Carpal tunnel syndrome surgery
Do you think you are suffering from carpal tunnel syndrome?
i. Conventional surgery is open surgery whose standard is to make two to four centimeters long incision in the palm of the hand. The aim is to cut the transverse ligament of the carpus to enlarge the canal. However, this technique requires sacrificing and sectioning some structures. The skin, the subcutaneous fatty tissue that often contains small nerve fibers, and the muscle that lies just above the transverse ligament of the carpus, are thus severed to allow access to the transverse ligament of the carpus which is the target of surgery.
ii. Indeed, all these structures are located above the ligament to be sectioned. This conventional technique usually relieves neurological symptoms but has many disadvantages. In fact, it sacrifices important structures unnecessarily and the period of healing is lengthened considerably. In addition, the risks of adhesion and postoperative stiffness increase. The scar in the palm of the hand may remain hypersensitive for months and may be unsightly. A loss of strength is a common complaint after this surgery. Traditional surgery is usually performed for one hand at a time to allow the free use of the second hand for personal hygiene. The second hand is rarely operable before a delay of three to four weeks after the first hand.
Minimally invasive surgery: Endoscopic surgery
There are other, more recent, sophisticated, and less invasive techniques that cut only the transverse ligament of the carpus without any incision in the palm of the hand. The skin, the delicate subcutaneous fat tissue and the muscles of the hand are therefore left intact and the surgical trauma is therefore very limited.
i. This is done via a very short incision at the wrist. This small hole allows the introduction of a small, high definition camera inside the channel to see the transverse carpus ligament perfectly. The ligament is then sectioned in order to lengthen it with a small retractable blade, under direct visual control via the camera.
ii. It is a very safe procedure that allows for a much faster recovery, with much less pain and stiffness, in addition to reducing the risk of having a painful scar in the palm.
iii. The consequences of the procedure are so minor that this modern technique even allows both hands to be operated on at the same time. The convalescence period is four times faster than that following traditional open surgery.
iv. Carpal tunnel endoscopy has been proven for decades and additionally, there are at least two types of endoscopic surgery. The most recent is the “uni-portal” technique that has followed the so-called “bi-portal” technique.
The single-incision endoscopic technique described by Dr. Agee
The most recent technique in endoscopic surgery involves a single short one centimeter incision in the fold of the wrist. This “uni-portal” technique has been described by Dr. Agee and bears his name. It requires specialized equipment. Its advantages are: a single and very short incision in the forearm and a perfect view of the anatomical structures. The wrist remains upright, or in other words, in an anatomical position, throughout the duration of the operation. This reduces the operative risks (the extension of the wrist used by the “bi-portal” technique described later, in fact, displaces the median nerve).
Chow’s endoscopic technique
The other endoscopic surgery technique is called “bi-portal,” because it requires two incisions, one in the wrist and another in the palm of the hand. It is called the “Chow” technique. Unfortunately, this technique requires the wrist to be placed in hyperextension during the operation, which tends to displace the structures, and in particular, to move the median nerve which sticks to the transverse ligament. The risk of complications is, according to some specialists, somewhat higher than with the “uni-portal” technique.
Post operative convalescence and work stoppage
i. During convalescence, it is important not to wear an orthosis. It is essential that the nerve mobilizes and slides freely in the wrist immediately after the surgery. The surgery created an internal wound in the ligament that will heal. The healing occurs via fibrosis and the nerve may tend to get caught in the scar. To avoid this, it is important to move the wrist and fingers rapidly and therefore not wear a brace. The less invasive the surgical technique, the less pain and swelling after surgery and the more comfortable it will be for the patient to mobilize his wrist and thus prevent adhesions.
ii. Depending on the operating technique chosen and the type of professional or leisure activity, the duration of the convalescence varies from a few days or a few weeks to several months.
1. For patients who have chosen endoscopic surgery, it may be possible to return to work more quickly after surgery. People with relatively light work may return to work after one to two weeks. Workers who perform heavy physical work will likely wait six weeks for healing after endoscopic surgery before returning to their jobs. After conventional surgery, this delay is prolonged and can easily reach three to six months per hand.
2. Daily living activities and hygiene:
In addition, with the endoscopic approach, patients can drive, dress, and feed themselves immediately after surgery, as soon as their hand is awake. Endoscopic surgery completely spares the palm of the hand, while conventional open surgery often leaves a scar that remains hypersensitive for weeks in a very exposed area of the hand.
3. Sports practice will be delayed depending on the type of activity. For cycling or golf, it takes about three to four weeks. For heavy physical activities such as push-ups or heavy physical work, it takes four to six weeks after endoscopic surgery, and three to six months after conventional surgery.
Results and possible complications
i. Possible complications
1. Infection is rare but can be caused by the fact that bacteria passes through the skin as soon as there is a skin incision. These bacteria can proliferate and cause an infection. The infection rate after such surgery is less than 1% and is even lower with less invasive surgery that damages less tissue. Healing problems are more rare with endoscopic surgery.
2. Nerve laceration, or in other words, section of the median nerve or of one of its branches, partly or wholly, is a rare complication. It is fundamental to choose a very experienced surgeon. The cautious surgeon will not hesitate to convert the endoscopic approach into open surgery in patients for whom endoscopic surgery is not possible.
3. C.R.P.S. (Complex Regional Pain Syndrome) is a complex pain syndrome that is localized in a specific region. This is an amplified and disproportionate reaction of the body to a painful trauma such as, for example, surgical trauma. This is a very rare complication with carpal tunnel surgery, and even more rare with endoscopic surgery since it does less damage and is less aggressive. It is important that your hand specialist quickly recognizes any symptoms of CRPS and treats it.
4. Stiffness of the wrist after surgery is mainly related to healing and healing fibrosis. It is still very rare with endoscopic surgery since the patient can move immediately. Stiffness of the fingers and the wrist is exceptional. Rehabilitation is rarely required after endoscopic carpal tunnel surgery. On the other hand, several weeks of rehabilitation are often prescribed when the surgery is performed in a conventional way.
ii. Recidivism and long-term outcomes
1. Endoscopic surgery and traditional surgery effectively decompress the median nerve in the carpal tunnel. Usually the results of surgery are permanent.
2. However, in a limited percentage of cases, symptoms may recur a few years later. This is called recidivism. It is often linked to an underlying disease, such as smoking, hypothyroidism, kidney failure or diabetes. It can also be linked to significant weight gain or adhesions. The recidivism rates reported in studies are highly variable because the definition of recidivism varies from one study to another. It is reasonable to estimate between 5% and 10%.
3. It is also possible, depending on the severity of the median nerve injury, for recovery and relief after surgery to be incomplete. This is not a recurrence since the term “recidivism” implies the reappearance of resolved symptoms. This is more common when compression of the median nerve has been present for a long time (months or years).
4. When nerve conduction studies and an electromyogram are repeated after decompression surgery, it is common to observe an improvement in nerve conductivity but without complete normalization. We should not worry about that. This does not justify repeating the procedure. The indication for re-surgery is based only on a clinical examination and on the symptoms reported by the patient.