Carpal tunnel syndrome

Last revised by Dr Yuranga Weerakkody on 05 Dec 2021

Carpal tunnel syndrome results from compression of the median nerve (tunnel syndrome) within the carpal tunnel. It is a cause of significant disability and is one of three common median nerve entrapment syndromes, the other two being anterior interosseous nerve syndrome and pronator teres syndrome

The prevalence of carpal tunnel syndrome is estimated to be 2.7-5.8% of the general adult population, with a lifetime incidence of 10-15%, depending on occupational risk 4.

Carpal tunnel syndrome usually occurs between ages 36 and 60 and is more common in women, with a female-to-male ratio of 2-5:1.

Carpal tunnel syndrome is primarily defined by pain and sensory symptoms: 

  • brachialgia paraesthetica nocturna, or nocturnal ascending pain emanating from the wrist, is typical
  • sensory symptoms affect the first three digits and, depending on innervation patterns, the radial aspect of the fourth digit
  • positive Tinel test: paresthesias elicited by tapping the median nerve at the wrist
  • positive Phalen test: paresthesias caused by wrist flexion over 30-60°

Hand weakness, as a rule, is a late and often functionally irrelevant symptom 5.

The dominant hand is affected more frequently, and bilateral involvement has been reported to occur in ~30% (range 8-50%) of cases.

The clinical presentation can harbor some pitfalls. Sensory and pain symptoms of the pronator teres syndrome (PTS) and carpal tunnel syndrome can overlap; one can distinguish the two by examining for numbness of the forearm, which does not occur in carpal tunnel syndrome and ask about nocturnal exacerbation, which is atypical in PTS. Provocation tests as detailed above can help further.

There is a wide spectrum of causative pathologies, converging on two mechanisms of disease, both of which lead to entrapment 5:

A useful mnemonic to remember these causes is MEDIAN TRAP.

Ultrasound and MRI are the two imaging modalities that best lend themselves to investigating entrapment syndromes. Next to directly visualizing direct causes and anatomical variants (e.g. a Gantzer muscle), recognizing pathological muscle signal patterns on MRI can point to the affected nerve.

In imaging median nerve syndromes, ultrasound is useful in examining carpal tunnel syndrome, potentially revealing, in fully developed cases, a triad of:

  • palmar bowing of the flexor retinaculum (>2 mm beyond a line connecting the pisiform and the scaphoid)
  • distal flattening of the nerve
  • enlargement of the nerve proximal to the flexor retinaculum

Enlargement of the nerve seems to be the most sensitive and specific criterion, but what cut-off value for pathological size remains debated; the normal cross-sectional area is given at 9-11 mm2 (0.09-0.11 cm2), but the range of sizes deemed pathological is wide. If the nerve is bifid some suggest measuring the combined cross-sectional area ref.

According to one study, a 2 mm2 difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99% sensitivity and 100% specificity for carpal tunnel syndrome 9.

Some of the other proposed findings include ref:

  • a flattening ratio of over x 3
  • bowing of the flexor retinaculum of >4 mm

MRI has good-to-excellent sensitivity (84-100%) and specificity (85-94%) for diagnosing carpal tunnel syndrome when using cross-sectional area >15 mm2 as a cut-off 12,13. MRI is especially well-suited for detecting masses, arthritic changes, and normal variants (e.g. bifid median nerve5.

In carpal tunnel syndrome, MRI can demonstrate 4:

  • palmar bowing of the flexor retinaculum
  • nerve thickening at the carpal tunnel inlet (level of the pisiform)
  • nerve flattening at the carpal tunnel outlet (level of the hook of hamate)
  • increased cross-sectional area
    • ultrasound values do not correlate with MRI values 11
    • >15 mm2 at the carpal tunnel inlet or outlet can be used as a diagnostic criterion or cut-off 12,13
    • >19 mm2 has been proposed as a marker for severe carpal tunnel syndrome 13
  • edema or loss of fat within the carpal tunnel
  • neural edema s +/- contrast enhancement

It is initially often treated conservatively with splinting and non-steroidal anti-inflammatory drugs (NSAIDS). Corticosteroid injections into the carpal tunnel can alleviate symptoms temporarily for about 4 weeks. Median nerve injury is a very rare complication 10

Surgical release of the flexor retinaculum is indicated in cases of pronounced nocturnal pain, permanent dysesthesias and prolonged distal motor latency on electroneurography (>6 ms). Long-term recurrence rates reach 30% 4.

Possible differential diagnoses of carpal tunnel syndrome include:

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Cases and figures

  • Figure 1: carpal tunnel diagram
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  • Case 1
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  • Figure 2: carpal tunnel syndrome
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  • Case 2
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  • Case 3
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  • Case 4
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  • Case 5
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  •  Case 6
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  • Case 7
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  • Case 8
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  • Case 9
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  • Case 10
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  • Case 11
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  • Case 12: carpal tunnel syndrome - postoperative ultrasound
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  • Case 13
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  • Case 14
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