Surgery

The traditional method: open release

The traditional surgical method is the open release. This involves making a long two- to four-centimetre incision in the palm of your hand in order to cut the transverse carpal ligament and make the tunnel bigger. This technique requires your surgeon to “sacrifice,” or unnecessarily cut, certain parts of your hand that are not related to the condition, including the skin, subcutaneous fatty issue that often contains little nerve fibres, and the muscle just above the transverse carpal ligament. Only then will they have access to the right ligament.

This method generally relieves nerve compression symptoms, but it has several drawbacks. For one, it unnecessarily sacrifices important anatomical structures, and the scarring period is considerably longer. There is also an increased risk of scar tissue (adhesions) and stiffness after surgery. The scar on the palm can be unsightly and extremely sensitive for months. Plus, patients commonly complain about a loss of strength after open releases. The traditional method is usually only performed on one hand at a time so patients can use the other hand for personal hygiene. Patients with bilateral carpal tunnel usually have to wait at least three to four weeks after their first surgery before operating on the second hand.

Minimally invasive surgery: The endoscopic method

The endoscopic technique is newer, more sophisticated, and less invasive, allowing surgeons to cut just the transverse carpal ligament without making an incision in the palm. This limits surgical trauma, since it leaves the skin, delicate subcutaneous fatty tissue, and hand muscles intact. The procedure involves making a very small incision in the wrist, which allows the surgeon to insert a small, high-definition camera into the carpal tunnel and get a clear view of the transverse carpal ligament. To lengthen the ligament, the surgeon will cut it with a small retractable blade, using the camera as a guide.

Endoscopic procedures are very safe and allow patients to recover much more quickly with less pain, stiffness, and a lower risk of painful scarring on their palm. The risks of this technique are so much lower that surgeons can operate on both hands during a single procedure. Patients recover four times faster than with traditional open surgery.

• Infections: Infections are rare but can occur whenever there is an incision in the skin through which bacteria can enter. These bacteria can multiply and cause an infection. Fewer than 1% of patients experience infections after a surgery like this, and the percentage is even lower with less invasive procedures that damage less tissue. Problems with healing are rarer with endoscopic surgery.
• Stiffness: The wrist may be stiff after surgery as the incision heals and scar tissue forms. Stiffness is very rare after endoscopic procedures because patients are able to move their hands right away. Finger and wrist stiffness is uncommon. Patients also rarely need physiotherapy after endoscopic carpal tunnel releases. The opposite is true after traditional surgery, when doctors often prescribe several weeks of physio.

• CRPS: CRPS (complex regional pain syndrome) is a painful disorder where the body reacts disproportionately to a painful injury or trauma, such as surgery. This complication is rare after carpal tunnel surgery and even rarer after endoscopic releases because they are less aggressive and cause less damage. It’s important for your hand specialist to recognize and treat any symptoms of CRPS.
• Nerve lacerations: Nerve lacerations are a rare complication that refers to partially or completely cutting the median nerve or one of its branches. This is why choosing a highly experienced surgeon is crucial. A cautious surgeon won’t hesitate to switch to the open technique if a patient isn’t a good candidate for endoscopic surgery.

• Incorrect diagnosis: Was carpal tunnel syndrome the right diagnosis? CTS symptoms can be mistaken for those of another condition, such as lacertus syndrome, neuritis (nerve inflammation), polyneuropathy, or cervical radiculopathy (a pinched nerve). Patients might also have double crush syndrome, where the median nerve is compressed in more than one spot. All too often, neurological exams for carpal tunnel are limited to the wrist but should extend to the entire arm. Surgeons should also take the patient’s complete medical history into account to determine all potential risk factors, such as diabetes, hypothyroidism, neck pain, and weak fingers.
• Poorly performed surgeries: One of the possible causes for a failed surgery is an incomplete release of the transverse carpal nerve. Thankfully, this rarely happens when an accomplished hand surgeon is performing the procedure. Complications can also occur during surgery, such as when the median nerve or one of its branches, such as the recurrent branch or the palmar cutaneous branch, is damaged during the procedure. The palmar arch (which contains arteries) and flexor tendons, which bend the fingers, are also at risk for damage. Some patients also have anatomical variations that put them at a higher risk of injury during surgery. Every procedure should be performed by an experienced surgeon who will pay attention to these risks. The more experienced the surgeon, the lower the risk of complications

• Bad luck: It’s impossible to predict all complications. For example, fewer than 1% of patients get infections. It can take longer to recover if the wound has trouble healing. Some patients even develop painful or hypertrophic (thick and raised) scars. Chronic nerve pain, such as complex regional pain syndrome (CRPS), can also occur, even though this is rare after carpal tunnel surgery. Some patients will experience pillar pain on the sides of the incision in the palm after the transverse ligament is cut. This pain can last for months after their procedure. It usually goes away with time, but in some cases, it can be permanent.
• Nerve dysfunction: Sometimes, injured nerves have trouble bouncing back from surgical releases, even when they’re done perfectly. This can be caused by permanent nerve damage after severe nerve compression or living with carpal tunnel for too long before getting the necessary treatment. In some cases, patients receive too many cortisone injections to manage their symptoms without treating the root cause, which can have permanent consequences. Doctors use nerve conduction velocity tests to evaluate nerve function before and after surgery. The results of these tests can help determine how much the nerve has been affected before performing surgery. However, these tests do not provide any guarantee that nerve function will return to normal.