Hand Surgery - Median Nerve Compression
Carpal Tunnel Release
The decision to have your carpal tunnel release is a combined decision between you (the patient) and surgeon. The challenge is to figure out whether carpal tunnel release will alleviate the symptoms you are having. Compression of the median nerve at the wrist is responsible for carpal tunnel symptoms.
There are many medical conditions that predispose to carpal tunnel symptoms. The most common include diabetes, thyroid problems, gout, crystal deposition diseases, vitamin deficiencies, and inflammatory conditions such as rheumatoid arthritis. If these medical conditions are properly addressed, your symptoms can improve thus avoiding the need for surgery. You should investigate these issues with your family doctor.
The median nerve starts at the level of the neck and there are multiple possible compression sites from the neck to the fingers. With a combination of clinical exam, nerve conduction study, and imaging we can give you a good sense of how confident we are that carpal tunnel release will improve your symptoms.
The surgery itself involves an incision from the wrist crease to the mid palm. The transverse carpal ligament is divided. This skin is then closed with sutures and a splint is applied to the wrist. Total operative time is less than 30 minutes.
By dividing the transverse carpal ligament, the contents of the carpal tunnel which includes flexor tendons and the median nerve are unroofed. The transverse carpal ligament will reform but does so with an enlarged tunnel. With this, the compression on the median nerve at the wrist will be alleviated.
A plaster splint is applied to the wrist at the end of the procedure. This remains in place for 1 week. This is removed at 1 week and the hand is regularly washed. The night splint can be worn on the hand after surgery to reduce the risk of hand overuse for a month after surgery.
The palm skin is quite tender post surgery. Post operative care instructions include no lifting of items greater than 10 pounds for one month after surgery. The palm remains quite tender for 2 to 3 months after surgery. If after one month there is significant stiffness, sensitivity or lack of range of motion, hand therapy is suggested.
As there should be no new compression of the nerve, symptoms such as nighttime awakening will resolve immediately after surgery. Sensory recovery of the fingers and motor improvement of the muscles at the base of the thumb have a variable degrees of recovery based on a multitude of factors.
Recurrence is rare but when it occurs it is often in the setting of tendon swelling (tenosynovitis). Incomplete release is also rare but imaging can confirm if either the ligament was incompletely released or if another site of compression is responsible for ongoing symptoms.
Non Operative Treatment
Nonoperative treatment includes splinting at the wrist at nighttime for 3 months. The sole purpose of the splints is to prevent flexion of the wrist. Flexion of the wrist occurs automatically when you fall asleep as the flexors of the wrist are stronger than the extensors. Flexion of the wrist causes compression of the median nerve at the transverse carpal ligament. Without conscious control, your wrists will bend and the nerve will be compressed. The damage to the nerve will occur and symptoms will persist throughout the day. Vigilant nighttime splinting often improves patient symptoms thus avoiding the need for surgery.