Overview Snapshot A 45-year-old woman presents to her primary care physician's office due to pain in her hand. The patient reports that the pain is worse at night and when her hand is outstretched. Her symptoms are also accompanied by paresthesias in the affected hand. She denies any recent injury to or pain in the hand or neck. She works as a secretary at a medical clinic. On physical exam, she has a positive Phalen and Tinel test. Introduction Clinical definition compressive median nerve neuropathy Epidemiology demographics bimodal distribution of age 50-60 and 70-80 years of age risk factors female gender obesity pregnancy hypothyroidism rheumatoid arthritis dialysis-related amyloidosis dialysisrelated amyloidosis repetitive use of the hand or wrist Etiology increased pressure within the carpal tunnel Pathoanatomy borders roof: transverse carpal ligament floor: proximal carpal row laterally: scaphoid and trapezium medially: hook of hamate and pisiform normal anatomy the carpal tunnel contains digital flexor tendons flexor pollicis longus tendon median nerve pathology synovial noninflammatory fibrosis and thickening leads to median nerve compression (most common) compression leads to microvascular insufficiency causing ischemic damage to the nerve Prognosis in mild-to-moderate cases, there is spontaneous resolution or response to conservative therapy Presentation Symptoms pain or paresthesia in the median nerve distribution median nerve distribution the first 3 digits and radial half of 4th digit symptoms typically worse at night weakness or hand clumsiness Physical exam provoking tests Phalen test patients flexes palm at the wrist pain and/or paresthesia in the median nerve distribution is a positive test Tinel test percussion over the course of the median nerve pain and/or paresthesia in the median nerve distribution is a positive test Studies Making the diagnosis the diagnosis can be clinically made; however, it is confirmed by nerve conduction studies Nerve conduction studies indication may be used when contemplating surgical decompression Electromyogram indication typically used to exclude other etiologies such as polyneuropathy plexopathy radiculopathy Differential Cervical radiculopathy compressing C5-C6 distinguishing factors patients have neck pain, worsening symptoms with head movement, and pain radiation to the shoulders and arm patients also have reduced biceps, brachioradialis, and triceps reflex Treatment Conservative splinting indication to improve mild carpal tunnel syndrome symptoms Medical corticosteroid (oral or injection) indication to improve mild carpal tunnel syndrome symptoms Operative surgical decompression indication for severe median nerve injury reflected by nerve conduction studies (e.g., severe axonal degeneration) or needle electromyography Complications Rare