Carpal tunnel syndrome

[Will Morris]

Agreed. That’s why the “the CTS was properly diagnosed” caveat was among my criteria for proceeding with it.

I love referring patients to a good ortho surgeon when I diagnose this because the efficacy of CTS release is so high.

That said, unfortunately, I have seen “failure to improve” follow the procedure in patients with classic median nerve distribution pain/numbness in the hand, a positive Tinel’s sign, and a positive Phalen’s sign (all confirmed by good orthopods) who didn’t get better but that’s the worse thing I ever saw. However even failure to improve is super rare in my experience.

Admittedly, in the years of practice when I was practicing more in a primary care setting, nerve conduction studies to confirm the diagnosis was not the standard of care and I rarely saw specialists order them to rule out CTS.

Pardon me for nerding out in what is to come but I have this question Will: I can understand how cervical radiculopathy can conceivably explain a distal median nerve pathology, but how can it explain positive Tinel or Phalen’s signs? As I understand it, those signs elicit evidence of actual entrapment of the distal nerve underneath the flexor retinaculum in the wrist.

As an aside, to lend credence to your statement that “its not a terribly involved procedure” I’ll add this: when I was a 4th year medical student rotating through what was then called Walter Reed Army Hospital, I scrubbed in on one and the hand surgeon had me do the case from start to finish.

Not only did the patient survive the ordeal but he had a great outcome. Trust me, if I could successively do one and not kill the poor bastard, then it cannot be a difficult operation!

Dr. Ford, the theory is that double crush phenomenon causes the nerve to be more irritable the entire course of the nerve downstream from the most proximal impingement, therefore, the phalens and tinnels cause symptoms. But, in these cases, without the cervical herniation, the tinnels and phalens would not produce symptoms.

The tinnels and phalens don’t necessarily elicit evidence of entrapment, rather, they are simply provocative tests that cause compression of the median nerve at the CT.

[JFord]

Dr. Ford, the theory is that double crush phenomenon causes the nerve to be more irritable the entire course of the nerve downstream from the most proximal impingement, therefore, the phalens and tinnels cause symptoms. But, in these cases, without the cervical herniation, the tinnels and phalens would not produce symptoms.

The tinnels and phalens don’t necessarily elicit evidence of entrapment, rather, they are simply provocative tests that cause compression of the median nerve at the CT.

Got it!