When is it time for surgery?
If conservative treatment is unable to ease your symptoms, you have trouble doing your work or completing certain everyday tasks, or your doctor diagnoses advanced carpal tunnel, it’s time to think about surgery and consult a hand surgeon.
You should think seriously about surgery if your symptoms don’t get better.
What does surgery entail?
What types of surgery are there for carpal tunnel?
Once you and your doctor decide you need surgery, there are two types of carpal tunnel release: open release and endoscopic release. While these procedures produce the same result, there are major differences in terms of surgical technique and recovery.
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.
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Are there different endoscopic techniques?
What types of endoscopic techniques are there?
Doctors have been performing effective endoscopic carpal tunnel releases for decades. There are at least two different techniques. The more recent is the single-portal (single entrance) technique, which was preceded by the dual-portal (two entrance) technique.
Single-portal endoscopic technique developed by Dr. Agee
The newest endoscopic surgical technique is called the single-portal technique. It was developed by and named after Dr. John Agee and involves making a single short incision one centimetre long where the wrist bends. It requires specialized equipment, but has two main advantages: a single, very small incision in the forearm and a perfect view of the affected anatomical structures. The wrist remains in a straight, anatomical position for the entire procedure, which reduces surgical complications. The wrist extension used during the dual-portal technique described below displaces the median nerve.
Dual-portal endoscopic technique developed by Dr. Chow
The other endoscopic technique is called the “dual-portal” technique because it requires two incisions: one in the wrist and one in the palm. It’s also known as the Chow technique. Unfortunately, this technique requires that the wrist be hyperextended during the procedure, which can displace certain structures, especially the median nerve, which presses up against the transverse ligament. According to certain specialists, the risk of complications is slightly higher with this procedure than with the single-portal technique.
What are the advantages of
Endoscopic releases offer several advantages when it comes to comfort and productivity. Since it’s less invasive, it causes less pain and discomfort while also relieving symptoms, restoring hand function, and getting patients back to their day-to-day activities much faster.
- Local anesthesia: Endoscopic release is an outpatient procedure performed under local anesthesia. This allows for better patient care, in addition to limiting the inconvenience of fasting and the discomfort caused by anesthesia.
- Minimally invasive: As opposed to the open method, endoscopic procedures don’t damage the anatomical structures between the skin and the ligament. The incision is much smaller and doesn’t even require stitches or special post-operative care.
- Shorter procedure: The actual procedure in the operating room only lasts about 10 minutes. The patient can go home shortly after the procedure is over and start recovering right away.
- Faster recovery: Because there’s less trauma, endoscopic releases allow patients to get back to normal much quicker. They can start driving and working again four times sooner.
- Less pain: There is considerably less pain after endoscopic releases, so patients can lessen the unpleasant effects of taking narcotics.
- Treating both hands at once: The endoscopic method lets your surgeon operate on both hands during a single procedure, significantly shortening recovery time.
A comparison of these two surgical methods
|Open release||Endoscopic release|
|Method||3–4 cm incision in palm||1 cm incision in wrist|
|Procedure length||15 - 30 minutes||10 minutes|
|Able to operate on both hands at once||No||Yes|
|Scarring||Yes, often painful and hypersensitive for months||Minimal|
|Post-op adhesion and stiffness||Common||Rare|
|Return to normal activities||Several weeks post-op||24–48 hours post-op|
|Resumption of light work||2–3 weeks||48 hours|
|Resumption of heavy work||3–6 months||4–6 weeks|
|Risk of complications||Low to medium||Low|
|Risk of recurrence||Low||Low|
|Patient satisfaction||Medium to high||Very high|
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Recovery and time off after surgery
During your recovery, it’s important not to wear a splint. The nerve must be able to move and glide freely through the wrist immediately after surgery. The procedure causes internal trauma to the ligament that needs to heal. As scar tissue forms, the nerve could potentially get caught in it. To avoid that, it’s important to be able to move your wrist and fingers, and wearing a splint would prevent this. The less invasive the procedure, the less pain and swelling afterwards and the less discomfort patients will feel mobilizing their wrists to prevent adhesions.
Depending on the surgical technique and the patient’s job or hobbies, recovery can span from several days to several weeks or even months.
Patients who get endoscopic releases can return to work much faster after surgery. People with jobs that aren’t too physically demanding can get back to work after one to two weeks. People who do strenuous physical work should wait to heal for about six weeks before returning to work after endoscopic surgery. After traditional surgery, the recovery period is longer and can easily last three to six months per hand.
- Day-to-day activities and hygiene: After endoscopic surgery, patients can drive, dress, and feed themselves right after surgery, as soon as the anesthesia wears off. The endoscopic method leaves the palm untouched, whereas open surgery can leave a scar that can remain hypersensitive for weeks on a very exposed part of the hand.
- Exercise: How quickly patients start exercising again depends on the activity. For example, patients should wait about three to four weeks before biking or golfing. For things like push-ups, more strenuous exercise, or physically demanding jobs, patients should wait about four to six weeks after endoscopic surgery and three to six months after traditional surgery.
Return to exercise
|Open technique||Endoscopic technique|
|Golf||3 months||1 month|
|Tennis||3–6 months||4–6 weeks|
|Biking||3 months||4 weeks|
|Skiing||3 months||3 weeks|
|Yoga||3–6 months||4 weeks|
*Information for reference only. Results are not guaranteed. The amount of time it takes to recover and resume personal and professional activities can vary from patient to patient.
Carpal tunnel releases are very safe operations, but all surgical procedures have a small risk of complications. The best way to ensure your operation is a success is to go to an experienced surgeon who specializes in hand and arm 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.
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Long-term results and recurrence
Both traditional and endoscopic surgery effectively release the median nerve in the carpal tunnel. In most cases, the results are permanent.
However, in a small percentage of cases, symptoms can reappear several years later. This is known as recurrent carpal tunnel syndrome. Recurrences are often associated with an underlying condition, such as hypothyroidism, kidney failure, or diabetes, or caused by lifestyle factors like smoking, significant weight gain, or adhesions (scar tissue). The rate of recurrence reported by various studies varies greatly because they don’t define recurrence the same way. A reasonable estimate is between 5% and 10%.
It’s also possible that the median nerve is so compressed that even after release, it does not fully recover, only providing partial relief. In these cases, it isn’t a matter of a recurring case, since the term “recurrence” implies that symptoms went away. This is more common when the median nerve has been compressed for some time (months or years).
When nerve conduction tests or electromyograms are completed again after a release, it isn’t uncommon to see improved (but still irregular) nerve conduction. This is perfectly normal and isn’t a reason to operate again. Your doctor will only recommend another procedure based on a reappearance of symptoms and a new physical exam.
Causes for a failed carpal tunnel release
The vast majority of patients who undergo carpal tunnel surgery are pleased with their results. However, in rare cases, the procedure can fail, meaning it only partially relieves symptoms or even makes the condition worse. Carpal tunnel release surgery can fail for the following reasons:
- 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.
Different surgical techniques
When is surgery needed?
Surgical release is recommended when symptoms persist or get worse despite conservative treatment (braces, rest, stretching/exercises). Whenever patients experience weakness or a loss of feeling or motor skills, they should schedule surgery as soon as possible.
What types of procedures are there?
The traditional method, also known as the open method, involves making an incision in the palm and then cutting the ligament. Endoscopic releases use a small camera and thin surgical instruments inserted through a small incision right where the wrist bends to release the compressed nerve.
Why are endoscopic releases better?
Endoscopic releases offer several advantages when it comes to comfort and recovery. The procedure only takes a few minutes and doesn’t require stitches. Patients heal much faster, which means they can get back to normal sooner. Plus, the technique allows surgeons to operate on both hands at once.
Can surgery fail?
When performed by an experienced surgeon whose practice is entirely dedicated to treating arms and hands, the risk of complications or a failed surgery is extremely low.
Practical and comprehensive
Everything you need to know to identify and treat Carpal tunnel syndrome. Written in clear and simple language by hand surgeon Dr. Jean-Paul Brutus, this e-guide identifies the causes, symptoms, and different ways to treat CTS and offers recommendations on how to ease your symptoms at home.