carpal tunnel syndrome

1. What 10 structures go through the carpal tunnel?
2. What are causes of CTS?
3. What is double crush syndrome?
4. What are 5 provocative tests for CTS?
5. What are conservative treatments for CTS?
6. What are indications for surgery?

Answer:
1. Flexor digitorum superficialis tendons (4), flexor digitorum profundus tendons (4), flexor pollicis longus tendon, and median nerve.
2. Idiopathic, thyroid disease, CHF, renal failure, mass, pregnancy (6 mo), fracture, arthritis, rheumatoid tenosynovitis, diabetes, or double crush syndrome (cervical radiculopathy or TOS).
3. This is when a proximal lesion (e.g. radiculopathy) causes an injury to an already vulnerable distal nerve (e.g. median nerve).
4. Tinel's test is percussion of median nerve at wrist. Phalen's test holds the wrist in 90 flexion for one minute. Tourniquet test reproduces symptoms with one minute of BP cuff inflation. Carpal compression test involves holding the thumb over the tunnel for 30 seconds. Reverse Phalen's test holds the wrist in extension for one minute.
5. Conservative treatment can be used if there's no weakness or atrophy or denervation on EMG. It includes hands splints 0-30 neutral to extension, NSAIDs, steroid injection, diuretics, Vit B6, ergonomic modifications, treatment of underlying disorders. Poor outcome more likely to occur with symptoms >10mo, constant paresthesias, positive Phalen's test in <10sec, weakness, atrophy, marked prolonged latency on NCS, spont activity on EMG.
6. Surgical indications include atrophy, severe pain, conservative treatment failure.