Carpal Tunnel Surgery is one of the most common procedures performed by hand surgeons in this country. It is extimated that over 200,000 people have carpal tunnel surgery in this country.
The classic symtoms of Carpal tunnel are pain and tingling or numbness of thumb, index and middle finger.
The anatomy of the carpal tunnel is both complex and elegantly simple at the same time. The carpal tunnel is a 3-4 cm funnel (about 1.5 inches) long. On one side of the funnel is a cradel shaped group of carpal bones, on the other is a wide and thick ligament, known as transcarpal ligament. 9 tendons and one nerve pass through the funnel. Due to genetics, overuse, pregnancy or other reasons the tendons get inflamed and swell up. Swelling creates increased pressure in the carpal tunnel and the weakest link (the nerve) gets squeezed. As the pressure increases, the blood supply to the nerve gets compromized and the nerve starts dying both from pressure and lack of blood supply.
As the result, the sensation changes and then weakness of the hand occur. If caught in time, the progression of the disease can be stopped by relieving the pressure on the nerve and allowing the blood flow to restore.
There are a few treatment options available.
Physical therapy, strtching exercises, splinting, non-steroidal anti-inflammatory medications and steroid injections are the non-surgical options. They are designed to reduce the inflammation and decrease the pressure to the nerve. They work well with temporary conditions, like overuse syndrome (if job responsibilities are diminished or changed), pregnancy-related carpal tunnel syndrome. If the job responsibilities are still the same or there is genetic component to carpal tunnel (size and shape of the bones) all the above methods are not likely to be successfull.
The indications for surgery are very broad. Some surgeons feel that most non-surgical options have 98% failure rate and with 95-98% success with surgery, it is indicated as early as 8 weeks after the symptoms start. However, others would suggest all the above non-surgical treatments first and trying to improve things non-surgically for at least 10 months. The Nerve Conduction Studies are helpful in dignosing the Carpal Tunnel but the severity of the test results does not necessarily correlate with the severity of nerve compression. Some studies show that 15% of patients with negative Nerve Conduction Studies have Carpal Tunnel that requires surgery.
There are several surgical techniques for Carpal Tunnel Release. Most of them take 2-15 minutes depending on a surgeon, technique used or other conditions.
Traditional incision is on the palm of the hand and is about 2 inches long. It produces great results but recovery is a bit longer and there is a possibility of chronic pain in the palm from injury to the small skin nerve.
Further advancement of surgery brought limited incision carpal tunnel release. The incision is about 1 inch long. It heals better and faster with less risk of nerve injury and pain.
The development of endoscopic equipment introduced Endoscopic Carpal Tunnel Release method. This technique can be done with one or two ports. With 2 ports the 1/4 - 1/3 inch incision is made 1/2 inch away from the wrist crease and another one of the same size on the palm. One incision is used for camera and another for a special endoscopic knife. The Transcarpal Ligament is divided under direct vision without cutting the skin.
With single Port technique, only the first incision is made and both camera and knife are placed through one opening that is about 1/4-1/3 inch long. The recovery is shorter. The risk of skin nerve damage is much lower.
However, it does not come without a price. The chances of incomplete division of a transcarpal ligament is higher, so is a rate of revision or recurrence of the symptoms. Also some surgeons are concerned about a higher risk of division of motor branch of the median nerve. That branch provides innervation to the muscles of the hand and the thumb.
Recovery varies depending on severity of nerve injury and technique used from 1-5 weeks. However, the nerve function recovery may takeup to a year. If Carpal Tunnel was neglected for a long time or surgery was delayed by other treatments for too long, the nerve may not recover much function back.
In todays world of internet docs and millions of "award winning devices" out there I would caution everyone against delaying proper treatment. Regardless of severity of your Carpal tunnel or results of Nerve conduction studies, seek an opinion of an experienced plastic, orthopedic or hand surgeon. Being treated by physical therapy or chiropractic maniputations is OK, but they do not solve the underlying problem - narrowing of the carpal tunnel and recurrent inflammation, unless the work responsibilities are drastically changed. With surgery the anatomy itself is changed, so it allows for more use even if inflammation persists.
Being a surgeon, I am obviously biased toward surgery. However, there nothing more disappointing then seeing a patient who went through 6 month of chiropractic manipulations or "lunar bone adjustments" to learn that the carpal tunnel syndrome is gone too far and the chances of recovery of nerve function is minimal.