What Is Carpal Tunnel Surgery?

In almost all situations, carpal tunnel surgery involves cutting ("releasing") the transverse carpal ligament on the palm side of the hand in order to relieve pressure on the median nerve in the wrist.

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).

Depending on factors like the complexity of the surgery and surgeon/patient preference, the operation may be performed under local anesthesia, with a regional block, or under general anesthesia.

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.

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 published in Current Review of Musculoskeletal Medicine.

Open Carpel Tunnel Surgery

• Fewer cases of nerve, arterial, or tendon injury (0.19% vs. 0.49%)
• Fewer cases of transient neuropraxia (0.25% vs. 1.25%)
• Scars are larger and tend to be more sensitive and obvious
• Less expensive ($1,200 vs. $1,900, approx.)
  
  

Endoscopic Carpel Tunnel Surgery

• Fewer complications per 1,000 surgeries (0.59 vs. 1.69 procedures)
• Faster recovery (typically six days shorter, in comparison)
• Faster return to work (about eight days sooner, in comparison)
• Scars are smaller and tend to be less sensitive or obvious

Generally speaking, 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).

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

Regardless of the approach used, the surgery is performed on an outpatient basis and usually takes around 10 to 15 minutes to complete.

Contraindications

A history of an adverse reaction to anesthesia may be a contraindication to carpal tunnel surgery. 

Beyond that, whether or not the surgery is recommended for you largely depends on the nature of your case and the extent to which carpal tunnel syndrome is affecting you.

The American College of Orthopedic Surgeons advises against pursuing carpal tunnel surgery based on a single concern, like diminished finger dexterity. Instead, they recommend that medical history and risk factors be assessed along with symptoms and test scores to make the appropriate decision.

Carpal tunnel syndrome sometimes arises during pregnancy. Since it almost always resolves after delivery, your healthcare provider may recommend that you wait until after you give birth to see if surgery is indeed necessary.

Potential 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:

• Median nerve injury, with symptoms ranging from transient neuropraxia (nerve pain with motor loss) to complex regional pain syndrome (chronic nerve pain affecting part or all of a limb)
• Nearby arterial or tendon damage
• Scar tenderness or pain
• Hypertrophic scar (a visibly raised scar)
• Post-operative infection

The risk of complications from carpal tunnel surgery is low (less than 0.5% of cases).

Purpose of Carpal Tunnel Surgery

The median nerve, which starts at the shoulder and extends down to the tips of the fingers, is one of the major nerves of the upper extremities. This nerve not only directs the contractions of muscles in the forearm and hand but provides sensation to the hands and fingers.

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

!!Carpal tunnel surgery is generally indicated when you fail to respond to conservative therapies after more than six months.!!

From a physiological standpoint, surgery should be pursued if carpal tunnel syndrome manifests with the following features:

• Severe chronic pain
• Inability to place the thumb in a perpendicular position (known as thenar muscle atrophy)
• Loss of finger dexterity
• Loss of protective sensation in the fingers and hand (meaning that they do not respond appropriately to stimuli that may cause injury)
• Loss of two-point discrimination, the ability to discern two separate objects touching the skin at the same time

By releasing the pressure on the median nerve, carpal tunnel surgery improves hand sensation and alleviates or reduces symptoms of numbness and tingling. Surgery also usually restores the functional status of the hand.

Pre-Operative Evaluations

Before scheduling carpal tunnel surgery, the orthopedic surgeon will perform tests to characterize the nature of your 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 computerized tomography (CT), magnetic resonance imaging (MRI), or X-rays. HRUS may be performed by the surgeon or an ultrasound technician at a different facility.

The healthcare provider 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 you look away
• 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. It is considered safe but does require preparation, not only with respect to the surgery itself but the recovery phase that follows as well.

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. 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 any morning medications. Within four hours of the operation, no food or liquids should be consumed, 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:

• Anticoagulants (blood thinners) like Coumadin (warfarin) and Plavix (clopidogrel)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, Advil (ibuprofen), and Celebrex (celecoxib)

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.

Be sure your healthcare provider is aware of all medications you are taking (prescription, over-the-counter, or recreational), as well as any herbs or supplements you use.

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 after your procedure.

Pre-Operative Lifestyle Changes

Although smoking in no way contraindicates carpal tunnel surgery, it can negatively affect 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 it.

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.

Day of Surgery : What to Expect

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

Accompanying the surgeon will be an operating nurse and, unless local anesthesia is being used, an anesthesiologist.

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.

You will be given the planned form of anesthesia:

For local anesthesia, an injection is delivered into the wrist; a tourniquet is placed on your arm to limit the amount of drug that enters the bloodstream.

For a regional block, an intravenous (IV) line is placed in your hand. A tourniquet is also used

If general anesthesia is being given, sedating medication that renders you temporarily unconscious and unable to feel any pain is inhaled or administered through an IV. Once you are asleep, an endotracheal tube is placed to provide airway and breathing support.

You will be in a supine (upward-facing) position on the operating table with your hand placed on a raised platform called a hand table.

During the Surgery

Once the anesthesia has taken full effect, the procedure itself can begin. Next steps depend on the type of carpal tunnel release you are having:

• 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. (Note: 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(s) 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 an hour to allow the anesthesia to wear off (this may take longer if you had general anesthesia). 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 it. 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 a covered 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 (mg) per day.

Healing

Prior to the removal of the sutures (around a week to 14 days after surgery), you will need to change the dressing as per your healthcare provider'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 (not too tight). Limit showers to no more than five to seven minutes.

Depending on your recovery progress, you may continue to wear a splint or brace for a month or so after surgery until you are fully healed. It's important to avoid heavy lifting and strenuous movements during this time.

When to Call a Healthcare Provider

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

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

Therapy

Your surgeon will refer you to an occupational therapist who will perform soft tissue massage around where the sutures were to reduce post-operative swelling.

To better cope with recovery and return to pre-treatment state, physical therapy should also 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.

Your 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.