CARPAL TUNNEL SURGERY
What is carpal tunnel syndrome?
The carpal tunnel is a narrow space at the front of the wrist. The tendons that bend the fingers and wrist pass through this space. A tough ligament sheet covers the carpal tunnel and prevents the tendons bow stringing at the wrist when it is bent. The median nerve passes through the tunnel to the hand. Space in the carpal tunnel is limited. Any swelling of tissues or fluid retention tends to increase the pressure within the tunnel and compress the median nerve and interfere with working of the nerve. This nerve gives sensation to the thumb, index, middle and half of ring finger and also works the small hand muscles to the thumb. The nerve to the little finger comes to the hand outside the tunnel and so its sensation is not affected.
When the median nerve is compressed in the carpal tunnel often the first symptoms are pins and needles in the longer fingers, worse at night. As the pressure continues the sensation becomes blunt in the 3 ½ fingers, causing people to be clumsy, drop things or burn the finger. Later the muscles are affected and working with the thumb becomes clumsier.
What are the Causes of carpal tunnel syndrome?
The cause of carpal tunnel syndrome is not fully understood in many of the cases, but it happens when there is a pressure on the median nerve.
It is often associated with the following:
Fluid retention in pregnancy (this tends to get better after delivery), Fractures and dislocation at the wrist, Wrist arthritis, Diabetes & underactive thyroid. In vast majority of cases the cause is unknown!
How is carpal tunnel syndrome Diagnosed?
Your doctor will make a diagnosis based on an examination and description of your symptoms and if required, a Nerve test. The vast majority of cases can be diagnosed by a clinical examination and nerve conduction is not required.
Nerve Conduction Study/Test (NCS)
Nerve and muscle tests are usually carried out to confirm the diagnosis in doubtful cases. Nerve tests assess how well a nerve is conducting electrical signals. The nerve is stimulated by a small electrical impulse, and then the time it takes for impulse to travel along the nerve is measured. A probe is held against the skin over the nerve. An electrode placed further along the skin records the electrical impulse. Slowing of the nerve impulse in the carpal tunnel is the evidence for CTS.
However as are many things in medicine nothing is 100% certain. Approximately 8% of people with normal NCS have CTS and a considerable number of patients with severe CTS on the nerve test have no symptoms whatsoever!
How can it be treated?
There are a number of different treatment options for carpal tunnel syndrome
· Bracing the affected wrist with a splint – ‘Carpal tunnel splint’ is available from Chemists and also over the internet, e-bay etc. (Google search- carpal tunnel splint)
· Non-steroidal or anti-inflammatory painkillers such as aspirin and ibuprofen are useful for relieving symptoms, albeit temporarily.
· Steroid injections can be given into the wrist reduce inflammation in the body’s tissues. They are not always suitable for people with diabetes. They can work for an average of 3 months
Doing nothing – some elderly patients may decide to live with the clumsiness if there is no pain or paraesthesia
Surgery
This is the gold standard treatment as it cures the condition.
If the symptoms of carpal tunnel syndrome are persistent, surgery may be required. If there is definite numbness or weakness of the small muscle of thumb, it is better to operate. If there is definite neurological loss, it may progress to irreversible nerve ‘death’. All surgical procedures aim at taking the pressure of the nerve by cutting the ligament sheet strangling the nerve. The ligament then reforms by process of natural healing but is more lax than before.
Surgery usually takes place as a day-case and it is done numbing the area with a local anesthetic injection.
Post Operative recovery
Pins and needles are usually relieved over-night. Skin wound heals in 1-2 weeks and internal healing takes about 6 weeks. Minor gaping of the wound sometimes occur due to the thickness of palm skin and is not due to infection. Scar tenderness on lifting or heavy work may persist for up to 6 months. Sensations usually return in 6-8 months.
It is important to make a fist and open hand fully to put the fingers through full range of movement straight after the operation and continue this exercise until the hand is normal.
You can expect to drive in 3 weeks and do manual work in 6 weeks. It usually leaves a small scar. However, the scar may be sore for some time after surgery.
If the operation is carried out on somebody who has had the syndrome for a long time – particularly if there is a lot of muscle wasting and loss of sensation – there may be only partial recovery. But even in this situation the pain is usually considerably reduced.
What are the complications associated with this procedure?
Although the operation of carpal tunnel release is very safe operation in experienced hands, no operation is without small complications rate
The possible complications are bleeding, infection, stiffness, and pain at the scar and rarely nerve damage. A very rare complication is called Complex regional pain syndrome (CRPS) where the fingers and wrist can become very painful red and stiff. CRPS, if severe can lead to many months or years of pain & stiffness requiring significant treatment in the hospital and permanent stiffness. The best way to prevent it is by active early movement of the fingers.
Infection occurs in about one in 100 people. Usually it is superficial and heals quickly. Deep Infection is extremely rare & can lead to many weeks of treatment , pain and a poor result. It can also lead to sepsis and loss of life.
Accidental nerve injury happens in one in 1000 operations. This will require nerve repair in hospital. It can result in permanent loss of use of the hand, numbness and nerve pain.
Pillar pain and Scar tenderness can persist for many months or years. Pillar pain is deep pain and tenderness at the base of the ball of thumb and little finger. We do not know why this happens: it can be intrusive pain for day to day activities, but generally gets better in about 6 -9 months.
Occasionally the wrist loses strength because the carpal ligament is cut.
Patients may need physiotherapy after surgery to restore wrist strength.
Some patients may need to adjust job duties or even change jobs after recovery from surgery.
Complications associated with Local Anaesthetic : Local Anaesthetic toxicity or allergy can be life threatening. Please tell the doctor or the nurse if you had any reaction to local anaesthetic injections before.
Can there be a recurrence?
Recurrence of carpal tunnel syndrome following treatment is rare. Majority of the patients recover completely.
The Results of operation.
The vast majority of patients are happy with the results of operation, but there is no guarantee or warranty that the operation will result in improvement of symptoms.
About 80% of patients will have good or excellent results. Another 10-15% will have good improvement. In another 4% there is no change in symptoms. In under1% of patients, the results are poor due to complications and they would wish they never had gone in for the operation.
People who smoke and those with mental health problems seem to have poorer symptom improvement.
Double crush and Neck Spondylosis. The median nerve starts from the spinal cord in the neck and travels all the way to the fingers. Another reason for lack of improvement is the pinching of the nerve in the neck due to spondylosis, which can also cause similar pins and needles in the fingers. Sometimes the nerve is pinched in both the neck and wrist, so called double crush. Operating on the wrist removes the pinch there; usually results in some improvement of pins and needles. If the symptoms are all due to Spondylosis, carpal tunnel operation will not give any improvement.
Advanced CTS. If the nerve is already damaged by long standing pressure, chances of recovery of sensation and power of thumb muscle bulk is bleak. Operation is still worthwhile to prevent further damage or to relieve troublesome pins and needles or burning pain.
Key Points are
This procedure can be efficiently done at St Luke Surgery and it is important to see your doctor early for the best chance of recovery.
It is important to see your doctor early for the best chance of recovery.
To watch the operation click this link
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