Carpal Tunnel Surgery: Endoscopic or Open Surgery

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Carpal tunnel syndrome is a condition that develops when one of the major nerves in the wrist becomes pinched. This nerve, called the median nerve, provides sensation and muscle function to the hand and fingers. The most common signs of carpal tunnel syndrome include numbness and tingling of the fingers, pain in the fingers, and weakness of the muscles of the hand.When carpal tunnel syndrome condition becomes persistent or does not respond to appropriate noninvasive treatment, your doctor may recommend surgery to relieve the pressure on the median nerve.

Goal of Surgery

The goal of carpal tunnel surgery is very straightforward: relieve pressure on the median nerve. In almost all situations, this is accomplished by cutting (or "releasing") the transverse carpal ligament in the palm of the hand. In some rare situations, something unusual is causing pressure on the nerves, such as a growth in the carpal tunnel. However, the vast majority of people find relief by simply cutting the ligament.

The question is how to cut this ligament completely to ensure pressure on the nerve is adequately relieved while not causing harm to nearby structures that should not be cut. Specifically, one common complication of carpal tunnel surgery is damage to one of the small nerves (or possibly even to the median nerve) in the wrist. This can lead to problems that may be even worse than the original symptoms.

In addition, avoiding damage to the surrounding soft tissues can help to speed recovery and prevent complications. Skin, connective tissue, muscle, and ligaments can all be damaged in the course of carpal tunnel release surgery. Trying to minimize the amount of damage to the structures can help to improve the recovery following carpal tunnel release.

Surgical Options

There are two major options when surgery is considered. One option is a traditional open surgery. In this procedure, a skin incision is made in the palm of the hand. The soft-tissues between the skin and the transverse carpal ligament are divided, and the ligament is directly visualized. It is important to see both ends of the ligament so that your surgeon can ensure that the ligament is completely released, and so that nearby nerves can be protected during the procedure. The length of the skin incision can be variable depending on your surgeon's preference, ability to see what needs to be seen, and the ability to adequately retract surrounding tissues.

The other surgical option is called an endoscopic carpal tunnel release. This surgery is also performed through an incision, but a much smaller incision that is over the wrist instead of the palm. A small camera is inserted just under the transverse carpal ligament, and the ligament is seen through the camera from its underside. A small cutting blade is deployed from the camera, and the ligament is cut while the surgeon watches on camera, again ensuring that nearby nerves are not injured.

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Which Is Better: What the Research Says

There have been many studies, including several meta-analyses, that have investigated whether endoscopic or open carpal tunnel release surgery is best. The data are clear on a few things.

  • People return to work faster when they have endoscopic carpal tunnel release compared to open carpal tunnel surgery. People who have an urgent need to return to work as quickly as possible, especially if they rely on hands for heavy lifting or gripping, often do best with endoscopic over open carpal tunnel surgery.
  • Grip strength is slightly better immediately after surgery in patients who have undergone endoscopic carpal tunnel release. While some surgeons have argued that this difference is not significant (meaning patients can't notice the difference), this may explain why people tend to return to work more quickly. After several months, this difference goes away.

There have been some concerns identified with endoscopic carpal tunnel release as well. One of the most concerning is a higher chance of nerve injury associated with this procedure. More recent studies seem to show that this concern is fading with time as surgeons become more experienced and the endoscopic equipment has improved.

There is also a concern about the cost of the endoscopic equipment. Traditional open carpal tunnel surgery uses very standard equipment and performing the surgery does not involve significant expenditures. Endoscopic carpal tunnel surgery requires expensive technology which may be a concern for some individuals.

Is Endoscopic Is Better? What Am I Missing?

Based on the data, it seems endoscopic is a better surgery. People have better grip strength and can be back to work faster. However, it's not quite that simple.

One variable that is hard to assess in studies is that open surgery has been modified over the years, and some surgeons are now able to perform the open surgery through a small enough incision that the cut in the skin is hardly any different in size from the endoscopic incision. This variation in technique, called a mini-open release, is thought by some surgeons to be even better than endoscopic surgery. Over time, these mini-open carpal tunnel surgeries can be compared to endoscopic surgery to see what differences (if any) show up between patients.

Traditional open carpal tunnel release does have some clear downsides. However, the endoscopic carpal tunnel release and mini-open carpal tunnel release may not be that different in terms of results. One of the most critical aspects of both of these procedures is the surgeon's experience. Surgeons who perform these procedures frequently have fewer complications and better results.

It's worthwhile to talk to your surgeon about your options and understand which procedure he or she performs. If you feel one of the other options would be better, request a second opinion from a surgeon who performs the alternative procedure.

A Word From Verywell

Carpal tunnel release surgery is one of the most common surgical procedures performed by orthopedists. Many carpal tunnel release surgeries are performed every day, and most patients have very successful results, no matter which type of surgery they have performed. That said, every patient wants a fast recovery without any risks or complications associated. Surgeons are constantly refining techniques to minimize the amount of damage that occurs at the time of surgery. Endoscopic carpal tunnel release is one way to minimize soft tissue damage at this time of surgery. Finding a surgeon who regularly performs this procedure and has significant experience will help to ensure that the risks of surgical intervention are minimal.

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Article Sources
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  1. Wipperman J, Goerl K. Carpal Tunnel Syndrome: Diagnosis and Management. Am Fam Physician. 2016;94(12):993-999.

  2. Sayegh ET, Strauch RJ. Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials. Clin Orthop Relat Res. 2015;473(3):1120-32. doi:10.1007/s11999-014-3835-z

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