Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

The carpal tunnel is a fibrous passageway in the wrist that contains the median nerve and the nine flexor tendons to the thumb and fingers. The median nerve is one of three major nerves of the hand. It is responsible for sensation to the thumb, index, middle, and thumb side of the ring finger.  In addition, the median nerve controls the muscles of the thumb to allow it to turn and touch each fingertip.  In Carpal Tunnel Syndrome, the fibrous passageway for the median nerve can become narrower in the wrist and lead to compression of the nerve.


What are the symptoms of Carpal Tunnel Syndrome?

With continued compression of the median nerve, patients can develop numbness and tingling of one or more of the areas supplied by the nerve (thumb, index, middle, and ring). Some patients experience dull, aching pain in the hand during nighttime or awaken in the morning with numbness in the thumb and fingers. In long-standing or severe circumstances, the nerve compression can lead to weakness or paralysis of the muscles moving the thumb and loss of muscle mass on the thumb side of the palm.

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What causes Carpal Tunnel Syndrome?

Risk factors for Carpal Tunnel Syndrome include repetitive wrist work, obesity, pregnancy, diabetes, and autoimmune disease. The common factor in these conditions is that they all lead to increased swelling in the fibrous passageway and decreased space for the median nerve. In this situation, the nerve remains in continuity but is its outer lining and blood supply can be damaged by the pressure caused by this tight passageway. In response, scar tissue replaces the natural outer insulation of the nerve, called myelin. Myelin is critical in speeding the transmission of electrical signals to the muscle to cause contractions or from the skin to the brain to produce feeling. With scar replacing myelin, electrical signals cannot easily travel across the nerve.


How is Carpal Tunnel Syndrome diagnosed?

Carpal Tunnel Syndrome can generally be diagnosed by the history of symptoms and by physical exam looking for signs of thumb and finger numbness, loss of muscle mass in the palm, or nerve inflammation (Phalen’s, Tinel’s, Durkan’s, and scratch collapse tests). In the Phalen’s test, the wrist is maximally bent for up to 60 seconds and the patient is asked if there are any symptoms of thumb or finger pain, numbness, or tingling. Using the Tinel’s test, the skin over the carpal tunnel is tapped and the patient is asked if there are any signs of tingling or electrical shocks traveling to the thumb, index, or middle finger.  In the Durkan’s test, the carpal tunnel is compressed for up to 30 seconds and the patient is asked if there are any symptoms of thumb or finger pain, numbness, or tingling.  For the scratch collapse test, the patient performs resisted shoulder external rotation exercises. The test is considered positive if the wrist is lightly scratched and the patient momentarily collapses while performing resisted shoulder external rotation.  In situations where the diagnosis is unclear, a nerve conduction and muscle study can be ordered to obtain more information on the health of the median nerve and its muscles.


What are the treatments for Carpal Tunnel Syndrome?

Treatment of Carpal Tunnel Syndrome begins with wrist splinting to minimize repetitive wrist motion, non-steroidal anti-inflammatory drugs to reduce the swelling and inflammation, diet and exercise in obese patients, and strict glucose control in diabetics. If these measures fail to eliminate the patient’s persistent pain, numbness, and/or muscle weakness, a carpal tunnel release is recommended. In this procedure, a nerve decompression / neurolysis is performed of the median nerve through a small incision in the palm.  The goal is to provide space for the nerve and its blood supply, giving it a chance to regenerate. Doing so in a timely fashion should lead to speedier electrical signals and return of movement, feeling, and function.


Am I a candidate for Carpal Tunnel release surgery?

With carpal tunnel syndrome, nonsurgical treatments are exhausted before Dr. Seruya even considers surgery. These include bracing/splinting, use of anti-inflammatory medication, changes in activity, nerve gliding exercises, and possible corticosteroid injections to reduce inflammation in the carpal tunnel. In most cases, surgery isn’t considered until after several weeks to months of nonsurgical treatment.

If these treatments have not resolved the pain in your hand and if you are having increasing numbness, surgery may be necessary. If not addressed, carpal tunnel syndrome can lead to constant numbness and wasting of your thumb muscles, which can become irreversible. Dr. Seruya will monitor if you are beginning to show damage to your median nerve, which would require surgery.


How is Carpal Tunnel release surgery performed?

Dr. Seruya performs these surgeries as outpatient procedures. The patient can be given either local or general anesthesia. There are two options: open surgery or endoscopic surgery. The goal is to relieve pressure on the median nerve by cutting the transverse carpal ligament that forms the roof of the carpal tunnel. When this ligament is cut, this increases the size of the tunnel and decreases pressure on the median nerve.

  • Open carpal tunnel release — In this method, Dr. Seruya makes a small incision in the palm of your hand and views the inside of your hand and wrist through this incision. He then cuts the transverse carpal ligament, and the incision is closed with stitches. The gap where the ligament was cut is left alone and it eventually fills up with scar tissue.
  • Endoscopic carpal tunnel release — In the endoscopic method, Dr. Seruya makes two small skin incisions, known as portals, in the wrist and in the palm of the hand. He then inserts an endoscope (miniature camera) into the incision in the wrist to provide visuals inside the hand and wrist. A knife is then inserted through the palm incision and is used to cut the transverse carpal ligament. The small incisions are closed with stitches.

Is there anything necessary to prepare for Carpal Tunnel release surgery?

There are no special arrangements when preparing for this procedure with Dr. Seruya. He will inform you of the necessary anti-inflammatory medications, supplements, or other medicines you are taking that will need to be stopped, at least for a few days, because they may hamper blood clotting and healing.

Your main preparation is to prepare to not be able to use the hand being operated on for a period of time. With open surgery, you may not be able to type or perform other repeating motions with that hand for from 6-8 weeks. If Dr. Seruya is able to use endoscopic techniques, these timeframes will be shorter.


What are the outcomes/benefits of Carpal Tunnel surgeries?

The outcomes of carpal tunnel release surgeries are usually very successful. With either method, most patients have fewer or no symptoms of pain and numbness in their hand. Sometimes this is immediate; other times it can take months to fully improve.

Recovery is somewhat longer with the open method, but research hasn’t shown any difference in the quality of the outcome with either approach over the other.


Is Carpal Tunnel release surgery safe?

This is a very low-risk procedure. The main risk is nerve damage, but this is shown to occur in less than one percent of patients. Particularly with the open method, you may have some pain in the wrist and hand and tenderness around the scar, but this will resolve. As with any surgery, there are risks of infection, poor wound healing, and the like, but this is a safe procedure.

The real risk is not addressing the nerve compression in carpal tunnel syndrome. Considering that permanent nerve damage and loss of coordination in your fingers and loss of strength in your thumb are the possible results of this compression, the risks of not having this surgery outweigh the low risks involved in doing so.


What happens after surgery for Carpal Tunnel Syndrome?

Open carpal tunnel release generally takes less than one-hour and can be performed under general or wide awake local anesthesia. After the completion of surgery, the wrist and palm are wrapped in a soft, bulky dressing. Following a 1-2-hour recovery period, patients are discharged home the same day on Tylenol, Motrin, and sometimes on a short course of narcotics. Elevation and finger motion are recommended to push out the swelling and prevent joint stiffness.  Light activity is encouraged when comfortable for the patient.  One week after surgery, patients may take off their bandages and get the incision wet. Lifting is limited to 5 pounds for 6 weeks. Six weeks after surgery, patients may resume full activity. With mild and/or intermittent symptoms, relief of numbness, tingling, and pain is often immediate. With long-standing or severe cases, relief of symptoms and return of muscle function may be more gradual and over the course of many months.


Is Carpal Tunnel release surgery covered by insurance?

Yes. After nonsurgical treatments have been tried and have proven ineffective, this surgery is deemed necessary to prevent permanent nerve damage.


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