Carpal Tunnel/ Ulnar Tunnel/ Numbness

CARPAL TUNNEL SYNDROME/ ULNAR TUNNEL SYNDROME/ NUMBNESS HAND

Carpal tunnel is a fibro-osseous tunnel in the palm side of the wrist through which the median nerve passes; that provides the ability to feel on the fingers and impulse to the muscles on the thumb. Carpal tunnel syndrome is caused by the compression and excess pressure on the median nerve within the carpal tunnel in one or both of the hands. The condition causes pain, numbness, tingling and weakness in the hand and occasionally the entire upper limb.

Minimally invasive treatment methodUlnar Tunnel syndrome is similar to carpal tunnel condition caused due to the compression of the ulnar nerve in the Ulnar tunnel (Guyon’s canal of wrist) causing pain in the inner wrist and numbness of little finger, ring finger and half of middle finger. The condition is developed due to the repetitive pressure on the ulnar nerve fibers that runs from the neck to the hand.

Both these conditions are caused due to the compression of nerve and obstructed blood flow causing numbness and activity restriction. The doctor conducts a physical examination to test the feeling in the fingers and the strength of the muscles in the hand through clinical examination and may order an electromyogram or nerve conduction test.

Conventional treatment methods include nonsurgical therapy using Nonsteroidal anti-inflammatory drugs. Surgery treatment methods include endoscopic single or double portal surgery or an open surgery to release the pressure and to free the affected nerve followed by physical therapy, prescription pain medication or by wearing a wrist brace.

ALTERNATIVE TREATMENT OPTIONS AT BETH YEHUWDAH ARTHRITIS CENTRE, PULLAD AND DAYSTAR CLINIC, ALAPPUZHA

Neural (Juxtaneural) & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

Almost painless injection technique using very thin needles under local anesthesia

• For those who want to avoid if not delay Carpal/ Ulnar Tunnel surgery of the wrist.
• Significantly reduces the symptoms associated with Inflammation in cases of Carpal/ Ulnar Tunnel Syndrome.
• Reduced risk of adverse events due to lower dosage compared to oral steroid tablets which are taken daily; in inflammatory joint diseases associated with carpal tunnel syndrome.
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• More effective treatment method in Carpal Tunnel Syndrome due to inflammatory conditions.
• Faster recovery.
• NESTIT treatment usually results in significant, effective, progressive improvement of pain, numbness, and function if given in series.

At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Carpal Tunnel/ Ulnar Tunnel/ Numbness. To know more about treatment plans and treatment cost, book an appointment now.