Carpal Tunnel Syndrome

 Carpal Tunnel Syndrome is a common hand condition whereby the median nerve is compressed at the level of the wrist causing symptoms of numbness, pain and paraesthesia. In severe cases the hand can become weak with loss of dexterity as well as loss of protective sensation (inability to feel the difference between hot and cold). The symptoms can vary with severity and in mild cases a splint will suffice as treatment. In more established cases especially where there is evidence of neurological deficit (eg established numbness, reduction in dexterity, weakness and wasting of hand muscles) surgical release of the carpal tunnel is advised (carpal tunnel decompression (CTD)

See guidance to British Society for Surgery of the Hand re Carpal Tunnel Syndrome

https://www.bssh.ac.uk/userfiles/pages/files/Patients/Conditions/CTS/cts_leaflet_2016.pdf

Treatment options

Splint – wrist splint holding wrist at neutral worn at night for 8 weeks. This is the first line treatment for mild cases

Steroid Injection – your clinician will inject the carpal tunnel with local anaesthetic and steroid and this can be effective in mild cases where a splint has not helped. In more significant cases of CTS steroid injections only help temporarily. They can be used in a diagnostic manner (ie symptomatic but negative Nerve Conduction Study). They are not usually advised repeatedly or for significant compression.

Surgical Treatment – Carpal Tunnel Decompression (CTD)

CTD is a day surgical procedure performed in the operating room under local anaesthesia (you will be awake). The procedure usually takes about 20 mins to perform in total (anaesthetic and procedure time). An incision is made in the palm and the nerve is released and the wound closed with sutures (removed or trimmed at 2 weeks). A single post-operative visit for a wound review is required for most patients.

A bulky dressing is applied (fingers are free to use) and this is removed by the patient at 3- 5 days and the wound covered with a clean dry dressing.

Postoperatively, you are advised to elevate the hand most of the time for the first 5 days (put hand on pillow at night-time if possible). Finger movement is advised (fully straighten and make a full fist) to avoid stiffness. Using the hand for light tasks is advised but heavy lifting and vigorous use is discouraged for the first 2 weeks. No driving for c2 weeks

Consent – risks, alternatives to surgery, what happens if not treated?

All operations minor or major have some risks. For CTD there are small risks of infection, bleeding, tender scars, stiffness, swelling, nerve or vessel injury, and failure to improve. The chances of a poor outcome are very low (<1%) and the vast majority (>90%) will have an excellent result.

The aim of surgery is to reduce the symptoms of numbness and tingling. Sometimes patients experience other symptoms such as pain which are not attributed to CTS and may continue after surgical release and you should discuss this with your clinician.

If symptoms are severe or there is established neurological deficit it is unlikely that the symptoms will improve without surgery and the longer the compression, the less likely it is that the symptoms will improve. Therefore, in such cases prompt surgical release is advised (matter of weeks). If the nerve remains severely compressed then the hand can become weak and protective sensation can be lost (ability to tell difference between hot and cold).

Splints and injections are alternative to surgery for mild cases and your clinician will advise when surgery is the best course of treatment.

Before embarking on surgery ensure you understand the following 

Benefit of surgery for you

Alternatives to surgery

What will happen if you don’t have surgery

The risks of surgery

Post-op care Elevate your hand above heart level most of the time but especially for the first few days and move and use your fingers. Avoid heavy lifting but typing and light use is permitted. Excessive post-op pain is not expected and usually paracetamol and ibuprofen for the first few days will suffice.

Remove the bulky dressing at 3-5 days post-op.

Keep the wound clean and dry until the 2 week post-op review when the stitches will be trimmed or removed by the nurse.

No driving for 2 weeks. Most patients require 1-2 weeks off work but some heavy physical workers may require 3-4 weeks.

No hand-held sports for about 4 weeks. Although quite a lot of activity is possible after 2 weeks, the hand will feel weaker than usual for c8 weeks. Swimming and running are fine after c 2 weeks.

Scars can sometimes be tender but the vast majority will become less sensitive with time and scar massage with moisturiser or baby oil can be therapeutic.

Overall the hand should improve day by day and if this is not the case get in touch with your clinician.