“The door is open but the ride ain’t free”
“Thunder Road” by Bruce Springsteen
Okay, we’ve gotten to the point where your doctor tells you that you have carpal tunnel syndrome. The big question becomes, “What do I do about it?” There have been a lot of misconceptions about the treatment of carpal tunnel syndrome, both surgical and non-surgical, so I’d like to try and give you the most recent and up to date information from the perspective of a hand surgeon.
In 2008 the American Academy of Orthopedic Surgeons (AAOS) published clinical guidelines for the diagnosis and treatment of carpal tunnel syndrome. The AAOS is the main medical organization for orthopedic surgeons and is heavily involved in continuing education for orthopedic surgeons. As part of their effort to develop guidelines for the treatment of common conditions a group of surgeons studied the available evidence and made treatment recommendations for carpal tunnel syndrome. They basically found that there are only a couple of things that work for carpal tunnel syndrome. Specifically, splinting, steroid injections into the carpal tunnel and surgery were shown to be the most effective treatments. Oral steroids and ultrasound have some evidence that they work, but everything else from acupuncture to magnets to diets and vitamins could not be recommended one way or the other.
This is the approach I’ve taken in my practice. As long as you don’t have severe carpal tunnel with muscle loss and/or loss of feeling, then it is reasonable to try a period of splinting. I usually recommend trying 4-6 weeks of wearing a wrist splint at night and seeing what happens. Carpal tunnel injections seem to work pretty well as a temporary measure but they don’t usually provide a long term cure. If you’re having a lot of problems with carpal tunnel syndrome and don’t want to have surgery then an injection makes a lot of sense. If the injections don’t work or quit working, then surgery is always an option.
I think carpal tunnel surgery probably has a much worse reputation than it warrants. Most published studies show success rates with improvement or complete resolution of symptoms over 90% of the time, and this seems to be my personal experience as well. Everyone wants to know if the have to have the surgery, and my usual recommendation is to at least try braces or splinting before considering surgery. If you have severe carpal tunnel syndrome either by exam or on nerve conduction studies, then it’s probably smart to go ahead and have the surgery done sooner than later. Otherwise you probably need to make your decision based on how much this is bothering you and whether it’s worth going through a surgery to get better. Each patient is different.
The surgery involves dividing a ligament (the transverse carpal ligament for those that are interested) that forms the carpal tunnel. This is called a release, so the surgery is called a carpal tunnel release. The key element of the surgery is to completely divide the ligament. There are a number of ways to do this and the two most common are the open and the endoscopic carpal tunnel release. In the open technique an incision if made and the ligament is cut while looking directly at the ligament. In the endoscopic release smaller incisions are made which allow the placement of a special instrument which cuts the ligament by looking at the ligament through a small camera. A recent survey of hand surgeons showed that 75% do some form of open treatment while 25% prefer the endoscopic technique. Most of the articles in the medical literature show little difference between the two techniques. Proponents of the endoscopic technique claim that their patients have a quicker return of function while those that use the open techniques think their technique is safer. I have used what is called a “limited” open release for many years. I have seen catastrophic complications (the nerve was cut in half) with the endoscopic technique and heard of other physicians seeing this complication, so I’ve never been drawn to the technique. If I, personally, was ever to have carpal tunnel surgery I would choose a surgeon who used the open technique. If you choose a surgeon who does endoscopic releases I would recommend choosing something extensive experience with the technique.
The surgery itself is very straightforward. I use local anesthesia, many times with no medication or sedation, but a lot of patients choose to be sedated so they won’t feel the injection in their hand. It usually takes me about 10 minutes to cut down to the ligament, release the ligament and close the skin. I use absorbable skin sutures so there’s no need to have sutures removed. I usually schedule a single therapy visit after surgery to encourage use of the hand. For the first 5-7 days the hand is weak and sore enough to impact activities, but usually improves week by week after that so that most folks are back to their normal activities in 4-6 weeks. Most patients have scar tenderness and weakness, but these usually resolve with time.
I hope this series of articles has been helpful if you’re seeking information on carpal tunnel syndrome. I’ll be continuing to blog on other topics about hand surgery, and if you have any thoughts or suggestions please send me an email at firstname.lastname@example.org.