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Carpal tunnel syndrome

Carpal tunnel syndrome is characterised by numbness and pins needles in the thumb, index, middle and ring fingers. It tends to come on at night and is worst in the mornings. It is very common in men and women and becomes more common with increasing age. It's not necessarily related to activities or occupation but it can have an association with vibrating tools.


Carpal tunnel syndrome is caused by compression of the median nerve which runs from the armpit to the hand and passes through a tunnel (the carpal tunnel) in the wrist before providing sensation to the fingers and movement to the thumb. If this tunnel becomes too tight, the median nerve is squashed which impairs its blood supply leading to a malfunction of the nerve which causes the symptoms. To begin with the compression and symptoms are intermittent, but over time they can become continuous. It is preferable to treat the condition before this stage because the nerve may become beyond recovery even after surgery. If the compression is very severe or prolonged, then the nerve that moves the thumb can be affected and this leads to wasting of the thumb muscles and weakness of the grip.


If your symptoms are intermittent and mild, then treatment is not necessarily essential. However, if symptoms become significant then wearing a wrist splint at night to stop your wrist bending may help. If this isn't successful, then a steroid injection in the wrist may cure mild cases. In most cases a steroid injection will give temporary relief of symptoms. It is my preference to inject local anaesthetic prior to the steroid injection as this makes the procedure more comfortable. The definitive treatment is a carpal tunnel release procedure which involves making a 1 inch incision in the palm followed by dividing the ligament that forms the roof of the tunnel that the median nerve is running through (flexor retinaculum). This procedure is usually performed under local anaesthetic but may be performed under general anaesthetic, particularly if it’s combined with other procedures.

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Carpal tunnel release surgery

On the day of the procedure I recommend you attend the hospital 30 minutes before the procedure time. This is so I can administer the local anaesthetic and give time for the anaesthetic and adrenaline to work. The combination of these medications gives excellent anaesthesia as well as stopping bleeding which means you do not have to wear a tourniquet on your arm. I also add bicarbonate to the solution so that it stings less. With the specific technique I use to administer the anaesthetic, the needle only needs to be inserted once and the injection is largely painless after this. If you are particularly worried about the injection you can apply some anaesthetic gel to the front of your wrist half an hour before the injection. Anaesthetic gel can be purchased in a pharmacy or online without a prescription. During the procedure you will lie on your back with your arm outstretched. The procedure takes about 20 minutes or so. I use a dissolving stitch under the skin to close the wound so that there are no stitches to remove. You will have an adhesive dressing on the wound and a bandage on top. You should take the bandage off your hand after about three days, or earlier if it feels too tight. The bandage provides comfort and prevents bleeding. The sticky dressing should be removed at about one week and thereafter the wound should be massaged to help soften the scar and to encourage the stitches to dissolve. You may see little pustules which can be mistaken for infection but are actually just the stitch dissolving. It's very important to keep your fingers moving.  Specifically you should fully straighten your fingers and make a full fist and this should be achieved by the end of the first week. It's very important to take painkillers throughout the first week such as regular paracetamol or co-codamol and ibuprofen or voltarol for breakthrough pain. Most patients don't need physiotherapy but if during the first week you feel you're struggling to get your movement back, please let my secretary know and we can arrange physiotherapy. Elevation of the hand is also important in the first week. Ideally the hand should be kept above the level of the heart for most of the time during the first week but the most important thing is to avoid the hand hanging down by your side.


You can use your hand more or less straight away for light activities such as holding a knife and fork, brushing your teeth and making a cup of tea. Over the course of the first week you'll be able to do more and more with the hand as the days go by. I'd recommend avoiding driving for the first week and also taking time off work or at least working with no expectation of using the hand. If you have a particularly manual job, then I recommend taking two weeks off work. If you play sports or go to the gym, you may need to wait until six weeks or before you can comfortably maintain a strong grip. Pain after surgery is normal. It does gradually subside and how quickly this occurs varies from patient to patient. You should not expect to be completely pain-free on returning to work after two weeks and it may take three months, sometimes more, for your hand feel pain-free entirely.

The risks of open carpal tunnel release are a tender scar, bleeding, delayed healing, infection, swelling, stiffness, pain with pressure on the palm (pillar pain e.g. getting out of a chair), nerve injury, incomplete relief or recurrence of symptoms. In general 85% of patients get good relief of symptoms, 10% have no change in their symptoms and about 5% can have worse symptoms including complex regional pain syndrome which is a condition of prolonged pain of the whole hand that is difficult to treat. You should be aware that a poor outcome from surgery would make work, hobbies and activities of daily living difficult or impossible temporarily and in a worst case scenario permanently. 

 

Carpal tunnel sydrome