Carpal Tunnel Surgery: Everything You Need to Know

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Carpal tunnel surgery, also known as carpal tunnel release (CTR) or carpal tunnel decompression surgery, is used to treat carpal tunnel syndrome. Carpal tunnel surgery occurs when one of the major nerves in the wrist becomes pinched, causing numbness, tingling, and shooting pains in the fingers as well as the general weakness of the hand muscles. When these symptoms become persistent or do not respond to conservative therapies (such as wrist splinting, steroid injections, and nonsteroidal pain relievers), your doctor may recommend carpal tunnel surgery.

What Is Carpal Tunnel Surgery?

Carpal tunnel surgery is performed to release pressure on the median nerve in the wrist. The median nerve is one of the major nerves of the upper extremities, which starts at the shoulder and extends downward to the tips of the fingers. The median nerve not only directs the contractions of muscles in the forearm and hand but also provides sensations to the hands and fingers.

When the median nerve is compressed in the carpal tunnel (a narrow passageway from the wrist to the hand made of tendons, ligaments, and bones), symptoms of carpal tunnel syndrome can develop and, over time, become chronic.

Carpal tunnel surgery can be performed as an open surgery (involving a scalpel and large incision) or minimally invasive endoscopic surgery (involving a narrow scope and operating equipment with a single small incision). The surgery is performed on an outpatient basis and usually takes around 10 to 15 minutes to complete.

Indications and Contraindications

There are no specific contraindications for carpal tunnel surgery given that the chronic compression of the median nerve can lead to permanent and severe nerve damage. Even so, there are general indications as to when carpal tunnel surgery is appropriate.

Broadly speaking, carpal tunnel surgery is recommended when you fail to respond to conservative therapies. From a physiological standpoint, the surgery should be pursued if carpal tunnel syndrome manifests with the following features:

  • Severe chronic pain
  • The inability to place the thumb in a perpendicular position (known as thenar muscle atrophy)
  • The loss of finger dexterity
  • The loss of "protective sensation" in the fingers and hand (meaning that they do respond appropriately to stimuli in a way that may cause injury)
  • The loss of "two-point discrimination" (the ability to discern two separate objects touching the skin at the same time)

The American College of Orthopedic Surgeons advises against pursuing carpal tunnel surgery based on a single but instead recommends that medical history and risk factors be assessed along with symptoms and test scores to make the appropriate decision.

Imaging tests, such as computed tomography (CT) or magnetic resonance imaging (MRI) scans, are generally not useful in determining whether carpal tunnel surgery is appropriate or not.

Possible Risks

Carpal tunnel surgery is one of the most commonly performed surgical procedures in the United States. While generally considered safe and effective, it still carries risks, some of which may make the condition worse rather than better.

Possible risks and complications of carpal tunnel surgery include:

The risk of complications from carpal tunnel surgery is low, occurring in less than 0.5% of cases.

Purpose of Carpal Tunnel Surgery

The aim of carpal tunnel surgery is pretty straightforward: to relieve pressure on the median nerve. In almost all situations, this is accomplished by cutting (or "releasing") the transverse carpal ligament on the palm side of the hand.

The challenge of carpal tunnel surgery is that the ligament needs to be severed without not causing harm to nearby structures. In up to 90% of cases, this is achieved.

One of the factors influencing response rates (as well as the risk of complications) is the choice of surgeries. In recent years, many surgeons have turned to endoscopic carpal tunnel release as an alternative to traditional open surgery, which has been shown to require shorter recovery times and allow people to return to work sooner.

Even so, only around 20% of cases in the United are treated endoscopically, according to a survey conducted by the American Association for Hand Surgery.

This is not to suggest that endoscopic surgery is "better" than open surgery. In the end, there are pros and cons to each that need to be weighed with your doctor, as detailed in a 2019 review in Current Review of Musculoskeletal Medicine.

Open Surgery
  • Recovery tends to take six days longer

  • Return to work tends to occur eight days later

  • Scars are larger and tends to be more sensitive and overt

  • Nerve, arterial, or tendon injury occurs in 0.19% of cases

  • Transient neuropraxia occurs in 0.25% of cases

  • Overall incidence of complications is higher (1.69 per 1,000 surgeries)

  • Cost is lower (around $1,200)

Endoscopic Surgery
  • Recovery is typically six days shorter

  • Return to work tends to occur eight days sooner

  • Scars are smaller and tend to be less sensitive or obvious

  • Nerve, arterial, or tendon injury occurs in 0.49% of cases

  • Transient neuropraxia occurs in 1.25% of cases

  • Overall incidence of complications is lower (0.59 per 1,000 surgeries)

  • Cost is higher (around $1,900)

In the larger scheme of things, open and endoscopic carpal tunnel surgeries have similar response rates. Although the endoscopic approach allows for faster recovery times with less scarring, open surgery is associated with slightly fewer complications and costs less.

Consideration also needs to be given to the skill and experience of the surgeon. Many surgeons do not perform endoscopic surgery simply because they are skilled at performing open surgery (including so-called "mini-open" releases that use the smallest possible incision).

Carpal Tunnel Syndrome Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Doctor Discussion Guide Man

Pre-Operative Evaluations

Before scheduling carpal tunnel surgery, the orthopedic surgeon will perform tests to characterize the nature of the condition. This includes getting a cross-sectional image of the carpal tunnel with accurate measurements. This will help direct how the surgery is approached and limit the size of the incision.

The imaging is typically performed with high-resolution ultrasonography (HRUS), which is better able to visualize peripheral nerves (those involved in sensations and movement) than CT scans or X-rays. HRUS may be performed by the surgeon or an ultrasound technician at a different facility.

The doctor may also perform a quality of life (QoL) assessment to establish how severely carpal tunnel syndrome has impacted your life. Questions may include:

  • Are you able to turn a key in a lock?
  • Are you able to pick up coins from a table?
  • Are you able to write with a pen or pencil?
  • How much difficulty do you have opening a child-proof bottle?
  • How much difficulty do you have removing wrappings from small objects?

The answers are rated on a scale of 1 to 5 (1 meaning "I can't do it" and 5 meaning "no difficulty"). The results not only help characterize the nature and severity of your condition but can be used at a later date to determine how well you have responded to the surgery.

Other in-office tests include the Semmes-Weinstein monofilament test (which identifies the loss of protective sensation by rubbing a filament across the hand or finger as the individual looks away) and the two-point discrimination test (in which two pointed objects, like the ends of a tweezer, are applied to the skin to see if you can discern two different areas of sensation).

How to Prepare

Carpal tunnel surgery is an outpatient procedure usually performed under local anesthesia or with a regional block. Surgeries that are more complex, such as those that involve a prior traumatic injury, may require general anesthesia.

Carpal tunnel surgery is considered safe but does require preparation, not only with respect to the surgery itself but also to the recovery phase that follows.

Location

Carpal tunnel surgery is performed in the operating room of a hospital or a dedicated surgical center. Some orthopedist offices are equipped with surgical facilities that can handle uncomplicated procedures.

What to Wear

Even though the surgery is limited to the wrist area, you will be asked to change into a hospital gown. Wear clothes that are loose-fitting and easy to take off and put back on, such as a tracksuit and mocassins. Leave any valuables at home, including jewelry and watches.

You will also be asked to remove eyeglasses, contact lenses, hearing aids, dentures, and piercings prior to the surgery.

Food and Drink

Do not eat or drink anything after midnight the night before the surgery. You will be allowed to take a few sips of water to take your morning medications. With four hours of the operation, no food or liquids should be taken by mouth, including gum or hard candy.

Medications

In advance of the surgery, you will need to stop taking certain medications that promote bleeding and slow wound healing. These include:

Surgeons will generally advise you to stop taking NSAIDs seven days before surgery and anticoagulants three to four days before surgery. You may also need to avoid taking some of these medications for up to two weeks following surgery.

What to Bring

To check-in at the hospital or surgicenter, you will need to bring a driver's license (or some other form of government ID) as well as your insurance card. If the upfront payment of coinsurance or copay costs are required, ask the office which form of payment they accept.

In addition, you will need to bring a friend or family member to drive you home. Even if local anesthesia is used, you will likely be in no condition to drive yourself home safely with one hand.

If general anesthesia is used, under no circumstance should you drive or operate heavy machinery for the first 24 to 48 hours.

Pre-Operative Lifestyle Changes

Although smoking in no way contraindicates carpal tunnel surgery, it does not aid with your recovery. Tobacco smoke causes the generalized constriction (narrowing) of blood vessels, restricting the amount of blood and oxygen that reaches tissues. This can slow healing and increase the risk of scar formation and scar sensitivity.

Studies have shown that smoking not only increases the severity of carpal tunnel syndrome before surgery but also increases the rate and severity of symptoms after surgery.

Surgeons generally recommend the cessation of smoking two weeks before and after surgery to ensure you attain the optimal benefits of a carpal tunnel surgery.

What to Expect on the Day of Surgery

Carpal tunnel surgery can be performed by an orthopedic surgeon or a specialist known as a hand surgeon who is board-certified as a general surgeon and has undergone additional training in hand surgery.

Accompanying the surgeon will be an operating nurse and anesthesiologist. If the surgery is performed under local anesthesia, an anesthesiologist is not needed.

Before the Surgery

After you check-in and sign the necessary consent forms, you will be taken to the back to change into a hospital gown. Vital signs will then be taken, including temperature, blood pressure, and heart rate.

If general anesthesia is to be used, an intravenous (IV) line will be inserted into a vein in your arm. For a regional block, an IV line is placed in your hand.

During the Surgery

For carpal tunnel surgery, you are placed in a supine (upward-facing) position on the operating table with your hand placed on a raised platform called a hand table.

In most carpal tunnel procedures, local or regional anesthesia is used. For local anesthesia, an injection is delivered into the wrist, while a tourniquet is placed on your arm to limit the amount of drug that enters the bloodstream. For a regional block, a tourniquet is also used, but the drug is delivered through the IV line.

General anesthesia is typically used when other surgical procedures are being performed alongside the carpal tunnel release.

Once the hand and wrist are numb, the release can be performed in one of two ways:

  • Open release: For this surgery, the surgeon cuts a roughly two-inch incision on the wrist. Conventional surgical instruments then sever the carpal ligament and enlarge the carpal tunnel. Surgeons trained in a mini-open release can perform the surgery using only a half-inch incision.
  • Endoscopic release: For this surgery, the surgeon makes two half-inch incisions, one on the wrist and the other on the palm. A fiberoptic scope (called an endoscope) is inserted into the wrist-side incision and guides the severing of the ligament in the palm-side incision. (Newer endoscopes have retractable cutting attachments in the neck, requiring only one incision rather than two.)

After the traverse carpal ligament is released, the wound (or wounds) are closed with sutures and covered with adhesive bandages called steri-strips. The hand and wrist are then splinted to immobilize them, although the fingers are allowed to remain free.

After the Surgery

Once the surgery is complete, you will be transferred to a recovery room and monitored for around one hour to allow the anesthesia to wear off. (People who have under general anesthesia may take longer.) The doctor will want to ensure that you can wiggle your fingers before you leave.

There will likely be pain and discomfort in your hand or wrist following carpal tunnel surgery, but the doctor will provide oral medications like Tylenol (acetaminophen) to help control the pain. Once your doctor gives you the OK, a friend or family member can drive you home.

Recovery

Once home, you will need to limit activity for the first 24 hours. To reduce pain, elevate the hand and wrist, and apply an ice pack every hour for no more than 15 minutes for the first day or two.

You can also take Tylenol every four to six hours to control pain, limiting your intake to no more than 3,000 to 4,000 milligrams per day.

Healing

You will need to keep the splint on your wrist until the sutures are removed a week to 14 days later. Even after the sutures are removed, you will need to treat your hand and wrist gently, avoiding heavy lifting or strenuous movements for the first four weeks.

Prior to the removal of the stitches, you will need to change the dressing as per your doctor's instructions, taking care not to get the sutures wet. When bathing or showering, place a plastic bag over the hand and wrist and secure it with a rubber band. Limit showers to no more than five to seven minutes.

During recovery, you may need to adjust job duties or even take time off from work to heal. Your doctor can refer you to an occupational therapist who can offer assistive aids and devices if needed.

When to Call a Doctor

Complications from carpal tunnel surgery are uncommon but can occur. Call your doctor immediately if you experience any of the following:

  • High fever (over 101.5 F) with chills
  • Increasing redness, pain, heat, or swelling at the surgical site
  • A foul-smelling, pus-like discharge from the wound

Coping With Recovery

To better cope with recovery and return to pre-treatment state, physical therapy should be pursued as soon as the sutures are removed. The physical therapist can help restore strength and range of motion with gentle exercises, which can also reduce scarring and scar sensitivity.

The physical therapist can also teach you simple exercises you can perform on your own while watching TV or sitting at your desk. These include:

  • Wrist extension stretch, in which you extend the arm with your palm down, grab the front of your fingers with the opposite hand, and gently pull them back to extend the wrist.
  • Wrist flexion stretch, in which you extend the arm with your palm up, grab the back of your fingers with the opposite hand, and gently pull them back to flex the wrist.

According to the American Academy of Orthopedic Surgeons, rehabilitation efforts should continue for three to four weeks after the sutures are removed and continue thereafter as maintenance therapy.

Long-Term Care

Most orthopedic surgeons will schedule a follow-up appointment four to six weeks after the surgery to assess your recovery. The visit may involve a repeat QoL test and other evaluations to assess your response to treatment.

it is important to keep any follow-up appointments your doctor schedules. If the symptoms are fully resolved after several months, ongoing medical care is generally not needed.

Although many people can return to work within a week or two of carpal tunnel surgery, it can take three to four months before you are fully recovered and up to a year before your grip strength is fully restored.

A Word From Verywell

As effective as carpal tunnel surgery can be, it should never be considered a "quick fix" for your condition. Even though the surgery takes only a few minutes to perform, it requires dedication and hard work for weeks and months to ensure a full and sustained recovery.

If your doctor tells you that you don't need carpal tunnel surgery, you can delay prevent surgery by avoiding repetitive motions of the hand and wrist, using an orthopedic brace whenever performing manual tasks, using ergonomic aids whenever possible, and doing routine hand and wrist exercises as prescribed by your doctor or physical therapist.pr

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