Last resort is often the best
Teresa Stitt began having trouble opening jars. Then she felt a shooting pain -- from her wrist halfway up her elbow -- when turning doorknobs, typing or carrying books.
When it got to the point that the 52-year-old couldn’t hold a pen without pain, she decided to see a doctor. As an elementary school teacher in Vandergrift, Pa., a small town about 35 miles northeast of Pittsburgh, she had to be able to write lesson plans and correct papers.
“All the little things you do with your hands and wrists, I just couldn’t do them,” she said. “I’d wake up at night with my hand numb and tingling.”
Stitt had carpal tunnel syndrome -- a condition that afflicts hundreds of thousands each year with burning pain, usually in the wrist and forearm. The syndrome is named for the “tunnel” through which the median nerve and nine tendons pass from the forearm into the hand. When the tunnel swells, it puts pressure on the nerve, causing pain.
A combination of factors is often to blame for the condition, which if left untreated can leave a person unable to distinguish hot from cold in the affected area. Some people are simply born with a small carpal tunnel. (Physicians believe this is why women are more prone to the condition than men, suffering from it at a rate of more than 3 to 1.) Injury or trauma can create swelling in the wrist, putting extra stress on the median nerve. Fluid retention during pregnancy and obesity also can contribute. In some cases, no predisposing cause can be discovered.
“There are a hundred different conditions that can lead to carpal tunnel or certainly make the symptoms worse,” said Dr. Ghassan Bejjani, an assistant professor of neurological surgery at the University of Pittsburgh Medical Center.
Although more research has to be done, it’s still unclear if repetitive motion is the major factor in carpal tunnel syndrome. A decade ago, most neurosurgeons, orthopedists and plastic surgeons -- who typically treat the syndrome -- widely believed that repetitive stress and trauma, such as the kind created by typing, was the chief culprit.
But a 2001 Mayo Clinic study found that even seven hours a day of computer use didn’t increase the risk for carpal tunnel. People in jobs such as dentistry, assembly-line manufacturing and meatpacking that require awkward wrist positions contract the condition at rates nearly three times higher than data-entry workers.
Bejjani first recommended anti-inflammatory medications to help reduce Stitt’s swelling. Then he assigned hand and wrist exercises, using a stress ball, in an effort to strengthen the area. Finally, he asked her to keep a journal of when the pain flared up and what movements preceded it.
Two months later, Stitt was still suffering. Bejjani placed Stitt’s wrist in a special splint to force her wrist to rest and prescribed a stronger medication, Celebrex, which is most often used to treat arthritis. She was supposed to follow this course for two to three months, but she lasted only a month. “It wasn’t doing anything for the pain,” said Stitt.
The only option left was surgery, typically recommended for patients who exhibit symptoms for more than six months. The surgeon cuts the carpal ligament to enlarge the tunnel and thus reduce pressure on the median nerve.
Surgeons use two basic techniques -- the open carpal tunnel release and the endoscopic release. In the open technique, the surgeon makes about a 1- to 2-inch-long incision at the base of the palm. In the endoscopic method, one or two smaller incisions are made in the wrist.
“I don’t like to cut blindly,” said Bejjani. “So I like the open release, but everybody swears by their own technique.”
A 2002 study published in the Journal of the American Medical Assn. found that surgery appeared to be more effective than splints for long-term relief from carpal tunnel syndrome. Of 176 patients, divided into two groups, surgery offered improvement in more than 90% of those receiving it; the improvement rate for splint-wearers was 37%.
Using local anesthesia, Stitt underwent the surgery on an outpatient basis. The surgery, covered by insurance, took about 90 minutes. “I remember him cutting and being told to move my hands, but that’s about it,” said Stitt.
Stitt was in significant pain for a week after the procedure, despite prescription pain medications. And she had to keep the hand immobile for a month, which meant, among other things, that she couldn’t drive.
She had planned the surgery for the summer break, however, so the recovery didn’t interfere with her job.
After a month, Stitt was glad she had undergone surgery. Although she wasn’t at 100%, the pain was largely gone. She now puts her functioning at around 85% and rarely has any pain in her left hand. Her regret was not doing it sooner.
Unfortunately, she may have to undergo the procedure again, this time on her right hand. (It’s common for a patient with carpal tunnel syndrome in one hand to have it or develop it in the other, said Bejjani.) It’s exhibiting the same symptoms as her left one did.
If surgery is required on both hands, the surgeon usually treats each hand separately, otherwise patients wouldn’t be able to do anything with their hands for six weeks. “I’m not looking forward to [the next surgery],” said Stitt. “But at least I know it works.”
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Getting Better tells the stories of people trying to achieve optimal health and well-being. Send ideas for future columns to health@latimes.com or to Health, Attn.: Getting Better, 202 W. 1st St., Los Angeles, CA 90012.
