Carpal Tunnel Syndrome

There are so many myths and so much misinformation regarding carpal tunnel syndrome (CTS) that I thought it might be good for a hand surgeon to go through the facts. Here are some common questions that I often hear:

What is the carpal tunnel?

The carpal tunnel is a passage for the median nerve (one of the major nerves to your hand) and the nine tendons that flex (bend) your fingers and thumb. It is located under the base of your palm. It has rigid, unyielding boundaries: Its back and sides are made of bone and the front is made up of the very thick transverse carpal ligament.

What is carpal tunnel syndrome?

Carpal tunnel syndrome occurs when the median nerve becomes compressed in the carpal tunnel. The carpal tunnel has a limited amount of space. Therefore, anything that takes up too much space in the carpal tunnel can compress and damage the median nerve. Carpal tunnel syndrome is, pure and simple, a space problem: there’s too much stuff in too little space. The most common thing that takes up too much space is the lining of the nine tendons, which can swell up.

What are the symptoms of carpal tunnel syndrome?

The symptoms of carpal tunnel syndrome come from irritation of the median nerve. People with carpal tunnel syndrome feel that their fingers become “numb”, “fall asleep”, or have “pins and needles” in them. This is often worse at night and when driving, writing or gripping objects. As carpal tunnel syndrome advances the fingers may permanently lose sensation. With more advanced carpal tunnel syndrome, some of the muscles in the hand may become weak can atrophy (die).

Carpal tunnel syndrome is usually worst at night, or upon awakening in the morning because we all sleep with our wrists flexed down, which further “pinches” the median nerve. If you wake up at night with your hand numb or painfully asleep, and have to “shake out” your hand to get relief, you’ve got carpal tunnel syndrome. This is why splinting the wrist at night often helps people with mild carpal tunnel syndrome – it keeps the median nerve from getting pinched while you sleep. The other reason why carpal tunnel syndrome is worst at night is because we tend to swell more at night. This swelling takes up space, further compressing the median nerve.

How is the diagnosis of carpal tunnel syndrome made?

The diagnosis of carpal tunnel syndrome should be made by your physician talking to you and examining your arm. Occasionally, there are other places in the arm where the median nerve can be compressed, which can lead to symptoms very similar to carpal tunnel syndrome. It is also important to determine whether or not the ulnar (funny bone) nerve is involved.

Nerve conduction studies are usually obtained, mainly to confirm the diagnosis of carpal tunnel syndrome. However, these studies are not perfect. In fact, they fail to diagnose approximately 20-33% of people with carpal tunnel syndrome. In the event that your history and physical examination strongly suggests carpal tunnel syndrome, but the nerve conduction study is negative, a steroid injection is indicated. An injection into the carpal tunnel is probably a better diagnostic test than the nerve conduction study. If the injection helps your problem, even for only a few days, then you almost certainly have carpal tunnel syndrome.

How is carpal tunnel syndrome treated?

Unless your carpal tunnel syndrome is causing constant symptoms or permanent nerve damage, initial treatment is often wrist splinting at night. If that doesn’t work, CTS should be cured by carpal tunnel release, which is a quick outpatient procedure. During a carpal tunnel release, the transverse carpal ligament that compresses your median nerve is cut. By cutting this ligament 25% more room is created for your median nerve, relieving the pressure on it, stopping the progression of the disease and allowing the nerve to heal. Unless irreversible nerve damage is already present, this decreases the symptoms of carpal tunnel syndrom in over 95% of patients.

Are all Carpal Tunnel Releases the Same?

An endoscopic carpal tunnel release is done through smaller incisions, with less pain, less suffering and a quicker return to work and other activities compared to open surgery. There are two types: 1) A one-incision endoscopic carpal tunnel release and 2) a two-incision endoscopic carpal tunnel release. The two-incision endoscopic carpal tunnel release puts a scar in both the wrist crease and in the palm. While it’s an improvement over the open carpal tunnel release, the wound in the palm still causes additional discomfort. The single-incision endoscopic carpal tunnel release is the least invasive technique. The incision is made in your wrist crease, which tends to hide it, and there is no incision in your palm. This leads to decreased palmar tenderness. Most patients return to work and other worthwhile activities sooner following single-incision endoscopic carpal tunnel release compared to following two-incision endoscopic carpal tunnel release.

How soon can I “get back” after Endoscopic Carpal Tunnel Release?

You can type and use computers as much as you want starting the day after surgery. You can do as much other activity as you want, but if you want to minimize pain and swelling, you should probably avoid heavy lifting and gripping for 4-6 weeks. You won’t damage yourself, but this stress will cause extra pain, discomfort and swelling that most people would rather avoid. You need to keep the wound clean and dry for 4 days. After 4 days you can remove your dressings and shower, but don’t submerge the incision under water for 10 days. There are no stitches to remove (they’re buried and absorbable).