aim to provide you with exhaustive information to help you tackle Carpal Tunnel Syndrome effectively.

Transcript

Robert A. Kayal, MD, FAAOS, FAAHKS: 0:16

Hello and welcome to another edition of the Kale Ortho podcast. Today is July 11th, 2023, and our special guest today is Dr Edward Lin. Dr Edward Lin is our chief of the hand service at the Kale Orthopedic Center, Today's topic Harpal Tunnel Syndrome, and we're so happy to have Dr Lin with us. Welcome to the podcast, Dr Lin.

Edward Lin, MD: 0:37

Thank you, Dr Kale. I really appreciate you inviting me here and being here. It's been looking forward to this podcast for a while.

Robert A. Kayal, MD, FAAOS, FAAHKS: 0:43

Likewise, likewise, so happy to have you, thank you. So let's just get started and then first let our viewing audience know a little bit about you, dr Lin.

Edward Lin, MD: 0:51

So I grew up in New York City in Flushing, queens, born and raised and went to junior high school in Manhattan, did Hunter College junior high school and then high school at Stuyvesant High School, also in Manhattan, and graduated and did the eight year BAMD program, which is an eight year program with NYU which includes four years of undergraduate study at NYU and then four years at NYU Land Goal and Medical Center for my medical school. And then I decided to stay at NYU for an additional five years for orthopedic training. It was a great, great experience, great residency and I did one year of additional training at the UPMC in Pittsburgh for a hand in upper extremity fellowship Wow.

Robert A. Kayal, MD, FAAOS, FAAHKS: 1:38

Impressive credentials. I'll never forget the first day I interviewed you for the job and I was so impressed by you and your credentials and your training and still am today. So we're so blessed to have you with us today. Dr Lin, We've had the privilege of having you take care of so many patients over the years that you've treated so successfully and we're just so happy to have you with us. As far as the conditions that you treat, safe to say that carpal tunnel syndrome was probably one of the most common conditions you see on a daily basis.

Edward Lin, MD: 2:05

Oh yeah, as a hand surgeon, it is the most common thing I see, I would say on a daily basis. I just saw one about 20 minutes ago. It's a common thing and a lot of people are dealing with this, especially in our day-to-day. People are using their hands all day long and that definitely has an effect on the rate of having carpal tunnel syndrome.

Robert A. Kayal, MD, FAAOS, FAAHKS: 2:27

Okay, so let's first and foremost define for a viewing audience exactly what carpal tunnel syndrome is.

Edward Lin, MD: 2:33

So that's actually a great question because there's a lot of confusion out there about what carpal tunnel is. A lot of people come to me and they're not sure or they think, oh, I'm having some kind of issue with my hand and must be carpal tunnel. So carpal tunnel syndrome at its base is a problem with the nerve. In your hand you have a nerve, it's called the median nerve. It's one of the main nerves that go into your hand. It's about half the width of your pinky and what that nerve does is it provides sensation into the hand, particularly into the thumb, the index and the middle finger. In carpal tunnel syndrome, what happens is that nerve is being compressed. It's being compressed right here in the hand. If you look in the hand, right in this area, right here, this is where the carpal tunnel is in the hand, and so that nerve is being compressed. And when the nerve is compressed it causes problems with the nerve.

Edward Lin, MD: 3:24

And the first thing you'll notice when the nerve is compressed is you'll see numbness and tingling in the fingers. Now, sometimes it's in just the thumb, the index and the middle finger, but sometimes it can be all the fingers and that's at its core what carpal tunnel is so. If you don't have numbness and tingling in your hand, you probably don't have carpal tunnel syndrome. That's essentially the first thing that people will have. Some people also have pain, and you can have pain in that same distribution in the thumb, index and middle fingers. You can also have pain in the other fingers. Sometimes it radiates into the forearm, into the elbow. Sometimes it can even radiate up into the arm, but most of the time most of the symptoms are located in the fingertips and in the hand.

Robert A. Kayal, MD, FAAOS, FAAHKS: 4:06

So this nerve, the median nerve, actually stems from the brain, right.

Edward Lin, MD: 4:10

So the nerve, all the nerves in the body, start off in the brain.

Edward Lin, MD: 4:14

That's where all the nerves originate, essentially, in the spinal cord, and the brain sends signals to the nerves down the spinal cord and the nerves then branch out through the spinal cord through what's called the dorsal root ganglion is also a ventral ganglion that comes down through the arm and then through down into the hand and into the fingers, and what can happen is there can be multiple sites of compression.

Edward Lin, MD: 4:38

So you can have these nerves compressed in your neck, you can have them compressed in the elbow, you can have them compressed in the forearm or you can have them compressed in the hand of the carpal tunnel, the most common sites of compression would be the neck and in the carpal tunnel. So when you have numbness and tingling in that distribution, that's where my mind goes to initially is this carpal tunnel? Is this coming from the neck? But potentially you can have compression anywhere along that nerve path which can cause similar symptoms, which is why sometimes it's difficult to discern where the problem is, because sometimes the problem can be in the hand, but it can also be further up along the path of the nerve.

Robert A. Kayal, MD, FAAOS, FAAHKS: 5:20

So this nerve, it provides only sensory, or does it also provide motor function?

Edward Lin, MD: 5:25

So the median nerve is what we call a mixed nerve. It's one of the major nerves in the body and it provides both motor and sensory. So at the level of the hand it provides sensation to the thumb, the index and the middle fingers and also part of the ring finger as well. But it also provides motor input to this muscle here, right here, and this area of the hand is called the thenar eminence, and what happens is the course of the nerve.

Edward Lin, MD: 5:51

If you look at it. It comes up this way and then it sends a branch right over here into this muscle. And what you'll see in some patients who have advanced carpal tunnel syndrome is that their nerve has been compressed for so long that this muscle has lost what we call its innervation, meaning the signals that are normally being sent to this muscle have disappeared. And if that lasts long enough, eventually the muscle actually dies and you can see patients who have a divot. You'll see an actual divot in their hand where the muscle is shrunk, and that's a telltale side that they probably or might have carpal tunnel syndrome. That's been untreated for a long time and has led to that what we call atrophy of the muscle.

Robert A. Kayal, MD, FAAOS, FAAHKS: 6:29

So what are some of the other symptoms that these patients will present with, besides the numbness and tingling they described?

Edward Lin, MD: 6:36

Yeah. So, as I said, you can have pain associated with it. It's oftentimes a nighttime phenomenon, so a lot of times patients will say I woke up with this in the middle of the night. I can't get a good night's sleep. That's very common, and sometimes patients will say I wake up in the middle of the night and the only thing that makes it better is if I shake my hands. That's actually a very telltale sign that you may have carpal tunnel. Some patients also find that they have symptoms going up and down the arms, but if that is the case, then you may also have or instead of carpal tunnel, you may have a compression in the neck that may cause arm symptoms as well.

Robert A. Kayal, MD, FAAOS, FAAHKS: 7:11

Yeah, and that we call a double crush phenomenon right, when patients sometimes can have a pinched nerve in their neck and also have a pinched nerve somewhere else in the arm. Because, as we discussed, all of these nerves ultimately stem from the brain and the spinal cord. So if that nerve is involved or compressed anywhere along its path it can present with symptoms in the distribution of wherever that nerve goes. If it's a sensory nerve, it can affect the sensation, resulting in numbness and tingling potentially, and if it's a motor nerve, it can often result in weakness as well to the muscle groups that are innervated by that nerve. And if you have a mixed nerve, as Dr Lin referred to, such as the median nerve, you can both get sensory and motor findings as well. So it can be a little complicated. Are there other nerves around the elbow that potentially can cause patients to also awaken from sleep and have numbness and tingling in their hands?

Edward Lin, MD: 8:07

Yeah, absolutely so. There's another major nerve in the arm. It's called the ulnar nerve and that nerve does a lot of what the median nerve doesn't do. So the median nerve goes to the thumb, the index, the middle and part of the ring. The ulnar nerve goes to the small finger and part of the ring, so it provides a sensation to those two small fingers.

Edward Lin, MD: 8:28

So if you find that you're having more numbness in the small finger, that may be the ulnar nerve, whereas if your numbness is more in these three fingers, that's more of the median nerve. Not 100% of the time, but that's a rough estimate of what we think about when we have patients coming talking about numbness and tingling. The ulnar nerve also controls the muscles in the hand. So inside the hand you have muscles. Here you actually don't have any muscles in the fingers, but you do have muscles in the hand itself and they help control the motion of the fingers going this way and also they help control some of the motion of the fingers going this way, keeping these straight, and so those are called intrinsic muscles and that's governed by the ulnar nerve.

Robert A. Kayal, MD, FAAOS, FAAHKS: 9:11

So why do they call it the carpal tunnel?

Edward Lin, MD: 9:15

So the carpal tunnel is a tunnel you can think of it like a train tunnel and it has walls, it has a floor and it has a ceiling. And if you think about it, the wall and the floors of the carpal tunnel are all made of bone. There are many different bones in the wrist and they form almost a solid foundation for the carpal tunnel. And then the ceiling of that tunnel is a very thick ligament. It's called the transverse carpal ligament and it's thickest right here, right here in this portion of the hand. And so the problem with that anatomical structure is that there's really no give because bones are very hard, they're not going to stretch out. That ligament over time becomes very, very thick and it's not going to stretch out. And so what that leads to is a problem with the pressure inside the carpal tunnel.

Edward Lin, MD: 10:06

So the normal pressure inside a carpal tunnel, I would say, is about two or three millimeters of mercury, and millimeters of mercury is just a measure of the pressure inside anything. In fact, if you look at your blood pressure, 120 millimeters of mercury, that's the unit of pressure. So normal pressure inside a carpal tunnel is about two or three, and patients with carpal tunnel syndrome it can be 20, 30, 40. And so once you get above 30, the problem is that you start to develop nerve damage. The nerve really doesn't like to be pressured. That's one of the things that nerves don't tolerate very well. And once you start putting pressure on that nerve, you're going to have to get a little bit of pressure. A lot of things begin to happen to that nerve that are not good.

Robert A. Kayal, MD, FAAOS, FAAHKS: 10:47

When you're evaluating a patient. We already talked about the history and their complaints. You said most of them would complain of pain and numbness and tingling and sometimes even weakness. Are there any other parts of the history that are relevant to helping you really hone in on the diagnosis of carpal tunnel syndrome?

Edward Lin, MD: 11:06

Yeah, absolutely so. Carpal tunnel syndrome can be caused by a whole variety of factors. Most of carpal tunnel syndrome is what we call idiopathic, and what that means is that we don't really have a direct cause for it. It just happens. But there's a good portion of patients who have carpal tunnel syndrome for a specific reason, and so some of the things that can cause carpal tunnel syndrome are diabetes, patients who have a thyroid condition, patients who have autoimmune problems, rheumatoid arthritis, psoriatic arthritis, patients who have kidney problems.

Edward Lin, MD: 11:40

There's a condition called amyloidosis, where the body deposits amyloid, which is a substance, into the carpal tunnel and that can increase the pressure inside the carpal tunnel. It can also have an occupational relationship. So patients who are always doing repetitive tasks that's what we hear over and over again you may be a factory worker or you may do something where you do the same motion over and over again, a thousand times a day, 10,000 times a week, and that can cause carpal tunnel to get worse. Patients who use vibratory tools jack hammering, anything that's causing vibration in the hand is going to make it worse. Patients who are constantly squeezing is going to make it worse. A lot of people ask me if computer use makes it worse, but the evidence for computers being linked to carpal tunnel actually isn't that great. So despite the conception that, oh, I have carpal tunnel and it must be because of the computer use, that link, at least scientifically, hasn't really been proven.

Robert A. Kayal, MD, FAAOS, FAAHKS: 12:38

But it is intuitive, isn't it? Considering all the other diagnoses and associated conditions that you've just described. The common element in all of them is that they, for the most part, all result in an increase in swelling right and we already talked about that the carpal tunnel is a closed compartment and the nerve doesn't tolerate any type of compression, not much pressure inside the carpal tunnel at all. The carpal tunnel is already a little crowded right. The carpal tunnel includes the median nerve and nine other flexor tendons, so there's really not a lot of room inside that closed compartment. Now we compound that with some medical conditions that are often associated with swelling, like pregnancy, hormonal changes, thyroid disorders, diabetes can definitely result in swelling and also increased in nerve injuries and neuropathy and some of the other conditions you mentioned as well.

Robert A. Kayal, MD, FAAOS, FAAHKS: 13:39

Anything that causes a crowding phenomenon, rheumatoid arthritis, because very often associated with that condition we get tinocinibitis and autoimmune disorders, where you get an immune response and swelling and crowding phenomenon. So those are all conditions that definitely result in swelling and crowding in the carpal tunnel and compression on the median nerve. So it is somewhat intuitive to imagine that if you're using computer a lot and overusing your risk, that it should cause that. So to me, regardless of what the medical literature suggests, I believe that overuse conditions such as computer usage should contribute. So I would certainly advise my patients at least that if they're doing too much of anything texting and video games or computer usage, to maybe quiet that down a little bit to see if it alleviates their symptoms. It does make sense intuitively.

Edward Lin, MD: 14:37

Yeah, I agree, I think that's you know. There's the medical literature and then there's common sense, right? So I think as a doctor, you have to use a little bit of both. You can't just look and see what the papers say. You have to listen to. You know what your common sense is telling you, but you also have to listen to your patient too. And if the patient's telling me I text over and over a thousand times a day and this is killing my hands, yeah, it's probably causing your carpal tunnel to get worse.

Robert A. Kayal, MD, FAAOS, FAAHKS: 15:01

They know their body's better than we do, right.

Edward Lin, MD: 15:03

Absolutely. I agree with that, only percent yeah.

Robert A. Kayal, MD, FAAOS, FAAHKS: 15:05

Now that we got inadequate history. You've done your physical exam. What other imaging modalities can you sometimes employ to help support your diagnosis?

Edward Lin, MD: 15:14

Right.

Edward Lin, MD: 15:14

So there are definitely other things that we can do with a suspected carpal tunnel case to both confirm the diagnosis or even try and figure out the diagnosis if we're not sure.

Edward Lin, MD: 15:24

So one of those things is an MRI, and an MRI can be really useful in carpal tunnel specifically because there are specific things that can cause carpal tunnel syndrome. So I had a patient who came in. She was about 18 years old and she had classic carpal tunnel signs, which you don't usually see in someone who's 18. You know, people who are in their teens and 20s usually don't get carpal tunnel syndrome just out of the blue. So we did an MRI and we have fantastic MRIs at our facility with amazing radiologists who are reading them and we found that she had a very large ganglion cyst sitting right inside of her carpal tunnel and that was what was causing her symptoms, and so in that case we were able to remove the ganglion and address it surgically, and she had a wonderful result. As soon as the next day, right after I removed the ganglion, I called her up and she said wow, my symptoms are gone.

Robert A. Kayal, MD, FAAOS, FAAHKS: 16:17

That's interesting. That's an interesting almost case report. Yeah, you nailed it. We don't typically see carpal tunnel syndrome in the young, except for the pregnant women. Right that with the hormonal changes. It's very rare to make that diagnosis in a young patient like that.

Edward Lin, MD: 16:34

Yeah, but so without the MRI? We got an MRI to see that ganglion cyst, to see what the location of that cyst was and to know that that was causing her symptoms. It would be difficult to make that diagnosis without the MRI. So that's one thing that's important. One other thing that we've been using more and more is ultrasound, and we have an ultrasound in every single exam room, which I think is something that no other facility really has. No one else has invested that kind of resources into having that technology. But the ultrasound is important because there's more and more data showing that you can actually make a diagnosis of carpal tunnel syndrome with an ultrasound machine, and the way you do that is you take the ultrasound machine and you measure the cross-sectional area of the nerve and if the cross-sectional area is more than about one square centimeter, that's highly suggested that you have carpal tunnel syndrome. So it's something to add to your armitarium of things to make a good diagnosis.

Robert A. Kayal, MD, FAAOS, FAAHKS: 17:29

So, dr Lin, we talked about using MRI, we talked about using ultrasound for the diagnosis. How about x-ray? Do we use x-ray as well to evaluate for carpal tunnel syndrome?

Edward Lin, MD: 17:40

Absolutely so. The x-ray is usually the first study that I get. We have an x-ray machine in every single facility that we have and you can make diagnoses based on that x-ray, including things that aren't related to carpal tunnel. So you may be coming in with what you think is carpal tunnel and you may find that you have a fracture. There's actually a very specific view we do in the x-rays, called the carpal tunnel view, and using that specific view we can look straight down the carpal tunnel and with the x-ray machine and we can see if there's a lesion in there. We can also see if sometimes you'll have a fracture of one of the bones that's in there. So we can definitely pick up things on an x-ray without any additional imaging, but oftentimes it will lead to other need for other additional imaging as well.

Robert A. Kayal, MD, FAAOS, FAAHKS: 18:27

Yeah, sometimes patients come in the office and they have a tendency to want to resist getting an x-ray right. But as a trained orthopedic surgeon many of us who have trained at world-renowned cancer centers we don't cut corners right. We can't cut corners, we can't miss the basic, fundamental imaging of an x-ray. The x-ray tells us so much it can evaluate for bone tumors, it can evaluate for fractures, lesions, different things that can contribute to orthopedic conditions. So I almost will never see a patient unless the patient gives me the permission to get a baseline x-ray, because certainly I never want to miss anything on a patient. And only after the x-ray is negative do we consider proceeding with MRI or further imaging. Do you do the same thing?

Edward Lin, MD: 19:15

I agree, that's my practice as well and the philosophy behind that is you don't know what you're going to find if you don't look. And so if you're not getting an x-ray and you're doing an operation or you're doing an injection, you're almost working in the blind a little bit because you haven't done your due diligence to rule out everything else that this could be. And you may do an x-ray and find something. You may do an MRI and find something. I can't tell you the number of times I've done an MRI and I was surprised and I was just so glad I got that MRI because if I didn't I would not have found tumors, I found cancers, really serious things that if addressed soon we can really make a difference. But if you wait, if you didn't get that MRI, if you didn't get that x-ray and you waited, it would have been disastrous.

Robert A. Kayal, MD, FAAOS, FAAHKS: 20:04

Okay, so are there any other studies besides x-ray MRI ultrasound that you would use to see if there was any damage to the nerve?

Edward Lin, MD: 20:14

Sure. So one of the things we rely on and I alluded to would be a nerve study. And a nerve study is a specific study and it does two things. One, it tests to see how the nerves are functioning, to see what the speed of the electrical signals that are going through the nerve is. And the nerves you can think of them almost like electrical wires. They send a signal from point A to point B through essentially we call them ions, but essentially an electric signal through these. We think of them as wires and that the speed of the signal conduction should be a certain speed, and if the speed slows down we know there's a problem with the nerve.

Edward Lin, MD: 20:52

We can also test the muscles that the nerve goes to. So that muscle we talked about this muscle right here we can test that muscle and see if that muscle is doing all right, to see if it's receiving the right signals, and if it's not, then we get a good sense that, okay, there's something wrong with the nerve. And so the test of the muscles, that's called an EMG and the test of the nerve conduction, that's called the nerve conduction study, and both of those are done by a pain management specialist, the person I trusted, dr Steve Nadin, who's in our practice, and he is a fantastic at doing nerve conduction studies. So having gotten one of these studies, you can see if there's a problem with the median nerve, you can see if there's a problem with the ulnar nerve, and it helps you to really hone in on that diagnosis.

Robert A. Kayal, MD, FAAOS, FAAHKS: 21:40

Yeah, it targets the area of compression. It gives you a nice baseline evaluation as well, just in case you're trying to monitor whether or not this nerve is in the future getting worse or getting better. So it's really critical to get a baseline EMG nerve conduction study. Typically we tend to want to wait about two to three weeks after the onset of symptoms, because often we won't even see changes on the EMG nerve conduction study until then. But I think it would behoove the patient to get a baseline EMG nerve conduction study. This way it can help the doctor monitor your progress to determine whether or not you're getting worse or better with treatment. And is that something you do regularly?

Edward Lin, MD: 22:20

Yeah, so I routinely order a nerve conduction study with anyone who comes in with numbs and tingling and it's helpful for so many different reasons.

Edward Lin, MD: 22:28

So one thing you can tell if well, if it comes back normal, that gives you information too, because if it comes back completely normal, then it's much less likely to be carpal tunnel syndrome. However, just because a test comes back normal doesn't mean you don't necessarily have carpal tunnel. So all of the tests that we have whether it's an MRI, a nerve conduction study you have to take a look at it holistically with the patient, what they're presenting with, and come up with a thought pattern of what diagnosis is, taking all these points of data into account. But the nerve study is good because it tells you if there's a problem and where that problem is. So to help locate is it at the elbow, is it at the wrist, is it in the hand and or all the above, or all the above. And using that information you can really help to hone in on what the problem is. And once you have a diagnosis, you can figure out what the best course of action it would be.

Robert A. Kayal, MD, FAAOS, FAAHKS: 23:22

It also helps guide us as we converse with our patients and give them prognosis right, because if a patient has a double crush phenomenon and you're opting to address the carpal tunnel syndrome first, it affords us the ability to at least tell that patient look, I'm going after the symptoms only associated with the carpal tunnel syndrome, but please be prepared that you're still going to have some symptoms from the compression of the nerve in your neck right and we might have to address that afterwards as well.

Edward Lin, MD: 23:55

Absolutely, and it can also help to grade the degree of carpal tunnel that you do have. So carpal tunnel, you can have mild carpal tunnel, you can have moderate and you can have severe. And in patients who have mild to moderate carpal tunnel let's say you end up doing surgery to correct that the results are much better than if you have severe carpal tunnel. It definitely gives you a good prognosticator to say that you have mild carpal tunnel, you are almost definitely going to get better after surgery, versus you have severe carpal tunnel. You have about a 50% chance of getting better after surgery and so that's important.

Robert A. Kayal, MD, FAAOS, FAAHKS: 24:28

It's like most orthopedic conditions right the sooner we address them, the easier it is for us to guarantee our results. Right, because when you're dealing with acute, reversible disease as opposed to chronic, sometimes irreversible conditions, it makes it more difficult to guarantee excellent results Because some of the damage to the tissues, and in this particular case, the nerves, can be permanent and irreversible.

Edward Lin, MD: 24:55

Absolutely, and this is something I'm always telling patients that in the beginning carpal tunnel starts off as mild, meaning that you have some compression of the nerve. But the nerve overall, the anatomy of the nerve, the structure of the nerve is still normal and so if you just relieve that compression the nerve will bounce back and sometimes it'll bounce back instantaneously. I've had patients who we did the nerve the surgery and then in the recovery room they said, wow, it feels better instantaneously. So that tends to happen in mild cases. But if you let that compression go on you're saying, oh, I'm having some numbness and tingling, but I can deal with it, Let me just sleep on it.

Edward Lin, MD: 25:31

You wait a few months to a few years and now that carpal tunnel that used to be mild is now moderate or it's now severe and you're developing what we call muscle atrophy, where that muscle we talked about is becoming smaller and the nerve over time unfortunately starts to have irreversible changes, meaning that scarring tends to happen in the nerve. The nerve is losing the blood supply because it's being compressed for so long and at some point these changes are permanent. They're irreversible, meaning even after you do surgery to decompress the nerve, these changes are not going to go away, and then you're left with, unfortunately, numbness and tingling that doesn't go away. So this is something where, if you do notice numbness and tingling in your hand, it's important not to just blow it off, not to say I'm just going to sleep on it. Come in, have us take a look at it and see if anything needs to be done.

Robert A. Kayal, MD, FAAOS, FAAHKS: 26:25

OK. So, Dr Lin, now that we've definitively made the diagnosis for our patients of carpal tunnel syndrome, what's the first line of treatment?

Edward Lin, MD: 26:33

So the initial line of treatment with carpal tunnel syndrome depends on how severe it is, and that's why I keep going back to the severity.

Edward Lin, MD: 26:40

It's important to get these things checked early so that you don't let it become severe. In the early stages mild to moderate carpal tunnel syndrome, the initial treatment is non-operative and the treatment initially is to wear a splint. Now you've seen many of these splints online and we offer a splint that I think is very good and the goal of the splint is it's a brace that you wear on your wrist and the goal of the splint is to keep your wrist in a neutral position, and the reason for that is because it's been found that if you have your wrist in this position flex position or an extended position it greatly increases the pressure inside the carpal tunnel. So I don't know about you, but my wife sleeps like this and so that's really bad for the carpal tunnel. So we give a splint and if you wear that splint at night, it prevents your wrist from going into those positions and that sometimes by itself will fix the problem, because a lot of patients have problems at nighttime. If we keep the wrist straight, then it solves the problem.

Robert A. Kayal, MD, FAAOS, FAAHKS: 27:39

And it also helps to immobilize the joint right, and we already discussed that. The carpal tunnel is filled with not only the median nerve but nine flexor tendons and very often the flexor tendons are contributing to the inflammation and swelling and compression on the nerve because they're overused and swollen. So by immobilizing the wrist joint with a wrist immobilizer, theoretically we're resting those flexor tendons, allowing for the inflammation and swelling to subside and therefore the compression on the median nerve to subside as well, absolutely.

Edward Lin, MD: 28:14

And another one of those treatments that seems very simple but is just rest. If you're doing something 1,000 times a day and it's causing your carpal tunnel syndrome to get worse, you should probably not be doing those things. So that's activity modifications also very important part of the treatment. One of the things that I always tell my patients is there's also an exercise that you can do to help your carpal tunnel syndrome, and I'll demonstrate to you. So what you do is you take your hand, make it flat and then you do this position this is called an intrinsic plus position and you bring it down to a full fist. You go back into your intrinsic plus position and you go like this that's called a tendon gliding exercise, so that. And then there's another portion where you go like this. This is a Another exercise.

Edward Lin, MD: 28:56

You can do another tendon gliding exercise you can do. You keep your palm flat like this. You move it into this position like this, make a full fist, move it back into this position and like that. That's the first way to do it, and the second way to do this come straight down and this is called a tendon gliding exercise and that's been shown to help with carpal tunnel. So between doing the bracing and the tendon gliding exercises. A lot of patients will get better just with non-operative treatment. In addition, you can take Tylenol pain medication, anti-inflammatory medication. There are also other medications such as Lyrica, neuropathic pain medications, and all of these medications can be taken as well to help with the symptoms.

Robert A. Kayal, MD, FAAOS, FAAHKS: 29:37

Like in so many orthopedic conditions, inflammation is the culprit, right? I say this podcast after podcast after podcast. Inflammation is associated with redness, warmth, pain and swelling and in this particular case, carpal tunnel syndrome, inflammation and swelling is the main cause of this condition because that nerve is getting compressed. So any of the medications that can alleviate inflammation will alleviate a lot of the symptoms associated with carpal tunnel syndrome. So the typical over-the-counter non-steroidal anti-inflammatory medications like Motrin, advil, aleve, ibuprofen would all be very helpful in treating this condition. It is somewhat counterintuitive that in this particular case, carpal tunnel syndrome, where there seems to be inflammation and swelling around the median nerve, causing the compression and therefore the symptoms of carpal tunnel syndrome, the guidelines from the American Academy of Orthopedic Surgeons argues against the usage of anti-inflammatory medications in this condition.

Edward Lin, MD: 30:45

Correct, yeah, that's true, and I think part of that is because the carpal tunnel, when someone comes in with carpal tunnel syndrome. The carpal tunnel syndrome can have a whole variety of causes and a lot of times it is inflammation. Particularly patients who have inflammatory conditions like gout, pseudo gout, rheumatoid arthritis or an autoimmune condition. It can definitely be inflammation as the culprit. But you also have a good subset of patients who don't have inflammation but have carpal tunnel syndrome for a variety of reasons. It could be idiopathic, meaning that we don't really know why. Maybe their ligament is just really thick in that area. It could be that they have an anatomic structure that's causing compression, and so I think it's difficult to recommend and say anyone who has carpal tunnel syndrome should get an anti-inflammatory for those reasons. But I do think there is a subset of patients who do have inflammatory conditions whether it be gout or pseudo gout or what have you who would benefit from an anti-inflammatory.

Robert A. Kayal, MD, FAAOS, FAAHKS: 31:40

But I think it's definitely a case-by-case basis, it seems somewhat controversial, and I don't believe that there's overall unanimity in the orthopedic community whether or not nonsteroidal anti-inflammatory medications are warranted or not. In my own practice I do believe in the usage of anti-inflammatories because I do believe inflammation is strongly associated with this condition, and that is because of the fact that overused conditions tend to contribute. Swelling from other conditions like thyroid disorders, swelling from hormonal changes in pregnancy, all seem to contribute. And clinically, when I perform surgery for carpal tunnel syndrome, I often do appreciate extensive inflammation inside the carpal tunnel causing compression on the nerve. And so in my own practice I'm a believer in the usage of nonsteroidal anti-inflammatory medications such as Motrin, advil, aleve, ibuprofen or other prescription anti-inflammatories and, in rare circumstances, potentially even oral steroid usage to help suppress the inflammation and swelling around the nerve. What do you do in your practice, dr Lin?

Edward Lin, MD: 32:54

I take a similar approach in that I do prescribe anti-inflammatory medication, but it depends on the patient's circumstance. So if I think that inflammation is playing a big role in the patient's condition, I will definitely prescribe an anti-inflammatory, but if I think that the condition is not an inflammatory condition, then I may hold back and say just take Tylenol or try something else. But it's also something that you have to ask the patient have you taken anti-inflammatories in the past and if you have, has it improved your carpal tunnel symptoms? If it has, then by all means continue taking them.

Robert A. Kayal, MD, FAAOS, FAAHKS: 33:29

One thing in my own practice that has really helped support that concept of inflammation being associated with it is the myriad of patients that have responded so favorably to a cortisone injection. It's almost the most rewarding injection that we give, because patients that are suffering from this pain, numbness and tingling, pins and needles waking up, having to shake that hand literally in three days it disappears. And what's funny in my own practice is what I've experienced is when patients have carpal tunnel in both sides, both the right and left hand after an injection I always find that the other side goes away too.

Edward Lin, MD: 34:12

That can be a systemic effect, because when you're giving the cortisone, it to one hand, eventually some of that cortisone does make it into your bloodstream and so it can affect the other hand. But that's very interesting. Speaking of cortisone injections, cortisone is injection is an important non-operative treatment modality for carpal tunnel, and I use it for two reasons. One is therapeutic I want my patients to get better and it's a way to do that. But it's also good for a diagnostic tool, because sometimes patients will come in with that double crush phenomenon that you mentioned. They have compression in the neck, they have compression in the hand and you're not sure which is really dominating.

Edward Lin, MD: 34:46

Is the problem coming from the hand? Is it coming from the neck? Is it coming from both? So when I give a cortisone injection and the patient tells me that there's 70 to 80% improvement in their symptoms, that tells me that most of their carpal tunnel symptoms are coming from the carpal tunnel. If I do the injection and they tell me there's virtually no improvement, that's a good sign that it's not carpal tunnel syndrome and then you can move on to other diagnoses. The compression may be coming from the neck, it may be somewhere else, but we can think it's less likely to be carpal tunnel syndrome, so that's an important thing to have. Yeah, it's very important.

Robert A. Kayal, MD, FAAOS, FAAHKS: 35:19

And how about other modalities or ancillary services like physical therapy, acupuncture, things like that?

Edward Lin, MD: 35:26

So, absolutely so. All of these things physical therapy, acupuncture are part of the treatment, nonoperative treatment of carpal tunnel syndrome, and so there's a lot of benefit that can be had from having a trained professional therapist work on your hand or an acupuncturist work on your hand to improve your symptoms without doing surgery. Right.

Robert A. Kayal, MD, FAAOS, FAAHKS: 35:48

Therapy. You know why therapy? Well, therapy can be employed to decrease inflammation and swelling. Sometimes there's significant swelling in the extremity, from whatever reason. It could be a fracture, it could be other things that have contributed to swelling, so therapy can be employed to help reduce that swelling. So sometimes, when nerves are compressed you already alluded to the fact that there can be some weakness associated from that nerve compression, because those nerves innervate muscles and if the muscles are weak then they can atrophy and physical therapy can often be employed to try to regain that strength and function. Why acupuncture?

Edward Lin, MD: 36:24

Well, acupuncture is a modality where needles are placed into the hand or into the body part. It tends to work for a whole variety of conditions. We're not 100% sure why or how acupuncture does work, but I have had patients come back and say, wow, that acupuncture really did help my carpal tunnel symptoms, and so I encourage patients to seek out acupuncture and physical therapy as addition to modalities to help them, because if they can help themselves and treat their carpal tunnel without surgery, then they've avoided the risks of surgery and the pain and everything associated with that. So that can be a useful tool.

Robert A. Kayal, MD, FAAOS, FAAHKS: 37:04

Sure, a lot of these holistic approaches and even natural remedies have been found to be helpful in some of these neuropathies and nerve compression syndromes. Acupuncture has been shown to cause some microscopic trauma which can increase some blood flow and promote healing. Some of the holistic medicines can be used as well. I know that Omega 3 fatty acids and the vitamin B complex antioxidants, things like that have been helpful as well in the treatment of some of these patients.

Edward Lin, MD: 37:37

Absolutely Vitamin B, in particular vitamin B6, has been shown in some papers to provide some benefit, especially for people who are having nerve issues like carpal tunnel.

Robert A. Kayal, MD, FAAOS, FAAHKS: 37:49

Now that we've diagnosed the condition, we've tried to treat them conservatively, whether it be by anti-inflammatories or Tylenol, or physical therapy, acupuncture, holistic approaches, et cetera. What if that fails, and how long will you give the patients in effort to recommend the next line of care?

Edward Lin, MD: 38:09

So it really varies in terms of how severe your carpal tunnel syndrome is. So if you come in and you have severe carpal tunnel syndrome, either by the symptoms that you have, by some of the testing we can do we can test your sensation in the office to see if there's actual nerve damage. There's a test called two-point discrimination we can do in the office to see how much nerve damage you have and that's a very simple test we can do at the bedside, based on your nerve studies to see how severe your carpal tunnel is. But if you have severe carpal tunnel syndrome, you really should be looking to treat that patient operatively. Meaning the window has passed for nonoperative treatment and we're having a discussion more of how do we fix this surgically.

Edward Lin, MD: 38:53

For the mild to moderate carpal tunnel patients, I try to go for at least three months of nonoperative treatment, including splinting and tendon-gliding exercises. Having said that, you have to see how you're doing so. If a patient has tried this for a month or two and they're saying it's getting worse, it's not getting any better, that's not a reason to continue for the third month. I think if you're trying something and it's not working, you have to change course, and so a lot of it just depends on how the patient is doing and how they're reporting their symptoms to you.

Robert A. Kayal, MD, FAAOS, FAAHKS: 39:26

But what if you get an EMG nerve conduction study and it already shows that the carpal tunnel syndrome is very severe and there's associated muscle atrophy and some very permanent changes to that nerve? What do you tell the patient and what do you do?

Edward Lin, MD: 39:42

Yes. So in that case the nerve has undergone severe permanent damage and so there really isn't a role for nonoperative treatment, and so we're talking more about doing surgery to fix that. But even in cases where we do do surgery for severe carpal tunnel syndrome, the results are not going to be as good as if you do it for mild to moderate, and so in mild to moderate carpal tunnel syndrome I would say 90% of patients will get 90% better. But in severe cases those numbers are not as good. And so there's a good proportion of patients who, even after carpal tunnel surgery, who have severe carpal tunnel, who don't get better. Or they feel better a little bit, or it takes them a whole year before their numbness and tingling goes away, or their numbness and tingling goes away partially, but they always feel a little bit numbness, and part of the reason is because even after you release the carpal tunnel sometimes it's too late the nerve has already had permanent damage, and patients may continue to feel numbness and tingling in the future.

Robert A. Kayal, MD, FAAOS, FAAHKS: 40:44

And my experience.

Robert A. Kayal, MD, FAAOS, FAAHKS: 40:45

What I found, and when I had those conversations with those patients, is that I sort of tell them that I can't guarantee that I'm going to help them get better or that they will recover, and more than likely they will not.

Robert A. Kayal, MD, FAAOS, FAAHKS: 40:58

But what I have found is that even in those patients, that numbness and tingling that wakes them up at night very often goes away and that to them is one of the most rewarding things because they get to enjoy, for the most part, a good night's sleep. Obviously, the muscle atrophy that they are suffering from and the numbness that they experience may never recover, but the one thing that I have noticed that most of them sleep better at night and they don't wake up with that numbness and tingling. So it's important to have those conversations with patients when it is very severe so that we can guide them properly and set their expectations so they're not disappointed when that muscle atrophy doesn't come back fully or maybe the numbness does not fully dissipate. But that just again drives home that point that it's incumbent upon us to see those patients the sooner the better and to treat them before they have permanent nerve damage and muscle wasting.

Edward Lin, MD: 41:58

Yeah, I agree wholeheartedly, and one of the things that I tell patients is sometimes, even if you don't get any better, an additional goal of the surgery is to prevent them from getting worse, because if you do nothing and you allow carpal tunnel syndrome to progress, that nerve is just going to get more and more damaged over time. It's almost a certainty. And so if you let that happen and let that proceed, it's going to get worse and worse and worse, to the point where you're going to lose function of your hand, and that's the worst thing to say.

Robert A. Kayal, MD, FAAOS, FAAHKS: 42:25

I tell them the same thing 100% Okay, so we've decided to do surgery that this patient needs. Surgery has failed. Nonoperative measures has failed to progress. Still quite symptomatic. What are the surgical options?

Edward Lin, MD: 42:39

So the surgical treatment for carpal tunnel surgery is called the carpal tunnel release, and what we're actually doing is we're lengthening that transverse carpal ligament, which is that thick ligament that sits on top of the nerve. It's pushing down on the nerve. We're opening it up and creating more room for the nerve, and that's called the carpal tunnel release.

Edward Lin, MD: 42:57

There are different ways to do it. You can do it with an open procedure, which is the traditional way of doing it, where we do surgery and we open up that ligament, eventually that ligament which, even if it's open, really doesn't have any effect on the function of the hand. So that ligament, if it's in a lengthened position or if it's divided, the hand will still function just fine in that condition and over time that ligament will heal back into a less compressive condition. So another way to do it is there's something called an endoscopic carpal tunnel release, where we use a small tiny camera to go in and release the ligament using a specialized device through a very small incision with the camera. And then there are also various other methods of doing it, but those are the two main methods.

Robert A. Kayal, MD, FAAOS, FAAHKS: 43:47

Both of them are done as an outpatient.

Edward Lin, MD: 43:49

Right? That's correct. Yeah, the procedure itself takes about anywhere from 10 minutes to 30 minutes and it's done as an outpatient, meaning you go home, you have a soft dressing on your hand and you're going to keep it dry for the first few days after the surgery. You can move your hands immediately after this. Actually, I encourage patients to move their hands immediately after the surgery to prevent scar tissue buildup, and most patients are able to return to work pretty quickly. Everyone's a little bit different, but patients are able to still use their hand. It might be a little sore, but for the most part, patients are still functional after this procedure.

Robert A. Kayal, MD, FAAOS, FAAHKS: 44:23

I liken carpal tunnel release to some of the most rewarding surgical procedures we do in the field of orthopedics right Hip replacement, shoulder replacements. Certainly carpal tunnel syndrome and its release is right up there with that. When patients can't sleep, they're miserable and they're so thankful and grateful to be able to get a good night's sleep without having to wake up repetitively with their hands going numb, and it's often an instantaneous level of gratification that we appreciate. I tell the patients today you're going to go to sleep and you're going to sleep through the night. They appreciate that relief that night, the night of the surgery, and it's one of the most gratifying procedures, I'm sure. For you you're most successful and most gratifying procedure, I'm sure.

Edward Lin, MD: 45:16

I agree. Personally, I love doing carpal tunnel releases for a variety of reasons. One is the patients do great. It's one of the ways you can really impact someone's life instantaneously. As you said, you can see what the problem is. So I'm a visual person. You can go in there and see the nerve being compressed and being released, and so you know exactly where the problem is, you know how to fix it and the results are great. So it's a really rewarding and satisfying procedure for sure.

Robert A. Kayal, MD, FAAOS, FAAHKS: 45:46

Yeah, just like in the spine, a severe case of spinal stenosis when a spine surgeon does a lumbar decompression and frees up that nerve. We all like to free up nerves. When nerves get compressed, whether it's in the spine, in the hand, in the neck, patients hurt, they suffer and it's a really bad form of suffering. It's one of the most painful conditions you can have. When a nerve is compressed, most debilitating. It can have many, many different consequences neurological consequences, numbness, tingling, pain, weakness, etc. In all parts of the body and nerves don't like to be compressed and so when you decompress that nerve, patients are very grateful and almost instantaneously. So it's an awesome surgical option for these patients and a lot of them end up wondering why they waited so long, because it's such a minimally invasive procedure with such an outstanding outcome instantaneous outcome that we encourage you. If you're suffering from this condition, wait no longer. We have treatment alternatives available for you immediately.

Edward Lin, MD: 46:54

Yeah, and this is a procedure where people often come with bilateral carpal tonal meaning in both hands, so we can do one side and then wait two weeks and do the other side. So it's something that the healing is fairly quick and you don't have to stop your life. You don't have to stop doing what you're doing, other than you do have to limit some of the major sporting activities that you're doing, but everyday life things that you're doing at home, you can continue using your hands for those.

Robert A. Kayal, MD, FAAOS, FAAHKS: 47:21

Is there any consideration given for orthopedic biological regenerative medicine like platelet-rich plasma injection therapy or anything like that for carpal tunnel syndrome?

Edward Lin, MD: 47:31

Yeah. So it kind of goes along with what we were talking about before with the inflammation. So with PRP, which is platelet-rich plasma, which I'm sure everyone has heard about. The goal is really to reduce the inflammation. So, just like doing a cortisone injection, you could consider doing a PRP injection to help reduce that inflammation and help improve the symptoms without surgery.

Robert A. Kayal, MD, FAAOS, FAAHKS: 47:52

So we've talked about the surgery now. Patients had the surgery. They're home. What's next?

Edward Lin, MD: 47:57

So usually after carpal tunnel surgery the recovery is fairly quick compared to other surgeries you might have had. We put on a soft dressing so you're moving your wrist and moving your hand. Immediately after the surgery you come back and see us in the office, usually within about a week. We check in the wound, make sure and everything is okay. The incision itself is something about there to there. So it's just about that big for an open carpal tunnel surgery and for endoscopic carpal tunnel surgery the incision is actually even smaller. It's just about from here to there. It's about one centimeter and I can perform both procedures.

Edward Lin, MD: 48:33

Either procedure is an acceptable treatment. I think there are pros and cons to either modality and it depends on the patient which one we ultimately decide to pursue. But the recovery is quick. The stitches come out in about 10 days. Some patients will need therapy afterwards. I would say the majority of patients don't necessarily need therapy because a lot of patients come in and they have great motion and a lot of them don't want to go to therapy and that's fine. But if patients do, that's something to consider as well after surgery to improve their strength and improve the motion of their fingers after the surgery.

Robert A. Kayal, MD, FAAOS, FAAHKS: 49:10

So what about recurrent carpal tunnel syndrome? Is that something that can happen, and if so, how can that be treated?

Edward Lin, MD: 49:19

Sure. So recurrent carpal tunnel does happen. And by recurrent carpal tunnel syndrome I'm talking about someone who's had carpal tunnel release, whether endoscopically or through an open procedure, and maybe a few months later, maybe a year later, they have their symptoms in return and we call that recurrent carpal tunnel syndrome because the symptoms have come back despite having a successful surgery. Usually they'll feel better for a period of time and then slowly they'll find that their carpal tunnel symptoms have come back. And in those patients, well, one thing it's really important to make sure that they actually do have carpal tunnel syndrome. Sometimes after surgery you may find that you still have numbness and tingling because it's coming from the neck or maybe you have some other condition that's causing that. But assuming you are dealing with carpal tunnel syndrome, the treatment for a recurrent carpal tunnel syndrome is to do a revision carpal tunnel release, and what that means is we go back in there and we try to open up the nerve again and try to release the compression that's come back Now when I do that procedure.

Edward Lin, MD: 50:23

First of all, it's pretty rare. The literature shows that recurrence occurs, depending on the paper, anywhere from a few percent, meaning two or 3%. Some papers show up to 20, 30%, but I think that's really unlikely. But I would say it's less than 10% the risk of recurrence. But when it does happen I will do a revision. Carpal tunnel procedure. Now that procedure is a lot more involved in the initial procedure, meaning we have to make a much bigger incision and it's a bigger surgery because we're dealing with a lot more scar tissue that was left behind by the first surgery. You're definitely not doing that endoscopically.

Edward Lin, MD: 51:00

No, no, I would not recommend doing that endoscopically. And then, in addition, what I do is I do what's called a hypothyner fat flap, where I take some fat from this area of the hand and we move it across the nerve and what that does is that covers the nerve in a nice layer of fat so that when it does heal it prevents scar tissue from forming around the nerve and causing compression again. But I would say that's a fairly rare procedure. In the most case, if you've done a carpal tunnel release, the symptoms are not going to come back.

Robert A. Kayal, MD, FAAOS, FAAHKS: 51:31

Right. Well, this was a very helpful and informative conversation, dr Lin. I hope that our viewing audience found this to be the same. We hope they learned something about carpal tunnel syndrome, and if I can give you a take home message, it's don't ignore your symptoms. Seek medical care, the sooner the better, because it is a condition that we can treat more successfully when we see it early and even with surgery if you need surgery outcomes will be better when we address the milder to moderate symptoms as opposed to the more severe and chronic conditions. Any closing words, dr Lin?

Edward Lin, MD: 52:10

Yeah, I agree. As I said, carpal tunnel syndrome is one of the most common things I see. I see it day in and day out. It can be very debilitating for patients patients who come in because your hands are so important. Use your hands. As surgeons, we appreciate that very personally, but people are using their hands for a whole variety of activities, whether it be sporting, whether it be at the job, whether it be taking care of a loved one. Your hands are so important and so it's important to take care of your hands so that you can continue to use them for everything you want out of life.

Robert A. Kayal, MD, FAAOS, FAAHKS: 52:46

Well, we truly appreciate your skill set and your education and training, your bedside manner, and I'm honored to call you a colleague and physician at Kailor Orthopedic Center. Thank you for spending the time with us and for educating our population about carpal tunnel syndrome. All right, thank you, dr Kailor. We appreciate it. Pleasure is mine.