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I
PENDAHULUAN
Latar Belakang
Penekanan terhadap persarafan pergelangan tangan (carpal tunnel syndrome) merupakan
kelainan yang paling sering mengenai N. Medianus sebagai sindrom jebakan nervus yang paling
sering ditemukan. Hal ini berkaitan dengan penggunaan tangan yang eksesif tak terbatas dan
trauma repetitif akibat paparan okupasi berkelanjutan. Ligamentum carpi transversum yang
terinfiltrasi oleh jaringan amyloid (seperti yang timbul pada myeloma multiple) atau penebalan
jaringan ikat pada rheumatoid artritis, acromegaly, mucopolysaccharidosis, dan hipotiroidisme
merupakan penyebab yang mudah diidentifikasi untuk memicu timbulnya carpal tunnel syndrome.
Kehamilan merupakan faktor penyebab yang bisa memicu timbulnya sindroma ini, namun jarang
teridentifikasi dengan jelas. Pada orang lanjut usia, penyebab timbulnya carpal tunnel syndrome
sering menimbulkan kerancuhan.
Dysesthesias dan nyeri pada jari tangan, mengacu pada “acroparesthesiae” merupakan
tanda klinis awal terjadinya sindrom penekanan N. Medianus pada awal tahun 1950-an. Tahun
1949, Kremer dkk pertama kali mengemukakan penyebab timbulnya sindrom ini dikarenakan oleh
penekanan terhadap N. Medianus pada pergelangan tangan dan gejalanya akan berkurang dengan
pemisahan fleksor retinaculum yang membentuk dinding ventral canalis carpi. Paresthesia timbul
cukup parah di saat malam hari. Nyeri akibat carpal tunnel syndrome sering kali menjalar hingga
ke lengan dan pundak. Gejala yang timbul secara esensial berupa sensorik satu, yakni hilangnya
sebagian sensibilitas superfisial pada jari jempol, jari telunjuk dan jari tengah. Kelemahan dan
atrofi pada otot abduktor pollicis brevis dan otot – otot lain yang dipersarafi oleh N. Medianus
seringkali ditemukan pada kelainan yang sudah cukup parah dan tak terobati. Uji elektrofisiologis
membantu dalam penegakan diagnosis dan memberikan kejelasan akan kemungkinan suksesi
tindakan operasi.
Tindakan pembedahan dengan pemisahan ligamentum carpal dengan dekompresi pada
persarafan merupakan tindakan pengobatan terbaik. Splint pada pergelangan tangan, untuk
menghindari gerakan fleksi, seringkali dapat menimbulkan ketidaknyamanan, namun bermanfaat
agar penderita tidak terlalu sering menggunakan tangan yang mulai terkena carpal tunnel
syndrome. Splint bermanfaat untuk sementara waktu dan terapi yang lebih baik dari splint berupa
injeksi hidrokortison ke dalam canalis carpi.1
Tujuan Penulisan
Penulisan text book reading (TBR) dengan judul “Carpal Tunnel Syndrome” ini
bertujuan untuk menjelaskan definisi, patogenesis & patofisiologis, gejala klinis, penegakan
diagnosis, diagnosis banding, penatalaksanaan dan prognosis mengenai Carpal Tunnel
Syndrome. Diharapkan dalam penulisan referat ini dapat memberikan informasi yang
bermanfaat bagi pembaca, terutama bagi penderita agar bisa memiliki kualitas hidup yang lebih
baik dan lebih layak.
II
TINJAUAN PUSTAKA
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome (CTS) merupakan tanda dan gejala klinik yang timbul akibat
tekanan terhadap N. Medianus yang berjalan melalui canalis carpi. Carpal tunnel syndrome
merupakan salah satu bentuk neuropathy pada ekstremitas superior yang menimbulkan efek nyeri
pada tangan berupa gangguan motorik dan sensorik yang dipersarafi oleh N. Medianus.
Gejala – gejala yang ditimbulkan oleh carpal tunnel syndrome berupa nyeri, paresthesia,
dan kelemahan pada regio yang dipersarafi oleh N. Medianus. Diagnosis carpal tunnel syndrome
berupa adanya nyeri, mati rasa (numbness) dan kesemutan pada tangan yang dapat menjalar hingga
pundak dan leher; gangguan ini sering terjadi di malam hari saat tidur dengan posisi tidur berbaring
ke satu sisi. Untuk mencegah terjadinya carpal tunnel syndrome akibat aktivitas repetitif yang
menimbulkan mati rasa (numbness) dan nyeri, perlu dilakukan gerakan meregang pergelangan
tangan, tangan dan jari tangan. Selain itu, pengobatan yang efektif bagi penderita carpal tunnel
syndrome dengan menggunakan splint (balut tangan), injeksi kortikosteroid dan pembedahan.
Mayoritas kasus carpal tunnel syndrome didiagnosis tanpa disertai dengan penyebab yang
khusus dan pada beberapa penderita dikarenakan oleh faktor genetik.
Latar Belakang Sejarah
Carpal tunnel syndrome mulai dikenal sejak Perang Dunia II. Seseorang yang menderita
gejala – gejala carpal tunnel syndrome akan menjalani terapi pembedahan di pertengahan abad ke
19. Tahun 1854, Sir James Paget pertama kali melaporkan tekanan pada N. Medianus di
pergelangan tangan akibat fraktur distal radius. Diikuti pada abad ke 20 didapatkan beragam kasus
penekanan N. Medianus dalam ligamentum carpal transversum. Kejadian Carpal tunnel syndrome
sering dipublikasikan dalam literasi kedokteran pada awal abad ke 20 dan mulai digunakan dalam
praktek klinis tahun 1939. Dr. George S. Phalen dari Cleveland Clinic pertama kali
mengidentifikasi patologis dari carpal tunnel syndrome pada sekelompok pasien di tahun 1950-an
dan tahun 1960-an dan menyimpulkan carpal tunnel syndrome merupakan cedera tangan akibat
penggunaan dalam aktivitas rutin secara terus – menerus yang sering didapatkan akibat pekerjaan.
Anatomi
Secara anatomis, canalis carpi (carpal tunnel) berada di dalam dasar pergelangan tangan.
Sembilan ruas tendon fleksor dan N. Medianus berjalan di dalam canalis carpi yang dikelilingi dan
dibentuk oleh tiga sisi dari tulang – tulang carpal. Nervus dan tendon memberikan fungsi,
sensibilitas dan pergerakan pada jari – jari tangan. Jari tangan dan otot – otot fleksor pada
pergelangan tangan beserta tendon – tendonnya berorigo pada epicondilus medial pada regio cubiti
dan berinsersi pada tulang – tulang metaphalangeal, interphalangeal proksimal dan interphalangeal
distal yang membentuk jari tangan dan jempol. Canalis carpi berukuran hampir sebesar ruas jari
jempol dan terletak di bagian distal lekukan dalam pergelangan tangan dan berlanjut ke bagian
lengan bawah di regio cubiti sekitar 3 cm.
Tertekannya N. Medianus dapat disebabkan oleh berkurangnya ukuran canalis carpi,
membesarnya ukuran alat yang masuk di dalamnya (pembengkakan jaringan lubrikasi pada tendon
– tendon fleksor) atau keduanya. Gerakan fleksi dengan sudut 90 derajat dapat mengecilkan ukuran
canalis.
Penekanan terhadap N. Medianus yang menyebabkannya semakin masuk di dalam
ligamentum carpi transversum dapat menyebabkan atrofi eminensia thenar, kelemahan pada otot
fleksor pollicis brevis, otot opponens pollicis dan otot abductor pollicis brevis yang diikuti dengan
hilangnya kemampuan sensorik ligametum carpi transversum yang dipersarafi oleh bagian distal
N. Medianus.
Cabang sensorik superfisial dari N. Medianus yang mempercabangkan persarafan
proksimal ligamentum carpi transversum yang berlanjut mempersarafi bagian telapak tangan dan
jari jempol.
Gejala Klinik
Carpal Tunnel Syndrome yang tidak diobati
Carpal tunnel syndrom menimbulkan beragam gejala khas dari gejala sakit sedang hingga
gejala sakit yang berat. Gejala – gejala ini akan semakin bertambah berat dan penderita yang telah
didiagnosis dengan carpal tunnel syndrome akan mengeluhkan sensasi mati rasa (numbness),
kesemutan, dan sensasi terbakar pada jari jempol, jari telunjuk dan jari tengah dimana ketiga jari
tersebut diinervasi oleh N. Medianus. Pada beberapa penderita juga sering mengeluhkan rasa sakit
pada tangan atau pergelangan tangan dan hilangnya kekuatan menggenggam. Rasa nyeri juga
timbul pada lengan dan pundak serta benjolan pada tangan; rasa nyeri ini akan terasa teramat sakit
terutama di malam hari saat tidur.
Mati rasa (numbness) dan kesemutan (paresthesia) pada area yang dipersarafi oleh N.
Medianus merupakan gejala neuropathy akibat sindrom jebakan canalis carpi (carpal tunnel
entrapment). Kelemahan dan atrofi otot – otot thenar akan timbul selanjutnya jika kondisi ini
semakin tak terobati.
Perempuan tiga kali lebih banyak daripada laki – laki pada penderita carpal tunnel
syndrome, yang diperkirakan karena ukuran canalis carpi pada perempuan lebih kecil
dibandingkan pada laki – laki.
Etiologi
Mayoritas kasus carpal tunnel syndrome tak diketahui etiologinya secara pasti (idiopatik).
Carpal tunnel syndrome dapat dihubungkan dengan beragam keadaan yang memicu penekanan
terhadap N. Medianus pada pergelangan tangan. Beberapa kondisi yang dapat memicu timbulnya
carpal tunnel syndrome, antara lain: obesitas, hipotiroidisme, arthritis, diabetes dan trauma.
Penyebab lainnya, faktor intrinsik dengan tekanan kuat dari dalam pada canalis dan faktor
ekstrinsik dengan tekanan kuat berasal dari luar canalis, yang dikarenakan oleh tumor jinak berupa
lipoma, ganglioma, dan malformasi vaskuler. Hingga saat ini masih belum ditemukan hubungan
yang jelas antara pekerjaan dan timbulnya carpal tunnel syndrome atau dikarenakan adanya
masalah kesehatan lain yang tak teridentifikasi.
Hubungan dengan Pekerjaan (Okupasi Ergonomik)
Sampai saat ini masih diperdebatkan hubungan antara insidensi carpal tunnel syndrome
dengan gerakan repetitif pergelangan tangan akibat pekerjaan. Occupational Safety and Health
Administration (OSHA) di Amerika Serikat mengeluarkan peraturan dan regulasi berkaitan dengan
trauma karena kelainan kumulatif akibat faktor pekerjaan. Faktor resiko pekerjaan akibat
penggunaan repetitif, pemaksaan, postur pergerakan, dan paparan vibrasi berulang. Akan tetapi,
perkumpulan The American Society for Surgery of the Hand (ASSH) telah menyatakan literatur
yang terkini tidak mendukung adanya hubungan kausal antara aktivitas pekerjaan dan
pengembangan penyakit akibat faktor pekerjaan seperti carpal tunnel syndrome.
Hubungan antara pekerjaan dan carpal tunnel syndrome masih kontroversi; di banyak
tempat para pekerja yang terdiagnosis dengan carpal tunnel syndrome harus mengambil cuti dan
menerima kompensasi. Di Amerika Serikat, dana yang dibutuhkan selama masa pengobatan carpal
tunnel syndrome sebesar US$30,000 yakni biaya pengobatan dan hilangnya waktu kerja karena
cuti.
Beberapa ahli berspekulasi bahwa carpal tunnel syndrome dapat terjadi dikarenakan
gerakan repetitif dan aktivitas manipulatif akibat paparan yang telah berlangsung dalam waktu
yang lama. Hal ini juga ditegaskan gejala yang timbul dikarenakan eksaserbasi dengan pemaksaan
dan penggunaan tangan dan pergelangan tangan secara repetitif karena faktor pekerjaan, namun
tidak dijelaskan jika gejala ini berupa nyeri alih (yang bukan gejala carpal tunnel syndrome) atau
gejala mati rasa yang lebih tipikal.
Sebuah data ilmiah yang dikeluarkan oleh National Institute for Occupational Safety and
Health (NIOSH) menyatakan jenis pekerjaan yang menyebabkan pergelangan tangan terpostur
melakukan pekerjaan secara repetitif berhubungan dengan insidensi carpal tunnel syndrome,
namun penyebabnya tidak dijelaskan secara terperinci dan perbedaan antara gejala yang
ditimbulkan oleh carpal tunnel syndrome dan nyeri pada lengan akibat hubungan kerja tidak
dijelaskan secara spesifik. Telah diketahui bahwa penggunaan lengan secara repetitif dapat
menimbulkan efek biomekanik pada ekstremitas superior atau menyebabkan kerusakan pada
jaringan. Juga telah diketahui assessment postural dan spinal bersamaan dengan assessment
ergonomic seharusnya dimasukkan sebagai kondisi determinasi. Saat ini belum ada bukti konkrit
tentang riwayat timbulnya carpal tunnel syndrome.
Carpal tunnel syndrome sering ditemukan pada populasi pekerja orang dewasa; oleh
karena itu, ada kemungkinan baik dikarenakan oleh faktor pekerjaan atau bukan. Saat sebuah otot
berkonstraksi, sebagai contoh memelintir dan melakukan gerakan fleksi pergelangan tangan,
terjadi penambahan luas otot berlebihan yang dapat memicu timbulnya kelainan muskuloskeletal.
Disamping tingginya hubungan antara faktor pekerjaan dengan insiden carpal tunnel syndrome,
pengetahuan mengenai hal ini masih kurang jika ditinjau dari pola dan kausalitas dari hubungan
kedua hal ini. Penelitian yang lebih luas perlu dilakukan untuk mengemukakan secara konkrit
hubungan ergonomik dan kecelakaan kerja yang di dalamnya termasuk carpal tunnel syndrome.
Hubungan Carpal Tunnel Syndrome dengan Penyakit – Penyakit Lain
Beragam faktor yang dapat memicu timbulnya CTS (carpal tunnel syndrome) yakni faktor
keturunan, ukuran dari ruas canalis carpi, hubungan penyakit secara lokal dan sistemik, dan
kebiasaan hidup. Penyebab non-traumatik secara umum dapat timbul setelah lewat suatu periode
waktu, dan tidak dipicu oleh hal lain. Kebanyakan faktor pemicu ini dikarenakan manifestasi
penuaan secara fisiologi, antara lain:
• Rheumatoid arthritis dan penyakit inflamasi lainnya yang dapat menyebabkan peradangan
pada tendon – tendon fleksor.
• Kehamilan dan hipotiroidisme, terjadinya retensi cairan dalam jaringan menyebabkan
pembengkakan pada tenosynovium.
• Perempuan hamil beresiko tinggi terkena CTS dikarenakan perubahan hormonal dan
retensi cairan yang sering terjadi pada masa kehamilan.
• Cedera di waktu lalu berupa fraktur pada pergelangan tangan.
• Kesalahan pengobatan dapat memicu terjadinya retensi cairan atau timbulnya inflamasi
berupa: artritis inflamasi, fraktur Colles, amyloidosis, hipotiroidisme, diabetes mellitus,
acromegaly, dan penggunaan kortikosteroid dan estrogen secara berlebihan.
• Carpal tunnel syndrome berhubungan dengan aktivitas repetitif pada tangan dan
pergelangan tangan, bersamaan dengan adanya pemaksaan dan postur yang kaku.
• Acromegaly, kelainan hormon pertumbuhan yang menekan persarafan akibat pertumbuhan
tulang abnormal pada tangan dan pergelangan tangan.
• Tumor, biasanya tumor jinak, yakni ganglion atau lipoma, dapat menimbulkan menekan
secara aktif ke dalam canalis carpi dan mengurangi ukuran ruang dalam canalis carpi.
Kejadian ini jarang terjadi (kurang dari 1% dari total insidensi).
• Obesitas juga dapat meningkatkan resiko CTS. Individu yang termasuk di dalam kelompok
obese (BMI>29) memiliki resiko 2,5 kali lebih tinggi dibandingkan individu yang bertubuh
kurus (BMI < 20).
• Mutasi heterozygot dalam gen dengan kode SH3TC2 berhubungan dengan Charcot-Marie-
Tooth yang menimbulkan neuropathy termasuk CTS.
Diagnosis
Clinical assessment by history taking and physical examination can support a diagnosis of CTS.
• Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding
this position and awaiting symptoms.[25] A positive test is one that results in numbness in
the median nerve distribution when holding the wrist in acute flexion position within 60
seconds. The quicker the numbness starts, the more advanced the condition.• Phalen’s sign
is defined as pain and/or paresthesias in the median-innervated fingers with one minute of
wrist flexion. Only this test has been shown to correlate with CTS severity when studied
prospectively.[19]
• Tinel's sign , a classic, though less specific test, is a way to detect irritated nerves. Tinel's is
performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of
tingling or "pins and needles" in the nerve distribution.• Tinel’s sign (pain and/or
paresthesias of the median-innervated fingers with percussion over the median nerve) is
less sensitive, but slightly more specific than Phalen’s sign.[19]
• Durkan test , carpal compression test, or applying firm pressure to the palm over the nerve
for up to 30 seconds to elicit symptoms has also been proposed.[26][27]
[edit] Prevalence
Carpal tunnel syndrome can affect anyone in the world. Within the U.S., an approximation of 50
out of 1000 people within the general public will suffer from the effects of carpal tunnel syndrome.
Caucasians have the highest risk of being diagnosed with CTS compared with other races such as
non-white South Africans.[32] Surprisingly, women suffer more from CTS than men with a ratio of
3:1 in between the ages of 45–60 years of age. Only 10% of reported cases of CTS are younger
than 30 years of age.[32]
CTS is not a life-threatening condition, but it can negatively affect lifestyle if left untreated. In
worst case scenarios, the median nerve can become severely damaged and result in total loss of
movement within that hand.
[edit] Prevention
A 2007 study conducted by Lozano-Calderon et al. the Department of Orthopaedic Surgery at
Massachusetts General Hospital states that carpal tunnel syndrome is primarily determined by
genetics and structure.[33] Therefore, carpal tunnel syndrome is probably not preventable.[original
research?] However, others[who?] think it is preventable by developing healthy habits like avoiding
repetitive stress, practicing healthy work habits like using ergonomic equipment (wrist rest, mouse
pad), taking proper breaks, using keyboard alternatives (digital pen, voice recognition and dictate)
and early passive treatment like taking turmeric (anti-inflammatory), omega-3 fatty acids, and B
vitamins. Those who favor activity as a cause of carpal tunnel syndrome speculate that activity-
limitation might limit the risk of developing carpal tunnel syndrome, but there is little or no data to
support these concepts[33] and they stigmatize arm use in ways that risks increasing illness.[34][35]
[edit] Possible Misdiagnosis
There are some, such as Dr. Janet G. Travell, MD and Dr. David G. Simons, MD who believe that
carpal tunnel syndrome is simply a universal label applied to anyone suffering from pain,
numbness, swelling, and/or burning in the radial side of the hands and/or wrists. Travell and
Simons concluded from research that myofascial (skeletal muscle) contraction knots called "trigger
points" may actually be producing these symptoms. For example, it is argued by trigger point
therapists that trigger points in any of the many muscles of the neck, arms, chest, and forearms can
result in compression of the median nerve in the forearm and cause numbness and/or a burning
sensation in the hands. Furthermore, trigger points in the scalene muscles of the neck can shorten
the thoracic outlet and compress nerves and blood vessels in the arm, which limits the flow of
blood and lymph fluid, causing swelling in the hands and fingers. Carpal tunnel surgery will
reduce strain on the median nerve by cutting the carpal ligament and provide relief of some or all
symptoms in some patients, but is unnecessary when trigger points are the root of the problem. As
a whole, the medical community is not currently embracing or accepting trigger point theories.[36]
[edit] Treatment
There have been numerous scientific papers evaluating treatment efficacy in CTS. It is important to
distinguish treatments that are supported in the scientific literature from those that are advocated
by any particular device manufacturer or any other party with a vested financial interest. Generally
accepted treatments, as described below, may include splinting or bracing, steroid injection,
activity modification, physical or occupational therapy (controversial), regular massage therapy
treatments, medications, and surgical release of the transverse carpal ligament.
According to the 2007 guidelines by the American Academy of Orthopaedic Surgeons,[37] early
surgery with carpal tunnel release is indicated where there is clinical evidence of median nerve
denervation or the patient elects to proceed directly to surgical treatment. Otherwise, the main
recommended treatments are local corticosteroid injection, splinting (immobilizing braces), oral
corticosteroids and ultrasound treatment. The treatment should be switched when the current
treatment fails to resolve the symptoms within 2 to 7 weeks. However, these recommendations
have sufficient evidence for carpal tunnel syndrome when found in association with the following
conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy,
pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.[37]
[edit] Stretching
Various stretching exercises can aide in the prevention of CTS, but most people do not know how
to effectively stretch the muscles of the wrist and hand. To reduce the probability of being
diagnosed with CTS, the following stretch exercises are helpful:
Exercise 1, Range of Motion.
Exercise 1, Range of Motion: Clench your fist tightly for 3–5 seconds, then release, straightening
out your fingers. Keep them extended for the same amount of time it was clenched. Repeat this
exercise at least 5 times for each hand.
Exercise 2, Stretching: The next exercise that helps relieve the pain and tension caused by
repetitive hand movements is the stretch exercise. With one hand, extend the fingers of the other
hand as far back and as gently as possible without causing more pain. A stretching feeling should
be felt on the palm and throughout the wrist. Hold this stretch for 3–5 seconds and then release.
Complete this exercise at least 5x times with each hand in addition to the range of motion exercise.
Exercise 2, Stretching.
Before performing any of the described exercises, speak with a healthcare professional to receive
more information about CTS prevention exercises.
[edit] Immobilizing braces
A rigid splint can keep the wrist straight.
A wrist splint helps limit numbness by limiting wrist flexion. Night splinting helps patients sleep.
The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but
many people are unwilling to use braces. In 1993, The American Academy of Neurology
recommend a non-invasive treatment for the CTS at the beginning (except for sensitive or motor
deficit or grave report at EMG/ENG): a therapy using splints was indicated for light and moderate
pathology.[38] Current recommendations generally don't suggest immobilizing braces, but instead
activity modification and non-steroidal anti-inflammatory drugs as initial therapy, followed by
more aggressive options or specialist referral if symptoms do not improve.[39][40][41]
Many health professionals suggest that, for best results, one should wear braces at night and, if
possible, during the activity primarily causing stress on the wrists.[42][43]
There are braces with various extra functions and abilities on the market, but the evidence of such
functions is usually limited.
[edit] Localized corticosteroid injections
Corticosteroid injections can be quite effective for temporary relief from symptoms of CTS for a
short time frame while a patient develops a longterm strategy that fits with his/her lifestyle.[44] In
certain patients, an injection may also be of diagnostic value. This treatment is not appropriate for
extended periods, however. In general, medical professionals only prescribe local steroid injections
until other treatment options can be identified. For most patients, surgery is the only option that
will provide permanent relief.[45]
[edit] Other medication
Using an over-the-counter anti-inflammatory such as aspirin, ibuprofen or naproxen can be
effective as well for controlling symptoms. Pain relievers like paracetamol will only mask the pain,
and only an anti-inflammatory will affect inflammation.[clarification needed] Non-steroidal anti-
inflammatory medications theoretically can treat the swelling and thus the source of the problem.
Oral steroids such as prednisone do the same, but are generally not used for this purpose because
of significant side effects. Use of non-steroidal anti-inflammatory drugs may worsen asthma
symptoms in some with a history of asthma, making the use of steroids such as prednisone the
safer option for treating CTS. The most common complications associated with long-term use of
anti-inflammatory medications are gastrointestinal irritation and bleeding. Also, some anti-
inflammatory medications have been linked to heart complications. Use of anti-inflammatory
medication for chronic, long-term pain should be done with doctor supervision.
A more aggressive pharmaceutical option is an injection of cortisone, to reduce swelling and nerve
pressure within the carpal tunnel. Methylcobalamin (vitamin B12) has been helpful in some cases
of CTS. [46]
[edit] Carpal tunnel release surgery
Scars from carpal tunnel release surgery. Two different techniques were used. The left scar is 6
weeks old, the right scar is 2 weeks old. Also note the muscular atrophy of the thenar eminence in
the left hand, a common sign of advanced CTS
Carpal Tunnel Syndrome Operation
Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is
recommended when there is static (constant, not just intermittent) numbness, muscle weakness, or
atrophy, and when night-splinting no longer controls intermittent symptoms.[47] In general, milder
cases can be controlled for months to years, but severe cases are unrelenting symptomatically and
are likely to result in surgical treatment.[48]
[edit] Procedure
In carpal tunnel release surgery, the goal is to divide the transverse carpal ligament in two. This is
a wide ligament that runs across the hand, from the scaphoid bone to the hamate bone and
pisiform. It forms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line
with the ring finger) it no longer presses down on the nerve inside, relieving the pressure.[49]
There are several carpal tunnel release surgery variations: each surgeon has differences of
preference based on their personal beliefs and experience. All techniques have several things in
common, involving brief outpatient procedures; palm or wrist incision(s); and cutting of the
transverse carpal ligament.
The two major types of surgery are open carpal tunnel release and endoscopic carpal tunnel
release. Most surgeons historically have performed the open procedure, widely considered to be
the gold standard. However, since the 1990s, a growing number of surgeons now offer endoscopic
carpal tunnel release.
Open surgery involves an incision on the palm about an inch or two in length. Through this
incision, the skin and subcutaneous tissue is divided, followed by the palmar fascia, and ultimately
the transverse carpal ligament.
Endoscopic techniques involve one or two smaller incisions (less than half inch each) through
which instrumentation is introduced including a synovial elevator, probes, knives, and an
endoscope used to visualize the underside of the transverse carpal ligament. The endoscopic
methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open
method does.[citation needed]
Many studies have been done to determine whether perceived benefits of a limited endoscopic or
arthroscopic release are significant. Brown et al. conducted a prospective, randomized, multi-
center study and found no significant differences between the two groups with regard to secondary
quantitative outcome measurements.[3] However, the open technique resulted in more tenderness
of the scar than the endoscopic method. A prospective randomized study done in 2002 by Trumble
revealed that good clinical outcomes and patient satisfaction are achieved more quickly with the
endoscopic method. Single-portal endoscopic surgery is a safe and effective method of treating
carpal tunnel syndrome. There was no significant difference in the rate of complications or the cost
of surgery between the two groups. However, the open technique caused greater scar tenderness
during the first three months after surgery, and a longer time before the patients could return to
work. [4]
Some surgeons have suggested that in their own hands endoscopic carpal tunnel release has been
associated with a higher incidence of median nerve injury, and for this reason it has been
abandoned at several centers in the United States. At the 2007 meeting of the American Society for
Surgery of the Hand, a former advocate of endoscopic carpal tunnel release, Thomas J. Fischer,
MD, retracted his advocacy of the technique, based on his assessment that the benefit of the
procedure (slightly faster recovery) did not outweigh the risk of injury to the median nerve.
Despite these views, many other surgeons have embraced limited incision methods. It is
considered to be the procedure of choice for many of these surgeons with respect to idiopathic
carpal tunnel syndrome. Supporting this are the results of some of the previously mentioned series
which cite no difference in the rate of complications for either method of surgery. Thus, there has
been broad support for either surgical procedure using a variety of devices or incisions. The
primary goal of any carpal tunnel release surgery is to divide the transverse carpal ligament and the
distal aspect of the volar ante brachial fascia, thereby decompressing the median nerve. [5]
All of the surgical options (when performed without complication) typically have relatively rapid
recovery profiles (weeks to a few months depending on the activity and technique), and all usually
leave a cosmetically acceptable scar.
[edit] Efficacy
Surgery to correct carpal tunnel syndrome has a high success rate. Up to 90% of patients were able
to return to their same jobs after surgery.[50][51][52] In general, endoscopic techniques are as effective
as traditional open carpal surgeries,[53][54] though the faster recovery time typically noted in
endoscopic procedures is felt by some to possibly be offset by higher complication rates.[55][56]
Success is greatest in patients with the most typical symptoms. The most common cause of failure
is incorrect diagnosis, and it should be noted that this surgery will only mitigate carpal tunnel
syndrome, and will not relieve symptoms with alternative causes. Recurrence is rare, and apparent
recurrence usually results from a misdiagnosis of another problem. Complications can occur, but
serious ones are infrequent to rare.
Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic or plastic surgeon.
Some neurosurgeons and general surgeons also perform the procedure.
[edit] Ultrasound treatment
Ultrasound radiation to the wrist gives significant improvement in people with CTS.[57] A treatment
process may consist of 20 sessions of 15 minutes of ultrasound applied to the area over the carpal
tunnel at frequency of 1 MHz and a power of 1.0 W/cm2.[57]
[edit] Physiotherapy and occupational therapy
Current evidence demonstrates a significant benefit (level B recommendations) from splinting,
ultrasound, nerve gliding exercises, carpal bone mobilization, magnetic therapy, and yoga for
people with carpal tunnel syndrome.[58] Otherwise, there is little evidence to support the use of
other physiotherapy or occupational therapy techniques for carpal tunnel syndrome. They seem to
be oriented primarily towards non-specific activity related pain rather than the numbness of carpal
tunnel syndrome.
Occupational therapy offers ergonomic suggestions to prevent worsening of the symptoms.
Occupational therapies facilitate hand function through remedial adaptive approaches.
Any forceful and repetitive use of the hands and wrists can cause upper extremity pain. More
frequent rest can be useful if it can be orchestrated into one's schedule. It has been shown that
taking multiple mini-breaks during the stressful activity is more effective than taking occasional
long breaks.[citation needed] There are computer applications that aid users in taking breaks. All of these
applications have recommended defaults, following the most effective average break configuration
—a 30 sec. pause every 3 to 5 minutes (the more severe the pain, the more often one should take
this break). There are also programs that automatically click the mouse. Before investing in these
types of programs, it's best to consult with a doctor and research whether computer use is causing
or contributing to the symptoms, as well as getting a formal diagnosis.
More pro-active ways to reduce stress on the wrists, which alleviates wrist pain and strain, involve
adopting a more ergonomic work and life environment. Switching from a QWERTY computer
keyboard layout to a more optimised ergonomic layout such as Dvorak was commonly cited as
beneficial in early CTS studies, however some meta-analyses of these studies claim that the
evidence that they present is limited.[59][60]
It is also important that one's body be aligned properly with the keyboard. This is most easily
accomplished by bending ones elbows to a 90 degree angle and making sure the keyboard is at the
same height as the elbows. Also it is important not to put physical stress on the wrists by hanging
the wrist on the edge of a desk, or exposing the wrists to strong vibrations (e.g. manual lawn
mowing). Position the computer monitor directly in front of your seat, so the neck is not twisted to
either side when viewing the screen.[citation needed]
Exercises that relax and strengthen the muscles of the upper back can reduce the risk of a double
crush of the median nerve.
Massage is one of the most overlooked methods for treatment of the symptoms of CTS. The use of
myofascial release and active stretch release can erase the pain, numbness, tingling and burning in
minutes. Then following up with the stretches and exercises afore mentioned will lengthen the
relief attained by these release techniques.
[edit] Long term recovery
Most people who find relief of their carpal tunnel symptoms with conservative or surgical
management find minimal residual or "nerve damage".[61] Long-term chronic carpal tunnel
syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. irreversible
numbness, muscle wasting and weakness.
While outcomes are generally good, certain factors can contribute to poorer results that have little
to do with nerves, anatomy, or surgery type. One study showed that mental status parameters,
alcohol use, yield much poorer overall results of treatment.[62]
Many mild carpal tunnel syndrome sufferers either change their hand use, pattern, or posture at
work or find a conservative, non-surgical treatment that allows them to return to full activity
without hand numbness or pain, and without sleep disruption. Some find relief by adjusting their
repetitive movements, the frequency with which they do the movements, and the amount of time
they rest between periods of performing the movements. Other people end up prioritizing their
activities and possibly avoiding certain hand activities so that they can minimize pain and perform
the essential tasks. Keyboard re-mapping software can help people whose condition is aggravated
by one-handed key strokes involving a combination of the Control, Shift, or Alt keys and an alpha-
numeric key. Programs such as Autohotkey allow a person to disable key combinations while they
train themselves to use two hands to perform the offending key strokes.
Recurrence of carpal tunnel syndrome after successful surgery is rare.[63] If a person has hand pain
after surgery, it is most likely not due to carpal tunnel syndrome. It may be the case that a person
who has hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpal tunnel
release has had no positive effect upon the patient's symptoms.
III
KESIMPULAN
IV
REFERENSI ILMIAH
1. Maurice Victor, Allan H. Ropper.“Diseases of Spinal Cord, Peripheral Nerve, and
Muscle”.Adams and Victor’s Principles of Neurology.7th ed.USA: McGraw-Hill
Companies, 2001: 1433 – 1434.
2. NN. 2009. “Carpal Tunnel Syndrome”.
http://en.wikipedia.org/wiki/Carpal_tunnel_syndrome. Diakses tanggal 24
September 2010.
3.
4.