CARPAL
TUNNEL
SYNDROME IN PREGNA LACTATION J. S. WAND
From the
Clinical Research Centre, Northwick Park 6-lospital Middlesex
A retrospective study of 40 women with carpal tunnel syndrome developing in pregnancy and women with carpal tunnel syndrome in the puerperium was undertaken. All the cases that developed in pregnancy occurred in the third trimester and resolved within two weeks of delivery. Those cases developing in the puerperium affected women who had breast-fed their infants and their symptoms lasted a mean of 5.8 months. These patients were older and more likely to be primiparous than if tbe condition occurred in pregnancy. All the pregnant women and none of the lactating women had symptoms of peripheral oedema. Spontaneous resolution with a good response to conservative measures occurred in both groups; only three cases were treated surgically. Residual clinical evidence of median nerve damage was present in 40% of all cases. Carpal tunnel syndrome which develops in pregnancy appears to be a separate clinical entity to that developing in the puerperium. Journal of Hand Surgery (British Volume, 1990) 15-B: 93-95
The association between carpal tunnel syndrome and pregnancy was first documented by Walshe (1945). Wallace and Cook (1957) described two pregnant patients with carpal tunnel syndrome and since then the condition has been recognised as a common complication of pregnancy, the reported incidence varying between 1% and 50% of all pregnancies (Gould and Wissinger, 1978 ; Voikt et al., 1983). Ekman-Ordeberg (1987) noted that all the 56 women he reported with carpal tunnel syndrome in pregnancy had generalised oedema, though only 9.3% had pre-eclampsia. Carpal tunnel syndrome presenting in the puerperium has rarely been described. Snell et al. (1980) reported five cases of carpal tunnel syndrome in the puerperium, developing in elderly primiparous women. The condition appeared to be related to breast feeding, in that the symptoms resolved within a few weeks of stopping breast feeding in four of the cases reported. The purpose of our study was to further characterise these conditions, to determine the natural history and to determine whether carpal tunnel syndrome developing in pregnancy and in lactation were part of the same clinical spectrum or whether they represented separate clinical entities.
pregnancy and 18 who had had carpal tunnel syndrome in lactation attended for review. All patients who responded to the article with carpal tunnel syndrome in the puerperium had breast-fed their infants. The mean duration of follow-up from the start of symptoms was 11.7 months (range 3-30 months). The women who developed carpal tunnel syndrome in lactation were significantly (pp>0.01 N.S. = Not significant. _ *-Student’s “t” test 7 = Fisher’s exact probability test.
93
J. S. WAND
a period of several weeks. Paroxysmal nocturnal pain was present in all patients at some stage during the illness. While only 20% of patients with carpal tunnel syndrome of pregnancy had been diagnosed as having pre-eclampsia, they all complained of peripheral oedema sufficient to prevent them from wearing their normal rings during the latter stages of pregnancy. By contrast, the lactating women had a lower incidence of preeclampsia (5%) and did not report any problems with peripheral oedema either in the latter stages of pregnancy or in the puerperium (Table 1). 80% of cases were bilateral in pregnancy and 94% of cases in lactation, but this difference is not statistically significant. The dominant hand was more severely affected than the non-dominant hand in 78% of bilateral cases that occurred in pregnancy and in 71% of cases in lactation (again not a significant difference). Of the unilateral cases of carpal tunnel syndrome in pregnancy, 62% affected the dominant hand, as did the one case in lactation. In all lactating women, symptoms developed within two weeks of establishing breast-feeding. At the time of review, 85% of all the women had had complete resolution of their symptoms. In spite of this, 33% still had a positive Phalen’s sign, 37% had objective evidence of a sensory loss in the median nerve distribution, 32% had some motor weakness of the abductor pollicis brevis and 5% had wasting of the small muscles of the hand. There was no significant difference between the two groups with regard to persistence of physical signs of median nerve compression (Table 2).
Diuretics had often been prescribed for the lactating women, and were effective in 82% of cases, but most women reported only temporary relief of symptoms. Local steroid injections provided a significant and lasting benefit in 62% of patients. Only three women underwent surgical decompression of their wrists. One pregnant woman had the operation because her symptoms did not respond to other measures and were rapidly progressive. She had good electromyographic evidence of a median nerve neuropathy and her condition rapidly improved following decompression. The two lactating women who underwent decompression were still lactating at the time of surgery. They both gained rapid relief of their symptoms following decompression. There was no significant difference between the two groups with regard to response to treatment (Table 3). Table 3-Results of treatment Pregnancy Duration of symptoms S.D.
(months)
Lactation
2.36 1.29
5.78 *H.S. 1.12
Symptomatic
relief with night splints
23/28 (82%)
13/15 tN.S.
Symptomatic
relief with diuretics
318 (37%)
14/17 tN.S. (82%)
Symptomatic injection
relief with steroid
315 (60%)
7/l 1 tN.S.
Symptomatic
relief with surgery
l/l (100%)
212 7N.S. (100%)
(86%)
(63%)
Table 2-Residual signs Pregnancy Positive
Phalen’s
Test
Lactation
23172
12/35 tN.S.
(32%)
(34%)
Decreased 2-point discrimination (less than 4 mm)
25112
15/35 7N.S.
(35%)
(43%)
Thenar
5172
l/35 7N.S. (3%)
wasting
(7%) Weakness
of abductor
pollicis brevis
18172
3135 tN.S.
(25%)
(9%)
H.S. = Highly significant p < 0.001 S.=SignificantO.OS>pz0.01 N.S. =Not significant. t = Fisher’s exact probability test.
Resolution of symptoms occurred within two weeks of delivery in 95% of the pregnant women, and in all cases by one month. The symptoms resolved significantly (p < 0.001) more slowly in the lactating group and lasted a mean of 5.8 months, with a range from 3 to 11 months. In general, the symptoms started to subside within a few weeks of starting to wean, and had resolved completely within a mean 6 weeks of stopping breast feeding. Symptomatic relief was obtained by wearing a splint, used mainly at night, in the majority of patients (84%). 94
H.S. =Highly significant piO.001 S. = Significant 0.05 > p > 0.01 N.S. =Not significant. _ *-Student’ s “t” test. t = Fisher’s exact probability test.
In 35% of all women the symptoms of carpal tunnel syndrome had been regarded as only annoying, in 50% the symptoms were regarded as more disabling (in that they had difficulty in holding cups, writing, etc.) while 15% considered that their symptoms had had a major effect on their lifestyles. At review 40% of all patients had some residual signs of median nerve damage, with clinical evidence of loss of two-point discrimination (measured statically), wasting of the thenar muscles or weakness of the abductor pollicis brevis. Both groups were equally affected. Discussion Tobin (1967) reported 14 cases of carpal tunnel syndrome developing in pregnancy and documented, without comment, one case which developed in the puerperium. Carpal tunnel syndrome has only rarely been recorded in association with lactation (Snell et al., 1980). They noted THE JOURNAL
OF HAND SURGERY
CARPAL
TUNNEL
SYNDROME
IN PREGNANCY
the clear relationship between breast-feeding and the severity of symptoms. The mean age of their patients was 29.8 years, with an age range from 25 to 35. Four of the five patients were primiparous when symptoms developed. The present study is in general agreement with Snell et al. (1980), confirming that carpal tunnel syndrome developing in lactation affects predominantly elderly primiparous women. Ekman-Ordeberg (1987) noted that patients who develop carpal tunnel syndrome during pregnancy were relatively elderly (mean age 30.2), were most likely to be nulliparous (60%) and all had generalised oedema. The present study confirms the high incidence of preeclampsia in pregnant women with carpal tunnel syndrome and the association of symptoms with generalised oedema, but pre-eclampsia and generalised oedema do not appear to be a feature of carpal tunnel syndrome in lactation. Voitk et al. (1983) considered that fluid retention in pregnancy could be sufficient to lead to nerve compression at the wrist. Ekman-Ordeberg (1987) also noted the association between oedema of the hand and carpal tunnel syndrome of pregnancy. While fluid retention may explain the development of carpal tunnel syndrome in pregnancy (and certainly all the pregnant women in this series had had peripheral oedema), it was not a feature of carpal tunnel syndrome in lactation. In the present study, carpal tunnel syndrome in both pregnancy and lactation was frequently bilateral and tended to affect the dominant hand more severely. The increased manual demands imposed on the mother in caring for her infant are unlikely to be the main cause of the carpal tunnel syndrome in the puerperium, since the problem does not appear to affect non-lactating women, though it may be related to the tendency to affect the dominant hand. It is interesting to note that there were no cases of carpal tunnel syndrome in the puerperium in women who did not breast feed. While sample bias, inherent in this type of study, might account for this finding, it would appear that carpal tunnel syndrome is uncommon in nonbreast feeding women. The duration of symptoms of carpal tunnel syndrome in lactation is greater than carpal tunnel syndrome of pregnancy, presumably because pregnancy is a finite event, and resolution of symptoms invariably follows delivery. Surgical decompression of the carpal tunnel is rarely indicated in view of the natural history of the condition, Three patients had rapidly progressive symptoms and signs which demanded early decompression of the carpal
VOL. i5-B No.
1 FEBRUARY
1990
AND LACTATION
tunnel. All these patients had a favourabie outcome, but two patients were still lactating at the time of surgery and perhaps a trial of conservative treatment with advice to stop breast feeding should have been advocated. Nicholas et al. (1971) and Wilkinson (1960) have described the occasional need for surgical decompression of the median nerve in pregnant patients, though there are no other reports of patients with carpal tunnel syndrome in lactation receiving surgical intervention. In conclusion, it would appear that carpal tunnel syndrome developing in pregnancy and in lactation represent separate clinical entities. In both situations, carpal tunnel syndrome affects elderly predominantly primiparous women, but lactating women are likely to be somewhat older. In contrast to carpal tunnel syndrome of pregnancy, carpal tunnel syndrome of lactation is not associated with pre-eclampsia or peripheral oedema. Spontaneous resolution occurs in both groups of patients and surgical intervention should be deferred whenever possible. Acknowledgements I would like to thank Dr J. Reeve of the Bone Disease Research Group and the Medical Research Council for their encouragement with this project.
References BRAIN, W. R., WRIGHT, A. D. and WILKINSON, M. (1947). Spontaneous compression of both median nerves in the carpal tunnel. Six cases treated surgically. Lancet, 1: 277-282. EKMAN-ORDEBERG, G., SiiLGEBACK. S. and ORDEBERG. G. (19871. Carpal tunnel syndrome in pregnancy. A prospective study. i\cta’Obs&tricia et Gynecologica Scandinavica, 66: 233-235. GOULD, J. S. and WISSINGER, H. A. (1978). Carpal Tunnel Syndrome in Pregnancy. Southern Medical Journal. 71: 2: 144-149. MELVIN, J. i., BURNETT, C. N. and JOHNSSON, E. W. (1969). Median Nerve Conduction in Pregnancy. Archives of Physical Medilzine, 50: 75-80. NICHOLAS, G., BARRETT NOONE, R. and GRAHAM, W. P. (1971). Carpal tunnel syndrome in pregnancy. The Hand, 3: 1: 80-83. SNELL, N. J. C., COYSH, H. L. and SNELL, B. J. (1980). Carpal tunnel syndrome presenting in the puerperium. The Practitioner, 224: 191-193. TOBIN, S. M. (1967). Carpal tunnel syndrome in pregnancy. American Journal . Obstetrics and Gvnecoioav, 97: 4-493-498. _ VOIKT, A. J., MUELLER, 3: C., FARLINGER, D. E. and JOHNSTON, R. U. (1983). Carpal tunnel syndrome in pregnancy. Canadian Medical Association Journal, 128 : 3 : 277-28 1. WALLACE, J. T. and COOK, A. W. (1957). Caroal tunnel syndrome in pregnancy. A report of two cases. American Journal of Obstetrics and Gvnecoloev. 73: 6: 1333-1336. WALSHE, F. ‘;i: R. (1945). On “Acroparaesthesia”and So-Called ‘*Neuritis”Of The Hands And Arms in Women. British Medical Journal, 2: 596-598. WILKINSON, M. (1960). The Carpal-Tunnel Syndrome in Pregnancy. Lancet, 1: 453-454.
Accepted: 18 November
1988 MI J. S. Wand, Northwick Park Hospital, W&ford Road, Harrow, Middlesex HAL 3UJ
0 1990 The British Society for Surgery of the Hand 02667681/90/00154093/%10.00
95
TUNNEL
SYNDROME IN PREGNA LACTATION J. S. WAND
From the
Clinical Research Centre, Northwick Park 6-lospital Middlesex
A retrospective study of 40 women with carpal tunnel syndrome developing in pregnancy and women with carpal tunnel syndrome in the puerperium was undertaken. All the cases that developed in pregnancy occurred in the third trimester and resolved within two weeks of delivery. Those cases developing in the puerperium affected women who had breast-fed their infants and their symptoms lasted a mean of 5.8 months. These patients were older and more likely to be primiparous than if tbe condition occurred in pregnancy. All the pregnant women and none of the lactating women had symptoms of peripheral oedema. Spontaneous resolution with a good response to conservative measures occurred in both groups; only three cases were treated surgically. Residual clinical evidence of median nerve damage was present in 40% of all cases. Carpal tunnel syndrome which develops in pregnancy appears to be a separate clinical entity to that developing in the puerperium. Journal of Hand Surgery (British Volume, 1990) 15-B: 93-95
The association between carpal tunnel syndrome and pregnancy was first documented by Walshe (1945). Wallace and Cook (1957) described two pregnant patients with carpal tunnel syndrome and since then the condition has been recognised as a common complication of pregnancy, the reported incidence varying between 1% and 50% of all pregnancies (Gould and Wissinger, 1978 ; Voikt et al., 1983). Ekman-Ordeberg (1987) noted that all the 56 women he reported with carpal tunnel syndrome in pregnancy had generalised oedema, though only 9.3% had pre-eclampsia. Carpal tunnel syndrome presenting in the puerperium has rarely been described. Snell et al. (1980) reported five cases of carpal tunnel syndrome in the puerperium, developing in elderly primiparous women. The condition appeared to be related to breast feeding, in that the symptoms resolved within a few weeks of stopping breast feeding in four of the cases reported. The purpose of our study was to further characterise these conditions, to determine the natural history and to determine whether carpal tunnel syndrome developing in pregnancy and in lactation were part of the same clinical spectrum or whether they represented separate clinical entities.
pregnancy and 18 who had had carpal tunnel syndrome in lactation attended for review. All patients who responded to the article with carpal tunnel syndrome in the puerperium had breast-fed their infants. The mean duration of follow-up from the start of symptoms was 11.7 months (range 3-30 months). The women who developed carpal tunnel syndrome in lactation were significantly (pp>0.01 N.S. = Not significant. _ *-Student’s “t” test 7 = Fisher’s exact probability test.
93
J. S. WAND
a period of several weeks. Paroxysmal nocturnal pain was present in all patients at some stage during the illness. While only 20% of patients with carpal tunnel syndrome of pregnancy had been diagnosed as having pre-eclampsia, they all complained of peripheral oedema sufficient to prevent them from wearing their normal rings during the latter stages of pregnancy. By contrast, the lactating women had a lower incidence of preeclampsia (5%) and did not report any problems with peripheral oedema either in the latter stages of pregnancy or in the puerperium (Table 1). 80% of cases were bilateral in pregnancy and 94% of cases in lactation, but this difference is not statistically significant. The dominant hand was more severely affected than the non-dominant hand in 78% of bilateral cases that occurred in pregnancy and in 71% of cases in lactation (again not a significant difference). Of the unilateral cases of carpal tunnel syndrome in pregnancy, 62% affected the dominant hand, as did the one case in lactation. In all lactating women, symptoms developed within two weeks of establishing breast-feeding. At the time of review, 85% of all the women had had complete resolution of their symptoms. In spite of this, 33% still had a positive Phalen’s sign, 37% had objective evidence of a sensory loss in the median nerve distribution, 32% had some motor weakness of the abductor pollicis brevis and 5% had wasting of the small muscles of the hand. There was no significant difference between the two groups with regard to persistence of physical signs of median nerve compression (Table 2).
Diuretics had often been prescribed for the lactating women, and were effective in 82% of cases, but most women reported only temporary relief of symptoms. Local steroid injections provided a significant and lasting benefit in 62% of patients. Only three women underwent surgical decompression of their wrists. One pregnant woman had the operation because her symptoms did not respond to other measures and were rapidly progressive. She had good electromyographic evidence of a median nerve neuropathy and her condition rapidly improved following decompression. The two lactating women who underwent decompression were still lactating at the time of surgery. They both gained rapid relief of their symptoms following decompression. There was no significant difference between the two groups with regard to response to treatment (Table 3). Table 3-Results of treatment Pregnancy Duration of symptoms S.D.
(months)
Lactation
2.36 1.29
5.78 *H.S. 1.12
Symptomatic
relief with night splints
23/28 (82%)
13/15 tN.S.
Symptomatic
relief with diuretics
318 (37%)
14/17 tN.S. (82%)
Symptomatic injection
relief with steroid
315 (60%)
7/l 1 tN.S.
Symptomatic
relief with surgery
l/l (100%)
212 7N.S. (100%)
(86%)
(63%)
Table 2-Residual signs Pregnancy Positive
Phalen’s
Test
Lactation
23172
12/35 tN.S.
(32%)
(34%)
Decreased 2-point discrimination (less than 4 mm)
25112
15/35 7N.S.
(35%)
(43%)
Thenar
5172
l/35 7N.S. (3%)
wasting
(7%) Weakness
of abductor
pollicis brevis
18172
3135 tN.S.
(25%)
(9%)
H.S. = Highly significant p < 0.001 S.=SignificantO.OS>pz0.01 N.S. =Not significant. t = Fisher’s exact probability test.
Resolution of symptoms occurred within two weeks of delivery in 95% of the pregnant women, and in all cases by one month. The symptoms resolved significantly (p < 0.001) more slowly in the lactating group and lasted a mean of 5.8 months, with a range from 3 to 11 months. In general, the symptoms started to subside within a few weeks of starting to wean, and had resolved completely within a mean 6 weeks of stopping breast feeding. Symptomatic relief was obtained by wearing a splint, used mainly at night, in the majority of patients (84%). 94
H.S. =Highly significant piO.001 S. = Significant 0.05 > p > 0.01 N.S. =Not significant. _ *-Student’ s “t” test. t = Fisher’s exact probability test.
In 35% of all women the symptoms of carpal tunnel syndrome had been regarded as only annoying, in 50% the symptoms were regarded as more disabling (in that they had difficulty in holding cups, writing, etc.) while 15% considered that their symptoms had had a major effect on their lifestyles. At review 40% of all patients had some residual signs of median nerve damage, with clinical evidence of loss of two-point discrimination (measured statically), wasting of the thenar muscles or weakness of the abductor pollicis brevis. Both groups were equally affected. Discussion Tobin (1967) reported 14 cases of carpal tunnel syndrome developing in pregnancy and documented, without comment, one case which developed in the puerperium. Carpal tunnel syndrome has only rarely been recorded in association with lactation (Snell et al., 1980). They noted THE JOURNAL
OF HAND SURGERY
CARPAL
TUNNEL
SYNDROME
IN PREGNANCY
the clear relationship between breast-feeding and the severity of symptoms. The mean age of their patients was 29.8 years, with an age range from 25 to 35. Four of the five patients were primiparous when symptoms developed. The present study is in general agreement with Snell et al. (1980), confirming that carpal tunnel syndrome developing in lactation affects predominantly elderly primiparous women. Ekman-Ordeberg (1987) noted that patients who develop carpal tunnel syndrome during pregnancy were relatively elderly (mean age 30.2), were most likely to be nulliparous (60%) and all had generalised oedema. The present study confirms the high incidence of preeclampsia in pregnant women with carpal tunnel syndrome and the association of symptoms with generalised oedema, but pre-eclampsia and generalised oedema do not appear to be a feature of carpal tunnel syndrome in lactation. Voitk et al. (1983) considered that fluid retention in pregnancy could be sufficient to lead to nerve compression at the wrist. Ekman-Ordeberg (1987) also noted the association between oedema of the hand and carpal tunnel syndrome of pregnancy. While fluid retention may explain the development of carpal tunnel syndrome in pregnancy (and certainly all the pregnant women in this series had had peripheral oedema), it was not a feature of carpal tunnel syndrome in lactation. In the present study, carpal tunnel syndrome in both pregnancy and lactation was frequently bilateral and tended to affect the dominant hand more severely. The increased manual demands imposed on the mother in caring for her infant are unlikely to be the main cause of the carpal tunnel syndrome in the puerperium, since the problem does not appear to affect non-lactating women, though it may be related to the tendency to affect the dominant hand. It is interesting to note that there were no cases of carpal tunnel syndrome in the puerperium in women who did not breast feed. While sample bias, inherent in this type of study, might account for this finding, it would appear that carpal tunnel syndrome is uncommon in nonbreast feeding women. The duration of symptoms of carpal tunnel syndrome in lactation is greater than carpal tunnel syndrome of pregnancy, presumably because pregnancy is a finite event, and resolution of symptoms invariably follows delivery. Surgical decompression of the carpal tunnel is rarely indicated in view of the natural history of the condition, Three patients had rapidly progressive symptoms and signs which demanded early decompression of the carpal
VOL. i5-B No.
1 FEBRUARY
1990
AND LACTATION
tunnel. All these patients had a favourabie outcome, but two patients were still lactating at the time of surgery and perhaps a trial of conservative treatment with advice to stop breast feeding should have been advocated. Nicholas et al. (1971) and Wilkinson (1960) have described the occasional need for surgical decompression of the median nerve in pregnant patients, though there are no other reports of patients with carpal tunnel syndrome in lactation receiving surgical intervention. In conclusion, it would appear that carpal tunnel syndrome developing in pregnancy and in lactation represent separate clinical entities. In both situations, carpal tunnel syndrome affects elderly predominantly primiparous women, but lactating women are likely to be somewhat older. In contrast to carpal tunnel syndrome of pregnancy, carpal tunnel syndrome of lactation is not associated with pre-eclampsia or peripheral oedema. Spontaneous resolution occurs in both groups of patients and surgical intervention should be deferred whenever possible. Acknowledgements I would like to thank Dr J. Reeve of the Bone Disease Research Group and the Medical Research Council for their encouragement with this project.
References BRAIN, W. R., WRIGHT, A. D. and WILKINSON, M. (1947). Spontaneous compression of both median nerves in the carpal tunnel. Six cases treated surgically. Lancet, 1: 277-282. EKMAN-ORDEBERG, G., SiiLGEBACK. S. and ORDEBERG. G. (19871. Carpal tunnel syndrome in pregnancy. A prospective study. i\cta’Obs&tricia et Gynecologica Scandinavica, 66: 233-235. GOULD, J. S. and WISSINGER, H. A. (1978). Carpal Tunnel Syndrome in Pregnancy. Southern Medical Journal. 71: 2: 144-149. MELVIN, J. i., BURNETT, C. N. and JOHNSSON, E. W. (1969). Median Nerve Conduction in Pregnancy. Archives of Physical Medilzine, 50: 75-80. NICHOLAS, G., BARRETT NOONE, R. and GRAHAM, W. P. (1971). Carpal tunnel syndrome in pregnancy. The Hand, 3: 1: 80-83. SNELL, N. J. C., COYSH, H. L. and SNELL, B. J. (1980). Carpal tunnel syndrome presenting in the puerperium. The Practitioner, 224: 191-193. TOBIN, S. M. (1967). Carpal tunnel syndrome in pregnancy. American Journal . Obstetrics and Gvnecoioav, 97: 4-493-498. _ VOIKT, A. J., MUELLER, 3: C., FARLINGER, D. E. and JOHNSTON, R. U. (1983). Carpal tunnel syndrome in pregnancy. Canadian Medical Association Journal, 128 : 3 : 277-28 1. WALLACE, J. T. and COOK, A. W. (1957). Caroal tunnel syndrome in pregnancy. A report of two cases. American Journal of Obstetrics and Gvnecoloev. 73: 6: 1333-1336. WALSHE, F. ‘;i: R. (1945). On “Acroparaesthesia”and So-Called ‘*Neuritis”Of The Hands And Arms in Women. British Medical Journal, 2: 596-598. WILKINSON, M. (1960). The Carpal-Tunnel Syndrome in Pregnancy. Lancet, 1: 453-454.
Accepted: 18 November
1988 MI J. S. Wand, Northwick Park Hospital, W&ford Road, Harrow, Middlesex HAL 3UJ
0 1990 The British Society for Surgery of the Hand 02667681/90/00154093/%10.00
95
