TreatmentsCarpal Tunnel Treatment
Carpal Tunnel Syndrome
Carpal tunnel syndrome occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. The median nerve controls sensations to the palm side of the thumb and fingers (although not the little finger), as well as impulses to some small muscles in the hand that allow the fingers and thumb to move. The carpal tunnel – a narrow, rigid passageway of ligament and bones at the base of the hand – houses the median nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. The result may be pain, weakness, or numbness in the hand and wrist, radiating up the arm. Although painful sensations may indicate other conditions, carpal tunnel syndrome is the most common and widely known of the entrapment neuropathies in which the body’s peripheral nerves are compressed or traumatized.
What are the symptoms of carpal tunnel syndrome?
Symptoms usually start gradually, with frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers. Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent. The symptoms often first appear in one or both hands during the night, since many people sleep with flexed wrists. A person with carpal tunnel syndrome may wake up feeling the need to “shake out” the hand or wrist. As symptoms worsen, people might feel tingling during the day. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic and/or untreated cases, the muscles at the base of the thumb may waste away. Some people are unable to tell between hot and cold by touch.
How is carpal tunnel syndrome treated?
Carpal tunnel release is one of the most common surgical procedures in the United States. Generally recommended if symptoms last for 6 months, surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. Surgery is done under local anesthesia and does not require an overnight hospital stay. Many patients require surgery on both hands. The following are types of carpal tunnel release surgery: Open release surgery, the traditional procedure used to correct carpal tunnel syndrome, consists of making a long incision in the palm and approaching the carpal tunnel from the outside in. This can result in a long painful scar (see picture). Many layers of tissue are unnecessarily divided resulting in a long painful scar in some patients. This can delay return to normal activities.
Endoscopic surgery may allow faster functional recovery and less postoperative discomfort than traditional open release surgery. The surgeon makes two incisions(about ½ inch each) in the wrist and palm, inserts a camera attached to a tube, observes the tissue on a screen, and cuts the carpal ligament (the tissue that holds joints together).
This two-portal endoscopic surgery is effective and minimizes scarring and scar tenderness, if any. (see picture) Over the past seven years Dr Mahoney has refined the technique developed at the Brown Hand Center. A study published in the Plastic and Reconstructive Journal in 2007 looked at the outcome of over 14,000 procedures performed using this technique. The procedure can be performed under local anesthesia; or full anesthesia is offered as well. Dr Mahoney is an expert in this procedure and has performed more of this type of procedure than any surgeon in the valley. Most of Dr Mahoney’s patients do not even require narcotic medication postoperatively. A few days of NSAIDS (ibuprofen) is all that is usually necessary. Here you can see the instruments inserted via two small incisions into the wrist.
Here, you can see a cross-sectional picture showing the instruments under the band of tissue that compresses the median nerve.
Here is the view from inside the carpal tunnel as viewed by the surgeon. You can see on the left the blade is dividing the ligament. On the right, you can see the ligament after it has been divided.
Although symptoms may be relieved immediately after surgery, full recovery from carpal tunnel surgery can take months. Some patients may have infection, nerve damage, stiffness and pain at the scar. Occasionally, the wrist loses strength because the carpal ligament is cut. Patients should undergo physical therapy after surgery to restore wrist strength. However, the majority of patients can be shown simple exercises to be done on their own at home. Some patients may need to adjust job duties or even change jobs after recovery from surgery.
Recurrence of carpal tunnel syndrome following treatment is rare. The majority of patients recover completely.
Abstract: Plast Reconstr Surg. 2007 Dec;120(7):1911-21.
A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.
- For more information on carpal tunnel: http://www.ncbi.nlm.nih.gov/pubmed/18090755
Plast Reconstr Surg. 2008 Jan;121(1):347.
Compared with the open technique, endoscopic carpal tunnel release has a shorter postoperative recovery period but has been associated with an increased risk of iatrogenic injury. Because of morbidity of the open method, including painful scars, pillar pain, tendon adhesions, scar entrapment of the median nerve, chronic regional pain syndrome, and a longer postoperative recovery period, many patients have been treated nonoperatively to circumvent or forestall surgery, resulting in unrelieved median nerve compression and an increased risk of permanent nerve injury.
Inclusion criteria included a diagnosis of carpal tunnel syndrome based on history and physical examination and electrodiagnostic studies; failure of a short trial of conservative therapy; and advanced disease as evidenced by sensory, motor, or atrophic changes in the median nerve distribution. Exclusion criteria included prior surgery, wrist extension of less [corrected] than 40 degrees, mass within the carpal tunnel, Guyon’s syndrome, and bony carpal tunnel abnormalities. Patients meeting these criteria were treated by the Brown two-portal endoscopic technique.
A total of 14,722 patients were treated with the Brown endoscopic procedure. Eleven patients (0.07 percent) required conversion to an open procedure. There was one iatrogenic injury. Postoperative results were inversely related to the severity of the preoperative electrodiagnostic studies and the duration of symptoms regardless of the method of nonoperative treatment given.
Operative decompression should be carried out promptly if symptoms have been present for 2 months or longer, as the occurrence of permanent nerve damage has been noted within this time frame. The authors advocate use of the two-portal endoscopic technique as previously described by Brown et al. for this purpose.