Carpal tunnel syndrome and the "double crush" hypothesis: a review and implications for chiropractic

Upton and McComas claimed that most patients with carpal tunnel syndrome not only have compressive lesions at the wrist, but also show evidence of damage to cervical nerve roots. This "double crush" hypothesis has gained some popularity among chiropractors because it seems to provide a rationale for adjusting the cervical spine in treating carpal tunnel syndrome. Here I examine use of the concept by chiropractors, summarize findings from the literature, and critique several studies aimed at supporting or refuting the hypothesis. Although the hypothesis also has been applied to nerve compressions other than those leading to carpal tunnel syndrome, this discussion mainly examines the original application – "double crush" involving both cervical spinal nerve roots and the carpal tunnel. I consider several categories: experiments to create double crush syndrome in animals, case reports, literature reviews, and alternatives to the original hypothesis. A significant percentage of patients with carpal tunnel syndrome also have neck pain or cervical nerve root compression, but the relationship has not been definitively explained. The original hypothesis remains controversial and is probably not valid, at least for sensory disturbances, in carpal tunnel syndrome. However, even if the original hypothesis is importantly flawed, evaluation of multiple sites still may be valuable. The chiropractic profession should develop theoretical models to relate cervical dysfunction to carpal tunnel syndrome, and might incorporate some alternatives to the original hypothesis. I intend this review as a starting point for practitioners, educators, and students wishing to advance chiropractic concepts in this area

Carpal Tunnel Syndrome: A Review of the Recent Literature

Carpal Tunnel Syndrome (CTS) remains a puzzling and disabling condition present in 3.8% of the general population. CTS is the most well-known and frequent form of median nerve entrapment, and accounts for 90% of all entrapment neuropathies. This review aims to provide an overview of this common condition, with an emphasis on the pathophysiology involved in CTS. The clinical presentation and risk factors associated with CTS are discussed in this paper. Also, the various methods of diagnosis are explored; including nerve conduction studies, ultrasound, and magnetic resonance imaging

Is there Light at the End of the Tunnel? Controversies in the Diagnosis and Management of Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common disorder responsible for considerable patient suffering and cost to health services. Despite extensive research, controversies still exist with regards to best practice in diagnosis, treatment, and service provision. Current best practise would support the use of history, examination and electro-diagnostic studies. The role for ultrasound scanning in diagnosis of carpal tunnel syndrome is yet to be proven. It appears magnetic resonance image scanning has a role where a rare cause for carpal tunnel syndrome may be suspected and also in the detailed reconstruction of the anatomy to aid endoscopic procedures. Treatment options can be surgical or non-surgical and patient choice will dictate the decision. For non-surgical interventions many options have been trialled but until now only steroid use, acupuncture, and splinting have shown discernable benefits. Open surgical decompression of the carpal tunnel appears to be more simple and cost-effective than minimally invasive interventions. For those patients who reject surgery, splinting, acupuncture, and steroid injection can play a role. Recent work looking at different service delivery options has shown some positive results in terms of decreasing patient waiting time for definitive treatment. However, no formal cost-effectiveness analysis has been published and concerns exist about the impact of a stream-lined service on surgical training. In this review, we look at the different diagnostic and treatment options for managing carpal tunnel syndrome. We then consider the different service delivery options and finally the cost-effectiveness evidence