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Numbness and Tingling

Could it be carpal tunnel?

Numbness and tingling of the hands is a common and bothersome symptom. Such tingling can and temporary. For example, it could result from pressure under your head as you fall asleep. The symptoms are soon relieved by removing the pressure that caused it.

In many cases, however, numbness or tingling in the hands can be persistent, severe , and can interfere with daily activities. Other symptoms such as pain, weakness, and dropping things may be present or show up later. In such cases, tingling may be a sign of nerve irritation or damage. There are several causes for nerve problems, some of which are reversible, whereas others are not.

Sensation and motor function to the hand is supplied by three major nerves. Those nerve reach from the neck, across the elbow and the wrist, until they reach the finger tips. On there way down, they cross one or more ‘tunnels’. Nerve compression across an anatomic tunnel is called a tunnel syndrome. Common areas for nerve compression are across the wrist (the carpus), and across the elbow (the cubitus) thus the names Carpal Tunnel Syndorme and Cubital Tunnel Syndrome.

CARPAL TUNNEL SYNDROME

MRI of the Wrist, showing the carpal tunnel. The median nerve is highlighted in yellow. The transverse carpal ligament is highlighted in red.

MRI of the Wrist, showing the carpal tunnel. The median nerve is highlighted in yellow. The transverse carpal ligament is highlighted in red.

The carpal tunnel is located at the palm side of the wrist. The bottom and sides of this tunnel are formed by wrist bones and the top is made of a strong ligament. The median nerve passes through the carpal tunnel before it reaches the finger tips. It provides feeling to the thumb, index, long, as well as one half of the ring finger. It also controls the muscles of the thumb. The nerve is accompanied with a total of nine tendons that also reach to the fingers and thumb.

Carpal tunnel syndrome occurs when the pressure in the tunnel goes up. Usually this is caused by swelling of the tissues around the nerve, leaving very little room for the nerve. This happens without any particular reason, but sometimes can be related to certain conditions.

Symptoms of carpal tunnel syndrome include numbness, tingling, ‘pins and needles’, pain, and electric shock-like feeling in the thumb, index, and middle fingers. These symptoms usually start gradually, get worse at night, and get worse with time. Patients may wake up at night because of it and sometimes notice partial relief with shaking the hand. With time, the hand may get clumsy, and patients start dropping things, and have difficulty holding objects because they cannot feel with their finger tips. Unfortunately, many patients assume that numbness and tingling is something that comes with age, and just live with it. This is not true, as carpal tunnel syndrome is easy to deal with and should always be addressed. If the patient dismissed carpal tunnel for a long time, irreversible damage occurs and shows as flattening of the thumb muscles and weakness of grip and pinch.

Treatment

Treatment for carpal tunnel syndrome can be very simple. I usually use a combination of a steroid injection and a semi-rigid wrist splint. This is usually highly successful. If symptoms persist or recur, we may repeat the injection or consider surgery. Surgery is simple- split the ligament on the top of the tunnel to make more room for the nerve. Before we commit to surgery, we may elect to confirm the diagnosis using a nerve test. Surgery for carpal tunnel syndrome does not require being put to sleep. I most commonly perform it under local anesthesia and send the patient home with an hour. Recovery is usually very quick after surgery.

CUBITAL TUNNEL SYNDROME

The cubital tunnel is located in the elbow, right where the funny bone is. As a matter of fact, the funny bone is actually the nerve that goes through the cubital tunnel. It is where the funny bone is. Similar to the carpal tunnel, the bottom, and sides of the cubital tunnel are formed by bone. The back side of the tunnel is made of a strong ligament. The ulnar nerve passes through this tunnel. It runs through the forearm, across the wrist, and feeds into the ring and little fingers. It supplies feeling to the ring and little fingers, and controls the fine muscles of the hand.

Cubital Tunnel Syndrome occurs when the nerve is squeezed or stretched in the tunnel, or sometimes when the nerve becomes loose within the tunnel and bounces across the side of the tunnel. This can happen without any particular reason, but sometimes, may be related to deformity, or prolonged pressure. Resting the elbow on the armrest while driving for long distances, or keeping the elbow bent for a long time holding a mobile phone, or going to bed with the hand tucked under the head can cause cubital tunnel syndrome.

Symptoms of cubital tunnel syndrome include numbness, tingling, pain, ‘pins-and-needles’, and electric shock-like feeling in the ring and little fingers. These symptoms usually start gradually, occasional at first but may evolve into persitent numbness. They may occur more frequently at night. With time, the hand may get clumsy, and patients notice weakness of grip and ultimately, the fingers may draw into claw-like posture.

Treatment

Treatment for cubital tunnel syndrome can be very simple. I usually recommend avoiding direct pressure (avoid placing the elbow on the armrest while driving), prolonged use of mobile phones (consider hands-free alternatives), and learn not to keep the arm bent at night. For this last point, there is a nice trick- wrap a towel around your elbow just before you go to bed. The towel will prevent you from bending your elbow too much, and in a few weeks you will have got used to not bending the elbow and will need the towel no more. If symptoms persist or recur, you may consider non-steroidal anti-inflammatories, but they may not be very effective. Once all options fail, we may consider surgery. Surgery is simple- splitting the ligament over the tunnel to make more room for the nerve. Before we commit to surgery, we may elect to confirm the diagnosis using a nerve test. The

OTHER CAUSES OF NUMBNESS AND TINGLING

So far we have covered two nerves, and one tunnel for each nerve. There is one more nerve, the radial nerve, and other tunnels / areas of compression that can cause similar symptoms. The symptoms may also be related to pinched nerves in the neck, cervical disc disease, as well as diabetes and a long list of medical conditions. For this reason, medical evaluation is critical to rule out other causes and determine whether treatment is available.

I believe that dismissing numbness and tingling is not smart, as treatment can be simple and highly successful when started in a timely manner. Even if a patient is diabetic and has baseline neuropathy, any change in sensory function should be addressed as diabetic patients can and do get carpal and cubital tunnel syndromes. Knowing that treating the tunnel syndromes may not completely relief the numbness, they sure can improve it, and that may be that is needed.

 


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