Carpal Tunnel Syndrome
Carpal tunnel syndrome is a very common disorder that occurs more commonly in women than in men. Most patients complain of numbness of their thumb, index, and/or middle fingers (and sometimes part of their ring finger). In the early stages of this disorder, the numbness comes and goes; patients often wake up in the middle of the night with their fingers numb and need to shake their hands to "wake them back up." As the disease progresses, the numbness stays around longer and some patients have constant numbness. In addition, sometimes it can cause pain in the wrist that can also travel up the forearm. People with carpal tunnel syndrome, or CTS, will frequently complain of dropping things, such as their coffee cups. When it gets worse, this weakness becomes more pronounced.
Carpal tunnel syndrome is caused by a pinching of the median nerve. This nerve passes through a "tunnel" in the wrist called the carpal tunnel; several other tendons that control the flexion of your fingers are also located in this tunnel (flexor tendons). The "roof" of this tunnel (closest to the skin of the palm) is called the transverse carpal ligament. Some people are just born with a ligament that is too tight or tunnel that is too small. Other patients acquire carpal tunnel syndrome after years of repetitive use of their wrists/hands that effectively shrinks the size of the tunnel and pinches the median nerve.
Carpal tunnel syndrome is relatively easy to diagnose. First, we will discuss your history of symptoms; frequently just talking to the patient is adequate to strongly suggest the diagnosis. A physical examination is then performed. This includes some simple tests (placing your hands/wrists in certain positions) that can also help diagnose CTS. X-rays are often obtained, mostly to rule out other disorders of the bones of the wrist that may be causing the symptoms (carpal tunnel syndrome itself does not show up on X-rays). We may perform an ultrasound in the office, using our new state-of-the-art machine, to measure the size of your median nerve; this can often be predictive of CTS. Patients are often sent for a test called an electromyelogram (EMG) and nerve conduction velocity test (NCV) which are often very helpful in establishing the diagnosis. In some cases, the EMG and NCV are negative for carpal tunnel syndrome, but that does not mean the patient does not have the disorder. In the earlier stages of CTS, these tests can often be negative, yet we still will proceed in treatment based on a clinical diagnosis (I tell my patients "If it walks like a duck, and talks like a duck, then it's probably a duck."
The initial treatment of carpal tunnel syndrome is with bracing. A removable velcro wrist brace is recommended to be worn at night. Often patients will respond to this treatment, and after several months, may be able to stop wearing the brace. If symptoms progress, other treatment options include physical therapy (mildly successful), activity modification (stop doing things that aggravate the symptoms, if possible), and steroid injections (in most cases, they only provide temporary relief). If those fail, then carpal tunnel surgery is an option.
Carpal Tunnel Surgery
Surgery for this problem is quite simple: we release (cut) the transverse carpal ligament. By doing so, this creates more space for the median nerve and symptoms usually subside. The ligament may grow back, but if so, it grows back in a looser, thinner version of its old self that does not cause similar irritation. Otherwise, cutting the ligament does not cause significant dysfunction or weakness.
There are three types of carpal tunnel surgery
- Open — utilizing a larger incision,
- Mini-open — utilizing a single smaller incision (approx 1 inch), and
- Endoscopic — utilizing one or two smaller incisions and a specialized scope system.
Although I am an arthroscopic specialist, and am trained in both types of endoscopic techniques of carpal tunnel release, I recommend and perform the mini-open technique. Numerous studies have shown that outcomes are similar between these techniques, however, there is an increased risk of complications with the endoscopic technique. If I were to have this surgery, it is the procedure I would want for myself. The scar with the mini-open technique is barely visible once it is completely healed.
What to Expect at Surgery
Typically patients are asked to arrive between 1-2 hours ahead of their surgical time, at the surgical center or hospital where their procedure is to be performed. They will speak with nurses and an anesthetist/anesthesiologist who will ask about their medical history. Most often, the surgery will be done under local anesthesia with sedation. You will be made sleepy by medications, then the wrist area will be numbed with local anesthetic medications. Most people do not remember the surgery at all. Typically the procedure takes about 15 minutes. You will be sent home when you are awake and alert. Because you will have been administered medications, you do need to have someone drive you home.
What to Expect After Surgery
Typically, there is very little pain associated with the procedure. We do provide you with a prescription for narcotics, just in case. Expect some numbness in your hand/wrist for about a day. In some patients, their carpal tunnel symptoms improve almost immediately after surgery; other patients take weeks.
Your wrist will have been placed in a bulky dressing/splint that will extend from your palm to your mid-forearm at the time of surgery, leaving your fingers and thumb free. This will be left in place until you return to the office 2 weeks later. With this splint on, I will allow you to use your fingers to hold and manipulate things, as long as they are not heavy. You will not be able to bend your wrist with the splint on.
When you return to the office two weeks after surgery, we will remove your dressing and your stitches. I will ask you to start using the hand, and will recommend squeezing a soft ball or sponge regularly. For most people, this will encourage full return of function; some patients will require physical therapy in addition. You may get your hand wet after the dressing is removed, but I will recommend avoiding submerging it fully under water (e.g., washing dishes) for an additional week. I recommend using your night wrist splint (i.e., the one you were using prior to surgery) until your symptoms completely resolve (usually within a few additional weeks, if not sooner).
Approximately 3-4 weeks after surgery, I recommend rubbing vitamin E into the incision to soften it up. An easy way to do this is to purchase Vitamin E gel capsules at the pharmacy; prick the end of the capsule with a scissor or nail clipper, and rub the gel into the incision 3-4 times a day, for two weeks or so.
Risks of Surgery
Risks of carpal tunnel surgery include infection, stiffness, nerve or vascular injury. These risks are fortunately very rare. The biggest risk, in my opinion, is the risk that your symptoms may not improve. This is also unlikely, but increases if you have severe carpal tunnel syndrome (for that reason, I do not recommend waiting until symptoms are severe before electing to undergo the surgery), or are elderly. Smoking has an effect as well; the less you smoke, the quicker your nerve will heal (smoking, and nicotine in particular, interferes with microvascular blood flow, which in turn slows down healing).
Although carpal tunnel syndrome is very common, it thankfully is also very treatable. Your best bet is to make sure that you treat it before symptoms get too bad and become irreversible. For those people that need it, carpal tunnel surgery is safe, easy, and very successful in relieving their symptoms and allowing them to return to activities they enjoy.