Studio Sense: Dealing With Carpal Tunnel Syndrome - ProSoundNetwork.com

Studio Sense: Dealing With Carpal Tunnel Syndrome

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Carpal Tunnel Syndrome (CTS): these three words have traditionally sent fearful shivers through the spines of most musicians and, yes, audio engineers. Many of us—myself included, a musician and a recording engineer—thought it meant painful surgery, weeks in a cast, months of rehab, endless doctor visits and an unknown amount of time not being able to play my instrument and/or work for a living. And even then, if choosing surgery, would the end result be worth it? Would my numbness and/or pain be gone and, if so, for how long?

In this installment of “Studio Sense,” I detail my own recent experience having carpal tunnel surgery on my right hand, discussing the symptoms, tests, the surgery and its final outcome. Included will be an interview with my surgeon, Dr. Angela Y. Giuffrida of Active Orthopedics & Sports Medicine in Hackensack, New Jersey.

Knowing There’s a Problem

I’ve known that something should be done about my hand for years now. Unlike some musicians who experience pain in their fingers/hand, I simply experienced numbness, especially when playing the guitar and doing endless DAW-related tasks. My assumption was that the repetitive combination of typing on a keyboard, mixing/producing/composing, using the trackpad on my laptop and playing my instrument had taken its toll on my hands, resulting in a well developed case of CTS.

Yet I wasn’t sure, as even with self-guided online research, I didn’t really know exactly what CTS was. Why would my right hand get numb all the time? Why did I begin to feel the same symptoms in my left hand? Maybe I had a pinched nerve in my neck and shoulders? Maybe something worse?

I tried to get around the problem by stretching constantly, wearing carpal gloves on both hands when I slept and simply shaking them out often. I went for hot stone massages that would focus on my neck, shoulders and hands (OK, that part was enjoyable)! Yet towards the end of this struggle, and before I took action to go see a doctor, I could only play guitar for a few minutes at a time before the thumb, index and middle finger on my right hand simply went numb. At gigs, I would have to constantly dangle my hand to try to get some feeling back. I’d say “give the drummer some” just so that I could take a few minutes to shake it out. I would not take touring gigs because I knew I would go numb at some time during the show, and be unable to perform. Clearly, the situation was not pleasant; it was progressively, measurably worsening over time.

When wearing my composing/recording hat, it was actually worse. Sitting in my chair in front of Pro Tools, I could only cut a short part before the numbness set in. I would sit there and wait for the feeling to come back before continuing. And playing a jumbo acoustic guitar was the worst; as my arm had to go over the guitar, my hand’s angle would almost instantly cut away all feeling. For bass guitar parts, I actually haven’t played with my fingers in years because of this problem; I developed an easier pick technique purely to alleviate numbness—sad, but true.

Though somehow I managed and still played well, I inherently knew that I could play much better than I was, and that this was potentially a career-ending situation if left untreated. Was I fearful? Damn right, I was. I had no idea of where I was headed, but I knew something had to be done.

Doctor, Doctor

The first real step towards healing came when I decided to seek out a doctor to tell me what was going on. My health insurance provider gave me a list of doctors in my area that specialized in CTS-oriented issues. Upon further research, I came across Dr. Angela Y. Giuffrida at Active Orthopedics & Sports Medicine, not far from my home. After all, this was my hand, my performances and basically my life; I wanted to make sure whoever I went to was at the top of their field, regardless of price.

In my first appointment with Dr. Giuffrida, she listened to me explain my symptoms, then ran through some basic tests, seemingly to test my hand strength and flexibility. Her initial diagnosis was that I did in fact have carpal tunnel issues, but we would need to do further tests to confirm CTS. These tests would also rule out that it was a shoulder/neck, muscular or skeletal nerve issue. At this point, she explained to me I basically had a few choices. We could try an oral anti-inflammatory drug, a cortisone shot, or go for the CTS relief operation. I decided to try some non-steroidal anti-inflammatory drugs (naproxen), knowing however that this was just temporary relief, and set up an immediate appointment to have further tests done. I left there feeling a sense of relief, in that I knew something could be done about this and that I was on the path to fixing this longstanding problem that had debilitated me for so long.

About a week later, I was in Dr. Giuffrida’s office for NCS (nerve conduction study) and EMG (electromyogram) tests. NCS uses electrical stimulation to measure the latency in milliseconds (ms) of the time it takes for the impulse to travel from the point of stimulation (on my forearm) to the recording spot (on my finger). They also measure the amplitude of the signal, measured in millivolts (mv). EMG uses small needles to test the reactions of your nerves. Together, NCS and EMG give complementary information about my condition. Since cold weather can affect these tests, they first had to give me heat packs to warm my hands up. Maybe it was a combination of the frozen winter and the fact that I was nervous, but my hands were cold! Once warmed up, they went ahead with measuring, shocking and probing me. It did hurt a little—small needles were inserted and voltage involuntarily moved my muscles—but it wasn’t that bad, and the entire process took under half an hour.

Immediately after the test, I met with Dr. Giuffrida to review the data. She confirmed that I indeed had CTS and that there were no pinched nerves or muscular issues causing my numbness, so that was good. The tests revealed what I already felt: the carpal was slightly more severe in the right hand than in the left. After consulting further with her, I decided to have the operation.

I scheduled this to take place just a few weeks later, giving me enough time to get all my upcoming TV cues recorded and any other mix work out of the way. I would have to stop playing for a while, but how long? I didn’t know, and I had so many unanswered questions, but I knew I was ultimately doing the right thing.

Surgery Time

Next was the big one: the actual operation. I arrived early in the morning to Hackensack Medical Center, and had to fill out a few papers and (of course) show my insurance card. After a short wait, I entered the operating room where they had me lie on the table and stretch my right hand out onto an extension. Dr. Giuffrida’s assistants washed my hand and arm thoroughly with an orange-tinged disinfectant, and then she explained to me exactly what she was going to do. They placed a sheet over my arm, numbed my hand, and it was game on.

The operation itself was a piece of cake. She finished the actual procedure in 6 minutes, then stitched me up. I felt nothing at all, but could sense the physical pressure of her work on my hand. She asked me if I wanted to see the wound and of course I said “sure.” Looking to my right, I immediately let an expletive fly, as—sure enough—the palm of my now-orange hand was stitched up, a la Frankenstein. They wrapped it carefully in bandages and it was over. After a few minutes, I sat up slowly and walked out of the room on my own, slightly light-headed but feeling just fine. The entire process from me entering the room to leaving took around 20 minutes.

I clearly recall having a feeling of “yes, I did it!” when I walked out; it was exciting to know that this long-standing problem was fixed and ready to heal. Looking at my now-bandaged right hand, I could see my fingers (still orange) had swollen up and I couldn’t move them. Dr. Giuffrida noted that each day I would be able to bend them a little more, and in 10 days I was to see her for removal of the stitches and a full inspection of my hand. She also told me not to play the guitar for at least two weeks and not to put any weight on the hand or lift anything using it. Lastly, she gave me a small prescription for Vicodin to help with any pain.

Over the next few days after the operation, I was constantly reminded how much I used my right hand. I couldn’t brush my teeth, comb my hair, twist a doorknob, open a jar or do much of anything with it; we take such simple things for granted. I took one Vicodin the first afternoon and one the next day, but that was it. There simply was no pain involved and the drugs just made me loopy. Each day I could move my fingers a little more and, most important to me, there was no numbness! It was gone.

Ten days later, I was back in her office to get the stitches out (a 5 minute procedure) and it was all over. She noted that I didn’t even have to see her again, and this operation should, under normal circumstances, last me a lifetime. At that point, I had almost regained full use of my hand.

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Once the stitches were out, it was time to play. I remember feeling a scary sense, thinking to myself “what if I feel that numbness again?” However, I was at a party that evening and picked up an acoustic to play with some other musicians. Strumming lightly, there was no numbness. I couldn’t have been happier! It felt so incredible to play guitar and truly feel my fingers, and I don’t think I’ll ever forget that moment.

The next day, I coincidentally ran across a musician/guitarist friend, Richard Mash, at Guitar Center. Showing him my scar, he told me he had a CTS surgery back in 1975. “I had a three day hospital stay and was in a hard cast for almost 2 months,” he noted. “I also had about a five month recovery time before I was able to get the use of my right hand back. I had about 19 stitches and a 5.5-inch scar. Also, I had horrible pain during the recovery and several months of physical therapy afterwards. Overall, it was almost a year before I was really back.” Wow, how things have changed.

Recovery

As I write this, I’m three months removed from the operation. I’ve done a lot of gigs and recorded many TV cues since, all with no tingling or numb sensations of any kind. In fact, I feel that I’m playing better than ever. I can play with my hybrid pick/finger technique and feel every nuance. I still am healing a bit as far as lifting certain things or putting full pressure on my hand, but its truly fine. You can hardly tell there’s even a scar.

Was it all worth it? Absolutely. I can’t recommend this enough for anybody who finds that they are suffering from CTS. For a 15-minute procedure and a few weeks of healing, I now have a lifetime of guitar playing in my right hand - without the dreaded numbness.

If you are suffering like I was, find a qualified doctor and have your hands tested. With a little effort and time, CTS will bother you no more.

Interview with Dr. Angela Y. Giuffrida at Active Orthopedics & Sports Medicine

Q: How does carpal tunnel syndrome happen?

A: Carpal Tunnel Syndrome is basically a restriction of the space in your wrist where a very important nerve happens to glide. Whenever the space becomes small, the pressure increases and cuts off the blood supply to the nerve, not allowing the nerve to function appropriately. That’s where you get the symptoms of numbness in the hand, cramping, and pain. It’s usually in the thumb, index finger, middle finger and half of the ring finger. However, most people will either have one or two fingers that hurt more, or will have any combination of those areas.

It usually happens for two reasons. Number one is age related, where regular changes in the bones and the joints cause a very slow, gradual closing down of that space. The other population is that which works with repeated motions of their hands. These cause inflammation in this small enclosed space, which essentially closes it down and compresses the nerve.

Q: What are the first tests you do to a patient who comes to see you complaining of these symptoms?

A: The initial clinical tests are basically provocative maneuvers where we actually push on the carpal tunnel to simulate a compression of the nerve – where that can elicit the symptoms. That would be either pain in the hand, numbness in those three and a half fingers, or cramping in the thumb.

There are also diagnostic tests, one of which is a nerve conduction test and the other, which is an EMG, or electromyography. It’s basically a physiologic measure of the function of the nerve. So when a nerve is compressed it will not send signals appropriately – and this test will detect how much of the signals are not being sent, whether the signals to the skin (early/mild compression) or muscle (late/severe compression) are involved, and what the severity is of that involvement. Knowing the severity helps to guide treatment.

Q: You also tested to make sure my problem was not a pinched nerve in the neck. How did you do that?

A: If you can imagine the nerves start in your spinal cord, and they come out through your neck all the way down your arm and into your hand. A pinched nerve at any location can mimic symptoms of a pinched nerve along the same nerve in a different location. So whenever you are considering having surgery for something, you want to be 100 percent absolutely sure that the area where you are doing surgery is actually the site of compression. That’s why the EMG test in particular is very important to make sure that a pinched nerve in your neck is not causing the same symptoms in your hand.

Q: If it’s determined that the problem is Carpal Tunnel Syndrome, what are the options?

A: The first line treatment is usually splinting of the hand. A garden-variety carpal tunnel splint is one that you can even get in Target or Wal-Mart. It has a metal bar along the palm aspect of the wrist and it keeps the wrist from bending. What happens when the wrist bends is that the space where the nerve lives gets smaller. So if we can keep the wrist from bending, the space will not get small and it should prevent symptoms. This is usually just a temporary fix. Sometimes it’s ok for a patient to have a temporary fix, because their symptoms are only temporary or very mild.

But if you have symptoms at all, you most likely have a very small space there and the carpal tunnel will not usually just go away by itself.

The other non-surgical options are oral anti-inflammatories, which help in the population that have a lot of repetitive motion in the hands. Sometimes that can help cut down the inflammation and increase the space. Sometimes a cortisone injection, which works basically in the same way as the oral anti inflammatory, except it delivers the medicine right to the carpal tunnel, and it helps to decrease inflammation and increase space. Again these are mostly temporary fixes. Cortisone usually lasts for a few months, although I have seen patients who get more than a year of relief from a single injection.

The final step is surgery. Surgery is for those who don’t get enough relief with the non-surgical treatments, or for those with severe carpal tunnel syndrome. What we do in surgery is basically create more space so that the nerve is not squeezed anymore.

The carpal tunnel has a very unique anatomy. Most of the border of that tunnel is bone and one small portion of the tunnel is ligament. So what the surgery does is release the ligament and enlarges it so that there is no longer a tight space where the nerve happens to run.

Q: How about the healing after surgery?

A: Everyone has a different physiology, so this will vary from person to person. What I usually tell my patients is that the night after your surgery, usually the nighttime pain and numbness will go away because you have that immediate increase in space and decrease in pressure. You usually feel that at nighttime, when you’re sleeping and your blood pressure goes down, your nerve can actually get circulation so it doesn’t wake you up anymore. In terms of activities like playing the guitar, I would restrict that at least until you come back in the 10 to 14 day mark to get your stitches out. At that time, I’ll usually recommend that you start very slowly to try and play. Of course, I don’t recommend a full work schedule or any vigorous activity until usually between 4 and 6 weeks. Your grip strength slowly increases over the course of the next few weeks.

Q: Are there things that a guitar player can do to stretch if they have carpal tunnel symptoms?

A: Well, anyone who consults Dr Google or gets information from the Internet will surely come across stretching exercises that you can do. In my opinion though, carpal tunnel is a mechanical problem – a problem of space. While stretching can help with gliding, such as with the tendons and the nerves that inhabit that space, it does not do anything to actually increase that space. Unfortunately, the only thing that can do that is surgery.

It doesn’t hurt to try these exercises – in fact, sometimes physical therapy is prescribed for this reason, mostly to work on nerve gliding. However, again, it does not increase the space you have in your carpal tunnel.

Q: Currently there are two kinds of surgery?

A: Yes. One is a traditional open approach where an incision is actually made in the skin, and the ligament, which is several millimeters below the skin, is divided and widened to create more space. The nerve itself is never manipulated, although we see it very clearly in surgery.

The other method is called an endoscopic carpal tunnel release, where it’s done in a minimally invasive fashion. In that procedure, a plastic trocar is inserted into the carpal tunnel, and a small knife is used to divide the ligament- without actually opening the skin overlying that ligament. Some studies have shown that can be a quicker return to work in the population that has this surgery, but there’s also a very important and very real risk of nerve injury with this procedure – especially if you have it done by somebody who’s not very proficient in this technique. When the initial studies came out, the equipment was a little bit different and the complications were a little bit more frequent. Now the equipment has changed somewhat to try to avoid these problems so the complications have gone down.

In my opinion, if it were my carpal tunnel, I would rather actually see the ligament that I was dividing than rely on a somewhat distorted view through an instrument. While complications are not common, an injury to the median nerve has devastating consequences.

Q: What kinds of surgeons perform this type of operation?

A: They can either be a general surgeon, a neurosurgeon, an orthopedic surgeon, or a plastic surgeon. Usually any of these four types of surgeons have done extra training in hand surgery.

Q: How long does the relief last after surgery?

A: The carpal tunnel release should be a permanent cure for this problem. However, I do sometimes see patients that had the surgery twenty or twenty five years ago that have developed recurring symptoms and show a repeat of the problem on their EMG and nerve conduction tests. The only explanation for this is that over time, you have a change in the bones and the joints that slowly encroach on this space and make it narrow once again. You can however, have a repeat surgery.

BIO: Rich Tozzoli is a Grammy-nominated engineer, mixer and composer as well as PAR’s Software Editor. richtozzoli.com