Carpal tunnel surgery is one of the most common procedures performed by hand surgeons in this country. It is estimated that over 200,000 people in the United States suffer from carpal tunnel syndrome.
What is carpal tunnel syndrome?
The classic symptoms of carpal tunnel syndrome are pain and tingling or numbness of the thumb, index and middle fingers.
The anatomy of the carpal tunnel is both complex and elegantly simple. The carpal tunnel is a 3-4 cm funnel (about 1.5 inches) long. On one side of the funnel is a cradle shaped group of carpal bones. On the other is a wide and thick ligament, known as the trans-carpal ligament. Nine tendons and one nerve pass through the funnel. Due to genetics, overuse, pregnancy or other reasons the tendons become inflamed and swollen. The 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 compromised and the nerve starts dying both from pressure and lack of blood supply.
As the result, the nerve sensation changes and weakness of the hand occurs. If diagnosed in the early stages, the progression of the damage can be stopped by relieving the pressure on the nerve and allowing the blood flow to resume.
What are the treatment options for carpal tunnel syndrome?
There are non-surgical and surgical options for treatment. The indications for surgery are very broad. Some surgeons feel that most non-surgical options have a 98% failure rate, with a 95-98% success rate with surgery. Surgery is indicated as early as 8 weeks after onset of symptoms, however, some physicians suggest pursuing the non-surgical treatments listed below for 10 months. If improvement is not achieved within that time line, the surgical route is warranted.
Non-Surgical forms of treatment:
Non-steroidal anti-inflammatory medications
These non-surgical options are designed to reduce the inflammation and decrease the pressure to the nerve. Temporary conditions such as pregnancy-related carpal tunnel syndrome or overuse syndrome, due to job related functions, can be improved with these options if the patient’s job responsibilities are changed or diminished, or as pregnancy reaches term. If the job responsibilities remain the same or if there is a genetic component to carpal tunnel (size and shape of the bones) all the above methods are not likely to be successful and surgery becomes the best option.
Nerve conduction studies for carpal tunnel syndrome.
Nerve conduction studies are helpful in diagnosing carpal tunnel syndrome however, the severity of the test result 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 syndrome that requires surgery.
There are several surgical techniques for carpal tunnel release. Depending on the surgeon’s techniques and conditions for surgery, most release procedures take about 15 minutes.
Traditional carpal tunnel release surgery
A two inch incision is made on the palm of the hand. A great result is achieved however recovery is longer and there is always a risk of chronic pain in the palm from injury to the small skin nerve.
Limited incision carpal tunnel release surgery
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.
Endoscopic carpal tunnel release surgery
The development of endoscopic equipment introduced the endoscopic carpal tunnel release method. This technique is performed with one or two portals (openings in the tissue). With the double portal method, a 1/4 to 1/3 inch incision is made a half inch from the wrist crease and another incision of the same size on the palm. One incision is used for the endoscopic camera and another for a special endoscopic scalpel. The trans-carpal ligament is divided under direct vision without cutting the skin.
With the single portal method, only one incision is made and both the endoscopic camera and scalpel 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.
As with any procedure, the above method comes with risks. The chances of incomplete division of a trans-carpal ligament is higher, as well as revision rate or recurrence of the symptoms. Some surgeons are also concerned about a higher risk of division of the motor branch of the median nerve. The motor branch provides stimulation to the nerves in the muscles of the hand and thumb.
What is the recovery period after carpal tunnel surgery?
Recovery varies from one to five weeks, depending on severity of nerve injury and technique used. The nerve function may take up to a year to fully recover regardless of the technique used. If the carpal tunnel syndrome symptoms were neglected for an extended time or surgery was delayed by other treatments for too long, the nerve may not recover completely.
In today’s world of internet medical advice and a myriad of “award winning devices” , Dr. Volshteyn would caution against delaying proper treatment. It is always more beneficial to seek the opinion of an experienced plastic, orthopedic, or hand surgeon, regardless of results from carpal tunnel severity tests and nerve conduction studies.
Treatment with physical therapy or chiropractic manipulations is acceptable, however this only masks the underlying problem. Unless the conditions that originally caused the symptoms change, the narrowing of the carpal tunnel and recurrent inflammation drastically increases. With surgery, the anatomy itself is changed, allowing for more use even if inflammation persists.