When is carpal tunnel syndrome bad enough for surgery?

               Carpal tunnel syndrome refers to compression of the median nerve at the junction of the hand and the wrist (i.e. a “pinched” nerve). It is the most common diagnosis that I see in the office as a hand surgeon.  The nerve sits inside of a tight canal called the carpal tunnel on the palm side of the hand.  The median nerve, as do all nerves, functions as an electrical cable sending electrical signals back and forth between the brain and body part that it supplies.  The median nerve supplies both sensation and muscle function to the hand.  The sensation is provided to the thumb, index finger, middle finger, and half of the ring finger.  The median nerve provides input to the muscles that control motion in the thumb.  Under normal circumstances this relationship allows the extraordinary function and sensation of the hand to work properly.

               The cause of carpal tunnel syndrome is poorly understood. Classical belief was that typing on the computer all day resulted in the development of carpal tunnel syndrome. However, this has been disproven and job-related tasks do not seem to correlate with the development of carpal tunnel syndrome. As humans, our anatomy is similar regardless of gender, race, or age. Why then do some people develop carpal tunnel syndrome and why do some not? This question remains unanswered.

               Carpal tunnel syndrome manifests with numbness and tingling in the thumb, index finger, middle finger, and half of the ring finger.  The pinky finger is not involved because it has a different nerve providing sensation input.  The age of onset of symptoms is highly variable and I have treated patients in their early 20s to their late 90s with this condition. In the early stages of the condition, patients will describe numbness and tingling in the affected fingers that is not consistent.  Symptoms can be mild and last for several seconds to minutes.  As the condition progresses, the main reason that will drive patients to seek care is numbness and tingling in the affected fingers that mostly occurs at nighttime. Initially patients may have symptoms that wake them from sleep one or two times per week.  However, it can become so severe that patients will wake multiple times throughout the night every night of the week.  This can be extremely disconcerting to have such disrupted sleep. Moreover, once patients wake from sleep due to the symptoms, they may have significant difficulty going back to sleep as a result of the severe numbness.  Many patients will describe needing to shake their hand or allow their hand to hang over the edge of the bed in order to get relief.  In severe cases of carpal tunnel syndrome, patients may also have consistent numbness in the affected fingers throughout the day that does not cease. In addition to numbness and tingling of the fingers, there can be associated muscle symptoms as well since the affected nerve provides input to muscles of the thumb. The muscle symptoms are not as easily recognized due to their subtlety when compared to the numbness. The muscle symptoms include difficulty with dexterity such as handwriting, handling coins, buttoning a shirt, or grabbing a water bottle. These symptoms typically only manifest in severe cases of carpal tunnel syndrome that have gone untreated.

               For us as hand surgeons, the diagnosis of carpal tunnel syndrome in the office is relatively easy and can usually be determined by the patient’s history and physical examination.  Your surgeon may perform a physical exam maneuver such as tapping firmly in the area of the nerve, which may cause “shock-like” sensations to the spread to the fingers. Another test involves placing firm, steady pressure over the nerve to reproduce the symptoms. Once the diagnosis is made, many hand surgeons will also send patients for electrodiagnostic testing or an “EMG”. This stands for electromyography. This test involves a separate visit with an experienced physician who regularly performs these studies. The test can also be used to diagnose other nerve abnormalities in the arms or legs. The results of the test will typically grade carpal tunnel syndrome as mild, moderate, or severe. The patient’s symptoms in combination with the test results typically guide the surgeon in choosing treatment.

               Treating carpal tunnel syndrome generally follows an algorithm always starting with nonsurgical treatment in the form of anti-inflammatory medications, braces for nighttime, and cortisone injections.  However, in cases that are severe or where the nonsurgical treatment options do not offer relief, then surgery is often required.  So, when is carpal tunnel syndrome severe enough for surgery?

               I recommend surgery to patients with severe symptoms such as significant sleep deprivation and disturbances, any muscle weakness, and to those who have gotten no relief of symptoms with at least 6-8 weeks of the nonsurgical treatment choices.  Surgery can be quite scary, but this is the most common surgery that I perform, as do most hand surgeons.  I first walk my patients through the process from start to finish in the office.  I want to know that my patients are comfortable with their decision to have surgery before they leave the office. Carpal tunnel surgery is done on an outpatient basis and no hospital stay is required.  Surgery can be performed in an outpatient surgery center in most cases.  I usually will recommend patients to have surgery under local anesthesia only, but this is certainly not required.  The local anesthesia method does not require the use of a general anesthetic, and therefore no preadmission lab testing  or fasting is required prior to surgery.  In many times patients can drive themselves to and from surgery.

               Preparation for surgery requires an understanding of the limitations after surgery.  A good support system with friends and family is always recommended to have help with recovery, especially since a surgical bandage is required to be in place for 10-14 days after the operation.  I allow my patients to use the hand for simple tasks immediately following surgery including eating, driving, typing, and writing.  Patients are asked not to do any heavy lifting or strenuous activities with the hand for about 2-4 weeks.  The surgery itself from start to finish only takes about 10-15 minutes in the operating room, and is used to relieve the pressure on the “pinched” nerve. The surgical incision is less than 1 inch in the palm of the hand. Dissolvable stitches and glue are used to repair the incision and as a result no stitches need to be removed at your first office visit with me about 2 weeks after surgery.  I allow patients to return to “normal” activities at about 2-4 weeks, but it is not uncommon to have soreness in the hand near the incision for several months.  Physical therapy is rarely needed following carpal tunnel release surgery. The surgery overall has a greater than 90% success rate, but it can take up to 1 year to see symptom relief after the surgery.  Some patients do not get complete relief of their symptoms if the symptoms are severe prior to surgery, but most patients will see improvement in their quality of sleep.  No surgery is without risks, but overall, the rate of complications following carpal tunnel release surgery is less than 1%.  Possible complications include bleeding, development of an infection, scar irritation, and nerve or tendon damage.

               Carpal tunnel surgery has a high rate of success, and it is the most common operation that I perform.  If you think you may have carpal tunnel syndrome, or if you have been diagnosed and have been putting off treatment, make an appointment with one of Rothman Orthopaedics’ Hand & Wrist specialists.

Dr. Kistler is an orthopedic hand and upper extremity surgeon who specializes in the treatment and care of all hand, wrist, and elbow conditions. He sees patients in Bensalem, PA; Newtown, PA; and Northeast Philadelphia.