Carpal Tunnel Surgery

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Introduction   

Carpal tunnel syndrome (CTS), the most common nerve entrapment disorder across the globe, has a multifactorial epidemiology and risk factors. Carpal tunnel syndrome (CTS) ranks among the most frequent peripheral neuropathies which occurs when the median nerve compresses while passing through the carpal tunnel [1]. The primary cause of CTS is increased pressure within this tunnel. Early symptoms include pain, numbness, and tingling (paresthesia) in the first three fingers and the lateral half of the fourth finger [2]. The symptoms can vary, with pain occurring at the wrist, affecting the entire hand, and sometimes radiating up to the forearm or beyond the elbow [2]. CTS-related pain seldom involves the neck [3][4].  

As the condition progresses, individuals may experience hand weakness, reduced fine motor coordination, clumsiness, and atrophy of the thenar muscles. CTS symptoms often emerge at night while lying down and tend to improve during the day. As the condition worsens, symptoms may start to occur during the day, often during activities that involve repetitive motions such as drawing, typing, or playing video games. In advanced stages, these symptoms may become persistent or constant. Occupations that require frequent computer use, exposure to vibrating equipment, or repetitive hand movements increase the risk of developing CTS [5]. Other contributing factors include obesity, genetic predisposition, diabetes, rheumatoid arthritis, hypothyroidism, and pregnancy [5][6].  

Treatment for CTS varies depending on the severity of the condition. Most clients start with conservative treatment options. Individuals with severe CTS or those who do not respond to conservative measures may need to consider surgical intervention. 

Etiology  

The carpal tunnel is a narrow passageway in the wrist, bordered by the transverse carpal ligament at the top and the carpal bones at the bottom containing the median nerve and nine flexor tendons [7][8]. Carpal tunnel syndrome (CTS) results from mechanical trauma, increased pressure, and ischemic damage to the median nerve.  

The normal pressure within the carpal tunnel ranges from 2 to 10 mmHg [1]. However, wrist extension or flexion can cause this pressure to rise by 8 to 10 times its normal level [1][9]. Repeated compression of the nerve can result in demyelination at the site of compression, and disrupted blood flow to the endoneurial capillary system can lead to endoneurial edema [10]. 

The exact cause of increased pressure in the carpal tunnel remains unclear, but certain conditions increase the risk of developing CTS. Several factors, including anatomical variations, sex assigned at birth, chronic illnesses, inflammatory conditions, medications, obesity, body fluid changes, other medical conditions, and certain workplace activities, have been linked to an increased risk of carpal tunnel syndrome by irritating or damaging the median nerve, though these factors have not been established as direct causes [1][11]. The square wrist test, which measures the ratio of wrist thickness to wrist width, can indicate a higher risk of CTS if the value exceeds 0.7 [1][12]. 

Risk Factors 

Risk factors for carpal tunnel syndrome include: 

• Dislocation or subluxation of the carpal bones 
• Fractures or improper healing of the distal radius 
• Wrist arthrosis, inflammatory arthritis, and infectious arthritis 
• Acromegaly 
• Cysts or tumors within the carpal tunnel 
• Pregnancy 
• Menopause 
• Obesity 
• Kidney failure 
• Hypothyroidism 
• Use of oral contraceptives 
• Congestive heart failure 
• Diabetes 
• Alcoholism 
• Vitamin deficiencies or toxicities 
• Exposure to toxins 

Epidemiology 

The first surgical release of the carpal tunnel occurred in 1924 [1]. Since then, CTR has become the most common hand surgery [14]. The incidence of carpal tunnel syndrome (CTS) in the general population ranges from 1% to 5%, with a higher prevalence in females than males, showing a 3:1 female-to-male ratio [15]. Obesity doubles the risk of developing CTS [16]. CTS is rare in children and most often appears in adults aged 40 to 60 [17]. 

Carpal tunnel syndrome represents the most common compressive neuropathy of the upper extremity, affecting about 3.1% of individuals aged 18 to 64 each year [1][12]. More than 400,000 carpal tunnel release (CTR) surgeries occur each year, accounting for around 0.1% of the U.S. population, with direct costs over 2 billion dollars [18].  

Pathophysiology 

Carpal tunnel syndrome (CTS) is a multifactorial condition that arises from a combination of client-specific, occupational, social, and environmental factors [1]. As a result, it is rare to identify a single, specific cause unless there is a clear physical finding that explains the client’s symptoms. 

The pathology of CTS involves a combination of compression and traction on the median nerve. The compressive aspect creates a harmful cycle of increased pressure, obstruction of venous outflow, localized edema, and impaired intraneural microcirculation of the median nerve [1]. These factors lead to the development of lesions on the myelin sheath and axon, resulting in inflammation and a loss of the normal protective and supportive functions of the surrounding connective tissues [1]. This deterioration in the nerve’s structural integrity further aggravates the dysfunctional environment. 

Repeated traction and wrist movements worsen this already dysfunctional environment, leading to additional nerve injury [10]. Moreover, any of the nine flexor tendons passing through the carpal tunnel can become inflamed, adding further compression to the median nerve [19]. Sensory fibers experience effects before motor fibers, and autonomic nerve fibers within the median nerve might also encounter issues. 

History and Physical 

Clients with carpal tunnel syndrome (CTS) often report numbness, tingling, and pain in the thumb, index finger, middle finger, and the radial side of the fourth finger, with symptoms worsening at night [1]. The distribution of these symptoms can vary from localized discomfort at the wrist to involvement of the entire hand, and may even radiate up the forearm, extending to the elbow or shoulder [1]. 

In the initial stages, symptoms appear during activities such as driving, reading, or painting. Nighttime symptoms that improve with hand or wrist shaking indicate CTS. As the condition progresses, symptoms can become more persistent, leading to permanent sensory loss, muscle weakness, clumsiness, and difficulty with tasks like opening doorknobs or buttoning clothes [1]. CTS can affect both hands, but symptoms begin in the dominant hand. Numbness in the fifth finger, the thenar eminence, or the dorsum of the hand or neck suggests a different diagnosis [1]. 

During a physical examination, clinicians assess for sensory loss or weakness in the median nerve distribution. The thenar eminence remains unaffected due to the palmar sensory cutaneous nerve bypassing the carpal tunnel. Additional findings may include reduced strength in thumb abduction and opposition, as well as atrophy of the thenar eminence.  

Several tests exist to reproduce CTS symptoms, each with different sensitivity and specificity. Clinicians should interpret these test results alongside the client’s clinical history for accurate diagnosis. The carpal compression test requires applying pressure to the carpal tunnel for 30 seconds [1]. The onset of paresthesia’s or pain in the median nerve distribution indicates a positive result.  

The Phalen test requires the client to flex their wrists by pressing the dorsal surfaces of both hands together with elbows flexed, holding this position for one minute [20]. The presence of pain and paresthesia in the median nerve distribution indicates a positive result. The Tinel test involves tapping over the carpal tunnel to trigger a response from the median nerve. The appearance of symptoms indicates a positive result [21].  

Clients diagnosed with mild carpal tunnel syndrome (CTS) do not need further diagnostic studies. In cases with atypical symptoms, sleep-disrupting pain, persistent numbness or weakness, or impaired hand function, conduct electrodiagnostic testing, including nerve conduction studies. Electromyography (EMG) may aid in surgical decision-making and help rule out alternative diagnoses. EMG can detect axonal integrity even without evident sensory or motor components. Electrodiagnostic testing, when correlated with specific symptoms and signs, serves as the gold standard for diagnosing CTS [1].  

Electrodiagnostic testing also assesses the severity of nerve damage and provides insight into prognosis, as clinical symptoms may not accurately reflect the extent of median nerve damage. CTS divides into three severity levels: mild, moderate, and severe [1]. Mild CTS shows sensory abnormalities on electrophysiological testing, while moderate CTS involves both sensory and motor abnormalities [1]. 

Conduct imaging studies only to investigate suspected structural abnormalities, such as tumors or ganglion cysts. Use ultrasound or magnetic resonance imaging (MRI) for this purpose. 

Surgical Intervention  

Carpal tunnel release (CTR) involves the surgical addressing carpal tunnel syndrome (CTS) by relieving pressure on the median nerve. Surgeons perform carpal tunnel release surgery using two main techniques: open surgery, which involves a larger incision, or endoscopic surgery, which uses smaller incisions and a camera for guidance, resulting in faster healing and less pain [22]. 

The median nerve and the tendons that control finger movement pass through the carpal tunnel, a narrow passageway formed by the wrist bones and the transverse carpal ligament. Swelling within this tunnel, due to injury or tightening, compresses the median nerve, resulting in symptoms such as numbness, tingling, pain, and loss of hand function if not addressed. Symptoms can be gradual and increase over time on the thumb side of the hand [1]. CTS can involve one or both hands [1]. In CTR surgery, the surgeon cuts the ligament pressing on the carpal tunnel, increasing space for the median nerve and tendons. This procedure improves pain and hand function.  

Endoscopic Carpal Tunnel Release 

Endoscopic carpal tunnel release (CTR) usage has increased in recent years. Data shows a 5% annual growth in endoscopic CTR from 2005 to 2012, compared to 0.9% for open CTR [23]. Initial concerns about higher nerve injury rates with endoscopic CTR arose, with some data showing a 125% increase in nerve injury risk requiring repair compared to open CTR [18]. However, other research reports a 45% lower complication rate with endoscopic CTR and no significant increase in complications when analyzing a large client population from 2000 to 2014 [18].  

Studies have found no significant differences in postoperative carpal tunnel volume between open and endoscopic carpal tunnel release (CTR), addressing concerns about the adequacy of nerve release in the endoscopic method. Caution remains for endoscopic CTR in cases involving abnormal anatomy, including nerve variants, cysts, amyloidosis, or rheumatoid tenosynovitis [24]. 

Endoscopic CTR has been associated with reduced immediate postoperative pain [25]. A comparison of bilateral CTR techniques in the same clients found that 80% preferred the endoscopic method due to less pain [25]. This finding contrasts with earlier reports but aligns with studies showing reduced pain and a lower need for analgesia following endoscopic CTR. Increasing experience in endoscopic techniques has demonstrated their safety, comparable to open techniques, and their potential to offer smoother early recovery [25]. 

Percutaneous Carpal Tunnel Release 

Recent exploration of ultrasound (US)-guided techniques for carpal tunnel release (CTR) aims to reduce the invasiveness and cost of the procedure [26]. Initial findings suggest that US-guided percutaneous CTR may improve symptom severity with minimal complications [26]. Proponents of this technique emphasize its short learning curve, allowing junior radiologists to perform the procedure after limited training. Ultrasound-guided PCTR sections the transverse carpal ligament, decompresses the median nerve, and improves self-reported symptoms [29]. Magnetic resonance imaging shows outcomes similar to those after OCTR, with complete ligament sectioning and successful nerve decompression [29]. 

As more non-surgical providers adopt CTR techniques outside the operating room, researchers will conduct further studies on the safety and efficacy of percutaneous methods. These studies will compare these methods with established techniques and include larger sample sizes to assess the risk of rare complications, such as nerve laceration or incomplete release. 

Post-Operative Considerations 

To support recovery after surgery, clients should take several steps to minimize swelling, manage pain, and care for the wound.  

Limb Elevation and Exercise 

Although significant swelling should not occur, elevate the hand and wrist during the first 24 hours after surgery and apply an ice pack to the wrist to reduce any potential swelling [27]. Maintaining finger mobility is also crucial to prevent internal scarring; clients should make a fist, straighten their fingers, and move the thumb across the hand toward the pinky finger. Clients should repeat exercises daily.  

Pain Management 

Pain management plays a key role in recovery; while clients do not expect significant pain, they should take prescribed pain medication as directed on the first day and then adjust as needed to stay comfortable and maintain mobility.  

Dressing Care 

The client must keep the dressing and all covered skin clean and dry for about five days, after which they may remove the dressing before their first post-operative visit. Once the client removes the surgical dressing, they must keep the wound clean with soap and water, avoiding immersion in water until removing the sutures. Discourage the use of antibiotic salves; instead, use soap and water or peroxide, and cover the wound with a non-adherent bandage [27]. 

Other Teaching Points 

Instruct clients on the following: 

• Avoid gripping or lifting objects with affected arm. 
• Wear bandage, splint, or cast per instructions. 
• Ensure the dressing, splint, or cast remains clean and dry at all times. 
• While showering, protect the hand and wrist by covering them with plastic and securing it with tape or rubber bands to keep the dressing, splint, or cast dry. Shower as needed 
• Apply an ice pack or a similar cold item wrapped in a thin towel to your wrist to reduce swelling during the first 48 hours. Use the ice pack for 20 minutes, then remove it for 20 minutes. Repeat as needed. 
• Elevate the arm above heart level for the first 24 to 48 hours following surgery. 
• Perform exercises recommended by provider. 
• Take pain medication as prescribed. 
• Do not drive until cleared. Avoid driving while taking opioid pain medication. 

Conclusion

Health care providers consider surgical intervention for carpal tunnel syndrome (CTS) when conservative treatments fail, or symptoms become severe. Carpal tunnel release (CTR) surgery, which aims to relieve pressure on the median nerve, involves either open or endoscopic techniques Open CTR involves a larger incision, providing direct visualization of the ligament, while endoscopic CTR uses smaller incisions and a camera, offering quicker recovery times and reduced pain. Both methods can alleviate numbness, tingling, and pain. However, client-specific factors, such as the presence of abnormal anatomy, may influence the choice of surgical technique. 

Post-surgical recovery from CTR can lead to significant improvements in hand function and a reduction in pain [18]. Clients undergoing endoscopic procedures tend to experience less immediate postoperative pain and prefer this method due to faster recovery [28]. Nonetheless, both open and endoscopic CTR have similar long-term outcomes in terms of functional improvement. Emerging techniques, such as ultrasound-guided percutaneous CTR, offer potential for less invasive options with minimal complications, though further research is necessary to confirm their efficacy and safety. Regardless of the method, proper post-surgical rehabilitation is crucial for regaining strength and fine motor skills. 

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