Carpal tunnel syndrome is often associated with occupational hazards. People who spend long hours at a keyboard are commonly affected. Pregnant women are also affected. This usually goes away after the pregnancy. Carpal tunnel syndrome is associated with arthritis in the hand as well. Further information about the causes may be found in this article: Carpal Tunnel Syndrome

If carpal tunnel syndrome becomes established, non-operative treatments may not be effective. This includes splinting and cortisone injections. Surgery for carpal tunnel syndrome will then be the recommended treatment.

In this short article I aim to give the reader an in-depth understanding of what is involved in surgery – a carpal tunnel release.

Surgery for carpal tunnel syndrome is minor elective surgery. It is performed as a day case procedure. This means that an overnight stay in hospital is not necessary. My preferred approach is to perform the procedure in the operating theatre as this is a controlled and safe environment.

Before having surgery for carpal tunnel syndrome 

You will be admitted to the surgical ward and prepared for theatre. You should be starved for surgery. This means that you should have had nothing to eat or drink for the six hours before your estimated time of surgery. The reason for this is to minimise the risk of regurgitating any food or liquid from your stomach. If this happens while you are sedated or under anaesthetic, it may cause significant damage to your lungs. It is however usually okay to have small sips of water for up to two hours before the surgery.

If you are on any chronic medication you may take these as normal on the morning of the operation. The exception is any diabetic medication. If you are a diabetic, you will have your glucose checked on admission and may be given insulin to control your sugar. You will usually be first on the operating list.

It is also important that you not be on any blood thinning medications at the time of surgery. You should have stopped these or at least discussed this with your surgeon well in advance.

In the operating theatre

In the operating theatre you will be lying in a comfortable position, flat on your back with your head on a pillow. The affected hand will be resting on a hand table. A tourniquet is applied to the upper arm. This will only be inflated once you are asleep. The reason we use this is to minimise bleeding and allow for better vision. After the anaesthetic is given your arm is cleaned with either a betadine or an alcohol solution and you are covered with sterile drapes.

The anaesthetic

Many patients ask: “Is carpal tunnel surgery painful?” The answer is…no! The operation is performed under anaesthesia and there are a few options available. My preferred approach is to perform the procedure under a local anaesthetic.

Another common question I get asked is: “Are you awake for carpal tunnel surgery?”. The answer depends on you. If the operation is performed under local anaesthetic, a light sedation is usually administered by the anaesthetist. This usually makes you sleep but it is not a general anaesthetic and you will be breathing normally by yourself. Some patients prefer not to sleep, and then sedation is not performed – the choice is yours.

Once you are sedated and are in a comfortable sleep the local anaesthetic is injected. You will not feel or remember any of this. The anaesthetic will anaesthetise the compressed nerve (the median nerve) causing the carpal tunnel syndrome. The anaesthetic will also numb the area of skin where the incision is made (this is located on the palm of the hand just after the wrist crease).

Because the entire nerve is anaesthetised the thumb, index, middle and ring fingers will feel completely numb after the operation. This is normal and the numbness can last until the next day or even longer. This is nothing to be concerned about. In fact, the longer the anaesthetic works the better will be your pain control.

Advantages of local anaesthetic and sedation for a carpal tunnel release

There are some advantages to having a local anaesthetic and sedation. It is generally regarded as being safer than a general anaesthetic with lower risk of potential anaesthetic complications. Patients normally wake up feeling fresh as a daisy and can go home almost immediately. There is no recollection of any events during the operation and the procedure is completely pain free.

Some people are not candidates for a local anaesthetic and sedation or simply prefer to have a general anaesthetic. In this case you will have a full general anaesthetic and your breathing will be controlled by the anaesthetist. You will still have a local anaesthetic injection to make the fingers go numb as described above. It usually takes longer to wake up fully from a general anaesthetic, but you can go home soon after surgery once you are comfortable and you have had something to eat and drink and are not nauseous.

The procedure

Once the wrist and hand has been cleaned and draped with sterile towels the procedure can begin. A surgical assistant (who is another doctor) usually assists with the surgery. The incision is made on the palm of the hand. It begins at the wrist crease in the middle of the wrist. I use a slightly curved incision which extends for only 2 or 3 cm towards the fingers. Any blood vessels encountered are sealed with a special electrocautery device to prevent further bleeding.

There is a small amount of fatty tissue under the skin which is retracted to reveal the fibrous tissue in the hand. Underneath this fibrous tissue lies the tough ligament which forms the roof of the carpal tunnel. These tissues are divided carefully to avoid injury to the nerve which lies just underneath. Once the median nerve is seen it is protected and the remaining ligament is cut to decompress the nerve.

Sometimes there is an excessive amount of inflamed tissue which has developed in the carpal tunnel. This is called synovitis and this excess inflammatory tissue can be removed. Uncommonly a small cyst may be discovered in the carpal tunnel (this may be the cause of the carpal tunnel syndrome). This is also removed at this time.

After the nerve is freed the tourniquet is released. A routine carpal tunnel release usually takes only a few minutes and the tourniquet is used for between 5 to 10 minutes. Once again, any small blood vessels which may be bleeding are cauterised. The wound is given a thorough wash with normal saline.

Skin closure…

The ligament which has been cut is not repaired but is left open. This will not cause any problems. Only the skin is closed using stitches. My preference is to use interrupted nylon sutures. These stitches work well for the type of skin that you have on the palm of the hand and the soles of your feet. A waterproof plaster is applied over the stitches.

A splint is then applied before you are woken up. The splint is called a backslab and is made of fibreglass. It is used to immobilise the wrist and is secured with wool for padding, and a bandage. You do not need to have a collar and cuff and you can move your arm freely.

After the operation you are transferred to the recovery room where you will be monitored before going back to the ward. Once you have had something to eat and drink in the ward and your observations are stable you will be allowed to leave.

Going home

You will need to collect the pain medication which has been prescribed for you from the pharmacy before going home. It is recommended that you begin to take this medication before the feeling comes back into your fingers for optimal pain control. You may not drive yourself home and you may not drive for 24 hours after having the anaesthetic and sedation, or a general anaesthetic.

When you are at home it is advisable to keep the hand elevated and move the fingers frequently to prevent swelling. The splint should be kept dry and you should not get the underlying dressings and wound wet. The plaster and splint should not be removed until I see you for a follow-up appointment. This is usually at 10 days after the surgery. During this time, you may use the operated hand as comfort allows. It should be possible to use the hand normally for most activities including writing and typing. Lifting heavy objects is not allowed.

At the 10-day follow-up the splint and dressings will be removed. The stitches are also removed at this stage. This is done in the rooms and is not painful. My preference at this stage is for you to use a removable splint for a further four weeks although this is optional.

I have carpal tunnel syndrome in both hands. Can they both be done at the same time?

Yes, they can, but I usually recommend against this unless necessary. Because I use a splint after the surgery it is easier for you to care for yourself if you have one “good” hand which is not immobilised or covered in dressings and that you can use for self-care. Having a carpal tunnel release on both hands however is certainly possible and I am happy to do this if circumstances dictate.

How long does it take to recover from surgery for carpal tunnel syndrome?

Patients usually feel better almost immediately but those who have had nerve compression for many months or years may take longer to recover fully. By three months you should have achieved maximal resolution. Those who have had prolonged compression and have developed weakness of the muscles in the hand as a result may only experience a partial relief of their symptoms. This is because the nerve may be permanently damaged due to the long-standing compression.

You will be able to do use your hand normally (within reason) immediately after the surgery, and once the splint and dressings come off at 10 days you may get the hand fully wet. I advise against lifting heavy things for at least 6 weeks.

What is the success rate of carpal tunnel surgery?

Surgery for carpal tunnel syndrome (carpal tunnel release) is one of the commonest procedures performed by orthopaedic surgeons. It is usually highly successful and has a low impact on your work and activities of daily living. Complications such as infection, nerve injury and bleeding are fortunately very rare. Recurrence is possible, and sometimes the procedure must be performed a second time, but once again this happens very infrequently.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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The Cause of Carpal Tunnel Syndrome

The median nerve is one of the main nerves to supply the hand and fingers. It is formed near the neck, and passes through the arm, forearm and then finally into the hand. In the hand it passes through a tight passage called the carpal tunnel before dividing into its final branches in the fingers. Anything which causes the space in this tunnel to become tighter may result in a squeezing of the nerve. This produces the symptoms of CTS. Sensation is usually affected first, resulting in the pain and altered sensation in the fingers. Power can also be affected, result in wasting of the muscles and weakness in the hand. This may become permanent if left untreated.

CTS is often associated with occupations that involve a lot of typing. it may also be caused by other activities that involve prolonged or repetitive flexion of the wrist.It may affect pregnant women due to fluid retention. Certain medical conditions such as diabetes affect the nervous system and may play a role in the development of the condition. Inflammation involving the wrist, (e.g. in rheumatoid arthritis), may cause a mechanical compression of the median nerve. Other conditions may also increase the risk. These include menopause, being overweight, thyroid disorders or kidney failure. In many instances, however, the cause is not established. Women are affected up to ten times more commonly than men. The condition is most prevalent between 45 to 60 years of age.

Symptoms and Signs

People with CTS commonly report numbness and tingling which affects the palm-side of the thumb, index, middle and ring fingers. Involvement of the little finger is not usual, and may point to a different or additional problem. The hand may “fall asleep” and there may be a tendency to lose grip or drop things.

The symptoms may come and go and are classically worse at night. It occasionally wakes a person from sleep, and is relieved by shaking the hand or wrist. Pain may be the main feature, usually felt at the wrist but may radiate to the fingers or even towards the elbow.

A person may report weakness or clumsiness of the hand. It is also possible to get a sensation of tightness, swelling or even changes in temperature and skin colour. These symptoms, however,  are not as common.

A thorough examination of the hand is performed but often there may be no abnormal findings. Sensation may be altered in the palm side of the thumb, index, middle and thumb-side of the ring finger. In severe and long-standing cases, the small muscles in the hand and thumb may be weak when power is tested. The muscle bulk may also be diminished.

The elbow, shoulder and especially the neck are usually examined. It is possible that conditions in these areas may cause symptoms similar to CTS.

Special Tests for Carpal Tunnel Syndrome

A number of special tests may be performed during the examination. These are used to aid the diagnosis although they are not always completely diagnostic. A tingling in the affected fingers with gentle tapping on the palm-side of the wrist over the nerve is a positive Tinel sign. A similar tingling or numbness may be reproduced after bending the wrist as much as possible for at least 60 seconds (positive Phalen sign). This may be positive even after simply applying direct pressure on the wrist over the nerve for at least 30 seconds.

Further Investigations

The diagnosis of carpal tunnel syndrome is often made clinically and without the need for further tests. This is the case if the history and examination are highly suggestive and the Tinel and/or Phalen signs are positive. Blood tests and X-rays are usually not needed, unless another diagnosis is being considered. On occasion, an ultrasound scan or MRI may be necessary if it is thought that there may be a “space-occupying lesion” in the carpal tunnel causing the symptoms. An example of this is a ganglion (fluid-filled cyst),

The most commonly requested test in doubtful or atypical cases is a nerve conduction study (electrophysiologic testing). This investigation may confirm the diagnosis and categorise the condition as mild, moderate or severe. This test also helps to ascertain if the symptoms might be present as a result of a compression at the level of the neck, as opposed to the wrist.

Treatment

The first steps to curing CTS would naturally involve correcting any contributing factors and making certain lifestyle modifications. This includes losing excess weight and increasing aerobic exercise. Anti-inflammatories may be used in those in whom wrist inflammation is causing the symptoms. The use of a splint worn mainly at night which keeps the wrist slightly extended for a period of at least three weeks may provide benefit in mild cases.

If the symptoms persist, consideration can be given to an injection of cortisone (a strong anti-inflammatory) into the carpal tunnel. This is useful in a pregnant woman where the CTS is expected to resolve after the pregnancy. The injection can be done in the doctor’s rooms and does not require admission to hospital.

Surgery for Carpal Tunnel Syndrome

If conservative interventions fail or if the CTS is severe, surgery is indicated. The operation is done as a day case – the patient does not need to spend the night in hospital. Modern anaesthetic techniques allow for the procedure to be done safely and comfortably under local anaesthetic and sedation to avoid having a general anaesthetic.

The operation itself involves a small cut on the palm of the hand, just beyond the wrist, although some surgeons prefer to perform the procedure endoscopically (through “keyhole surgery”). The tight ligament over the nerve is cut through. The tension on the nerve is thereby released. A splint may be applied for a few weeks after surgery. In most instances it is not necessary to take extended leave from work. Driving and writing is possible even while wearing a splint.

Most activities can be resumed soon after the operation. Strenuous exercise and heavy lifting should be avoided for at least six weeks.

For an in-depth description on what carpal tunnel surgery involves, please read: Performing surgery for carpal tunnel syndrome.

The success rate of the procedure is high and often patients experience resolution of symptoms immediately after surgery. The potential risks involved are small. Injury to the median nerve is possible, as is infection and excessive bleeding. In the majority of patients the condition does not recur, but this is certainly possible. If it recurs the patient may require another operation.

Summary

Carpal tunnel syndrome is a common but very treatable condition. The results of surgery are good and complications are low.

As an orthopaedic surgeon, I see and treat many patients who have carpal tunnel syndrome. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

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