Carpal Tunnel Syndrome
About Carpal Tunnel Syndrome
Carpal tunnel syndrome is a common problem that revolves around constant use of the fingers, including computer work or any detailed work with the fingers assembling pieces or repair work of small instruments. It’s caused by constant, repetitive movement of the hands.
It’s estimated that about 3% of employed Americans experience symptoms of carpal tunnel syndrome, with women experiencing the problem twice as much as men. While it can affect both hands, often it affects the dominant hand. More than 400,000 Americans have carpal tunnel surgery each year.
Swelling of the carpal tunnel tissues due to injury or trauma causes the median nerve at the wrist to compress. This nerve connects and supplies sensation to many other areas of the hand. This swelling can be a result of constant typing, driving, assembly-line work, writing or the use of hand tools.
If you were to think of the tendons, ligaments and nerves traveling through the wrist, swelling prevents these nerves from having enough room. This causes the symptom of numbness in the fingers. Typically to resolve these symptoms, either swelling has to go down, or surgery is needed to cut the fibrous band on the inside of the wrist, known as the flexor retinaculum, which is constricting the nerves. By cutting this thick band, it then allows more room for the nerves to function properly.
Carpal Tunnel Syndrome typically causes numbness and tingling in the fingers, especially in the tip of the index finger, tip of the thumb and middle finger. Other symptoms of Carpal Tunnel Syndrome can include:
- Weakness in the hand
- Mild or severe pain in the hand
- Difficulty gripping an object
- Tendency to drop objects
- Pain in the joints of the fingers
- Loss of ability to sense temperature
- Sensation that hand is “asleep”
If left untreated over a few months, carpal tunnel syndrome can cause the median nerve to become permanently damaged, which leads to muscle injury and weakness that may be irreversible. Extreme numbness in the fingers that has persisted for a couple months, or there is worsening symptoms like hand weakness or loss of sensation in the hand, all represent more emergent symptoms that should be seen by a carpal tunnel specialist.
Non-surgical treatment options
The most common non-surgical treatment option is for the person to wear a wrist splint at night when numbness symptoms may worsen. If numbness persists during the day, a person may try wearing them during the day as well. Sometimes, a physician may recommend medications such as anti-inflammatory drugs or diuretics.
Iontophoresis is the use of electrical current applied to the wrist to transmit chemical through the skin (transdermal) to reduce inflammation. It involves a series of treatments administered by a licensed hand therapist. However, many insurance companies refuse to pay for these treatments because they are somewhat experimental and not often effective.
In more serious cases, surgery is ultimately required to relieve pressure from the nerve. A procedure called carpal tunnel release relieves pressure by cutting the ligament covering the median nerve. This surgery usually takes away pain symptoms. Surgery is most successful when performed before permanent damage has occurred.
Diagnosing carpal tunnel syndrome
Because advanced, minimally invasive Carpal Tunnel Surgery can be done in 30 minutes, symptom relief can be immediate and recovery is usually within days, the worst case scenario is to undergo carpal tunnel surgery when the symptoms are caused by something else.
Consequently, a prudent surgeon will require an EMG diagnostic test. This test uses electric current to determine the source of the nerve impingement and confirm that the problem is indeed related to the carpal tunnel.
About carpal tunnel surgery
It’s important to note that sometimes simple cases of carpal tunnel can self resolve without surgery through the use of wrist orthotics that hold the wrist open while sleeping. Consequently, surgery is only performed when numbness in the fingers has persisted for three months, or there is worsening symptoms like hand weakness or loss of sensation in the hand that implies serious nerve damage is occurring.
Carpal tunnel surgery is typically performed in an Ambulatory Surgery Center with the patient going home the same day since the procedure is relatively quick.
There are two possible surgical approaches:
Open carpal tunnel release: This is an older approach that is not widely used anymore by the most advanced surgeons since the advent of minimally invasive endoscopic carpal tunnel surgery. In open carpal tunnel surgery, the surgeon makes a long two-inch cut on the inside of the wrist, and then cuts right through the lower palm of the hand to release the carpal ligament.
Single portal endoscopic carpal tunnel release: This is the most modern and advanced minimally invasive approach to relieve carpal tunnel and can often be performed in under 30 minutes. In single portal carpal tunnel release, a tiny half-inch incision is made at the bottom of the hand. The surgeon then inserts a thin instrument called an endoscope about the width of a thin ballpoint pen through the opening, This single tool holds both a camera and a cutting device. Once the tip of the instrument is past the carpal ligament, a tiny hook blade is released upward which then opens the carpal ligament from the inside as the instrument is pulled backward. The tiny half-inch portal incision is then stitched closed.
The benefits of endoscopic carpal tunnel release over open surgery include:
- It can be performed more quickly, often under 30 minutes.
- The incision is much smaller and pain after surgery is much less.
- Recovery time is faster and less painful with some patients able to return to activity in under a week. For example, a golfer is able to chip and putt after 10 days.
- For those patients who are comfortable in a clinical setting, the procedure can be performed without general anesthesia, using a local anesthetic called a Bier block, that numbs the lower arm during the short surgery. This eliminates the risks associated with general anesthesia.
For endoscopic carpal tunnel surgery, relief of numbness can be immediate in the recovery area with sensation quickly returning to fingers, provided surgery was done soon enough to prevent permanent damage to the median nerve. In other cases, it may take a week or so for complete sensation to return to the tops of the fingers.
In cases where the person waited several months with numbness, the median nerve may be more compromised and it might take weeks or months for sensation to return.
After surgery, the patient’s wrist is bandaged with a splint, and is instructed to keep the surgical site dry for several days to prevent injection as the incision heals.
Considerations about when to use surgery
If the person waits too long to have surgery, the median nerve may be permanently damaged and sensation and strength may never return to the hand or fingers.
Consequently, the likelihood of successful carpal tunnel surgery is higher if surgery is done at an earlier stage, such as within three months of persistent numbness in the fingers.
Some research studies find that up to 90% people report that their symptoms have improved after carpal tunnel surgery, or that they are symptom-free several years later.
Preventing carpal tunnel syndrome
Some ways that may help to prevent carpal tunnel syndrome:
- Avoid repeated stress on the hands.
- Do hand and wrist exercises and stretches periodically.
- Use proper hand and wrist positioning and pay attention to ergonomics.
- Take breaks during work.
- Set your computer monitor at eye level, and keep elbows at a 70- to 90-degree angle and wrists in a neutral position.
- Wear splints at night.
- Use tools and equipment in your daily tasks that are designed to minimize the risk of wrist and hand injury.
- Use cold treatments (such as ice packs) to reduce inflammation in the hands
- Treat underlying medical conditions that contribute to the development of carpal tunnel syndrome, such as diabetes, thyroid disease and arthritis.
Scott B. Phillips, MD is a neurological surgeon based in San Antonio who specializes in minimally invasive spine surgery, artificial disc replacement, carpal tunnel surgery, spinal cord stimulator implants and other brain disorders, including brain tumor and chiari decompression. Patients travel from Bexar County, San Marcos and South Texas, including Corpus Christi, Kingsville, McAllen and Brownsville for treatment of back pain, neck pain, brain tumor, carpal tunnel and epilepsy-related neurological problems. Dr. Scott Phillips provides second opinions for back surgery and neck surgery, and emphasizes non-surgical treatment options in advance of spine surgery. Where surgery is necessary because of a herniated disc or spinal instability, Dr. Phillips uses minimally invasive spine surgery techniques and advanced technology like the artificial disc to help patients relieve pain symptoms and get back to activity. This spine neurosurgeon expertise enables many patients to have outpatient spine surgery and be home the same day.