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.

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4.