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Carpal Tunnel Release

by Maria Adams, MS, MPH

Anatomy and Physiology
The wrist joint is made up of eight carpal bones and the two bones of the forearm, the radius and the ulna.

The median nerve supplies sensation to the thumb, index finger, middle finger, and half of the ring finger. It runs through the carpal tunnel, a narrow passageway in the wrist. The carpal tunnel is bordered by the wrist bones and a strong, rigid band called the transverse carpal ligament.

Reasons for Procedure
The median nerve shares the limited space inside the carpal tunnel with many tendons that pass through it to the fingers. If these tendons, or other structures within the tunnel, become inflamed and/or swollen, the median nerve may become compressed and irritated. This condition is known as carpal tunnel syndrome.

Carpal tunnel syndrome may be caused by: repetitive wrist strain, incorrect hand and wrist positioning, wrist injuries, rheumatoid arthritis, or hormonal or metabolic changes.

Symptoms include numbness, tingling, pain, and weakness in the affected hand. These symptoms usually occur in areas supplied by the median nerve: along the palm side of the thumb, first finger, middle finger, and half of the ring finger.

Some people also experience numbness and pain in the forearm. Many people find their symptoms are worse in the middle of the night while they're trying to sleep.

Treatments
Unless your case is severe, you will be advised to try conservative treatments before resorting to surgery. These may include: avoiding repetitive wrist motions, correcting hand and wrist positioning, applying ice, taking anti-inflammatory medications, doing physical therapy, ultrasound, or prescribed exercises, wearing a wrist brace, and/or having steroid injections to help settle the inflammation.

If you continue to have pain, weakness, and/or numbness despite these non-surgical therapies, a carpal tunnel release may be required. Carpal tunnel release surgery involves cutting the transverse carpal tunnel ligament that stretches across the wrist. This releases the pressure on the median nerve, relieving symptoms of carpal tunnel syndrome.

Procedure
During the weeks leading up to your procedure: Arrange for a ride to and from the hospital and for help at home as you recover. The night before, eat a light meal, and do not eat or drink anything after midnight. If you regularly take medications, herbs, or dietary supplements, ask your doctor if and when you need to temporarily discontinue them. Do not start taking any new medications, herbs, or dietary supplements before consulting your doctor.

Prior to the procedure, an IV line will be started and you may be given medications to help you relax. You will receive one of the following methods of anesthesia: general anesthesia that will put you to sleep for the duration of the operation; regional anesthesia that will keep you numb from the shoulder down; local anesthesia that will numb only the area of your wrist where the surgery is performed.

There are two types of carpal tunnel release procedures: Traditional open carpal tunnel release requires one large incision, from the palm of your hand to your wrist. Newer, endoscopic techniques require only two tiny "keyhole" incisions or ports, usually resulting in a less painful, shorter recovery period.

Carpal tunnel release surgery usually takes 30-90 minutes. In an open carpal tunnel release, your surgeon will make a 3-5 inch incision in your lower palm and wrist area. He or she will cut through the tissues of your palm and wrist to reach the transverse carpal ligament and cut it, creating more room for the median nerve.

In the endoscopic procedure, your surgeon will make two small incisions in the palm and wrist. He or she will then insert an endoscope with a miniature video camera into one incision and surgical instruments into the other. Looking at the video monitor, your surgeon will cut the transverse carpal ligament, freeing the median nerve.

After either type of surgery, the incisions are closed with stitches and wrapped in bandages. Your arm will be put into a splint and elevated to control swelling.

Risks and Benefits
Possible complications during carpal tunnel release include: damage to nerves or tendons in the wrist, wound infection, bleeding, and/or side effects from the anesthesia. Rarely, your surgeon may encounter unexpected problems during the endoscopic procedure and need to revert to the open procedure.

Possible complications following the surgery include: swelling and stiffness of the wrist, stiffness of the fingers, pain when making a fist or leaning on the wrist, scar tenderness, continued numbness, tingling, weakness, or pain, abnormal wound healing.

Benefits of carpal tunnel release include: decreased tingling and pain, and increased strength, in your wrist and hand; avoidance of permanent damage to the median nerve.

In carpal tunnel release, or any procedure, you and your doctor must carefully weigh the risks and benefits to determine whether it's the most appropriate treatment choice for you.

After the Procedure
After the surgery, you will be taken to the recovery area for monitoring. You'll be given pain medication as needed. Most patients are able to go home within 3-4 hours.

After leaving the hospital, you will be advised to: keep your hand elevated and apply ice periodically for 2-3 days; avoid lifting heavy things or straining your hand or arm until cleared by your surgeon; return to your surgeon in 7-10 days to have your stitches removed.

Call your doctor immediately if you experience: signs of infection, such as fever or chills, redness, swelling, increasing pain, excessive bleeding, or discharge from the incision sites, nausea or vomiting that lasts for more than two days, increased tingling or weakness in your hand, cough, shortness of breath, or chest pain. You may have to wear a brace or splint for several weeks after surgery. Complete recovery can take four weeks or longer, but the numbness or tingling in your hand and fingers should improve rather quickly. Your grip strength will also begin to return, but more slowly.

Sources:

  • Carpal Tunnel Decompression. Queensland Government website. Available at: http://www.health.qld.gov.au/informedconsent/ConsentForms/Ortho/c_t_d.pdf. Accessed February 19, 2004.
  • Carpal Tunnel Release. University of Iowa Health Care. Available at: http://www.uihealthcare.com/topics/bonesjointsmuscles/bone4241.html. Accessed August 6, 2003.
  • Carpal Tunnel Syndrome. American Academy of Orthopaedic Surgeons. Available at: http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=5&topcategory=Hand. Accessed August 6, 2003.
  • Carpal Tunnel Syndrome. American Society for Surgery of the Hand. http://www.assh.org/Content/NavigationMenu/Patients_and_Public/Hand_Problems_and_Diseases/Carpal_Tunnel_Syndrome/Carpal_Tunnel_Syndrome.htm. Accessed August 6, 2003.
  • Carpal Tunnel Syndrome. Oregon Health and Science University. Available at: http://www.ohsuhealth.com/plassurg/carp.asp. Accessed August 6, 2003.
  • Carpal Tunnel, Ulnar Tunnel, and Stenosing Tenosynovitis. Campbell's Operative Orthopaedics, 10th ed., St. Louis: Mosby, Inc., 2003. pp. 3761-3772.


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