Performing surgery for carpal tunnel syndrome

Carpal tunnel syndrome is a common condition affecting the handSurgery for carpal tunnel syndrome is one of the commonest orthopaedic procedures. The most common presentation is altered sensation or pins and needles in the fingers. Usually the thumb, index, middle and ring fingers are involved. One or all the fingers may be affected. The symptoms are usually worse night. Often the patient is woken from sleep and needs to shake his or her hand to get rid of the symptoms…

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 

Carpal tunnel syndrome may require surgery to treatYou 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

Carpal tunnel release for carpal tunnel surgery is a common orthopaedic operationOnce 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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