Carpal Tunnel Syndrome: What Is The Surgery?
In part four of our intro series to get you up to speed on all things carpal tunnel, today we will go into the specifics of carpal tunnel release surgery.
What is the surgery for carpal tunnel syndrome?
Surgery for carpal tunnel syndrome (CTS) involves a small incision in the palm to access and divide the transverse carpal ligament. This increases the volume of the carpal tunnel to relieve pressure on the median nerve.
Who Needs Surgery For Carpal Tunnel Syndrome?
Let’s say you’ve been diagnosed with carpal tunnel syndrome and you have tried 4-6 weeks of consistent nighttime wrist bracing. Maybe you’ve had ‘nerve tests,’ officially known as electromyography/nerve conduction studies. And nothing is working — you’re still waking up at night with miserable numbness, tingling, or burning in your thumb, index finger, and middle finger.
It might be time to consider surgery.
As we’ve discussed before (here), the roof ligament (carpal ligament or transverse carpal ligament) of your carpal tunnel has become too thick. This causes compression of the median nerve. Compression of a nerve will cut off its blood supply, nutrients, and oxygen, thus fueling a cycle of internal damage that can become permanent.
The solution is to increase the space available in the carpal tunnel.
In theory, we could chip away at the bones that form the walls and floor of your carpal tunnel to create more space. But then the architecture of your wrist would collapse, and you’d be far worse off. Or we can do something more simple — divide the thick roof ligament.
Do I Have Surgical Options?
Though not important for today’s short discussion, there are two options for surgery. Those options are ‘Open’ or ‘Endoscopic’ carpal tunnel release. Both have their pros and cons, but both ultimately accomplish the same goal — dividing the transverse carpal ligament.
What Happens In Carpal Tunnel Surgery?
To perform the surgery, I make a small incision in the base of the palm to reveal the ligament (see Figure 1). This ligament sits right on top of the nerve and, once divided (red line in Figure 2), the whole tunnel relaxes. This causes the volume of the tunnel to dramatically increase.
Now your nerve can receive all the blood supply, nutrients, and oxygen it needs to begin the healing process.
And that brings up a subtle but crucial point.
All I do as your surgeon is divide the ligament. That’s it. The rest is up to your body! After I increase the size of the space within the carpal tunnel, that blood flow rushes back into your nerve and your body begins to heal the nerve.
Can I control that process? Unfortunately not.
Does Carpal Tunnel Release Surgery Guarantee Symptom Relief?
Patients who have had a carpal tunnel release with me know this next point well.
I almost annoyingly belabor it, but I think it’s an important part of being informed about your surgery. I can absolutely in no way guarantee any improvement in your symptoms after surgery. In fact, I am clear that we do this surgery only to prevent any worsening of your symptoms.
The reason to do surgery is so that you don’t continue to worsen and go on to have profound hand weakness, with muscles that won’t ever function again. This is how you need to think about this surgery.
Now, what’s the reality?
The reality is that most people get substantially or completely better. Anecdotally, the majority of my patients get rapid resolution of their burning, shooting pain, wake-you-in-the-middle-of-the-night symptoms. That’s because your body has a tremendous capacity to heal itself. Those patients who have had numb fingers 24/7 for months prior to surgery will often experience slower resolution of the numbness, and some are left with areas of permanent numbness.
What If My Hand Muscles Have Already Withered Away?
And then there’s the more rare patient who comes to me with such advanced carpal tunnel syndrome that their palm muscles have already withered away…those patients rarely get better, even after surgery. Any associated pain oftentimes improves, but muscle damage in this setting is typically permanent. We perform surgery in those patients to prevent even further worsening of the weakness.
Hopefully, this makes sense.
A final review. The nerve is under pressure. Pressure causes nerve damage. Nerve damage causes painful symptoms. I relieve pressure by surgically dividing the roof of the tunnel. Your body then heals the nerve as much as it can.
“The reason to do surgery is so that you don’t continue to worsen and go on to have profound hand weakness, with muscles that won’t ever function again. This is how you need to think about this surgery.”
What Is The Recovery Time After Carpal Tunnel Surgery?
For reasons we will discuss another time, I perform the ‘open’ version of carpal tunnel release rather than endoscopic.
I typically tell patients they will have three or four stitches in their palm for about two weeks. During those two weeks, and for one week after, I ask them to avoid heavy lifting or gripping. That is purely to prevent ‘popping open’ the wound, which obviously nobody wants.
Once your stitches are out and your skin is healed, you can return to whatever activities you would like. Many have some sensitivity over the scar or generalized throughout the palm for 6-8 weeks, but this is typically a small annoyance rather than a limiting condition.
Obviously, there is much more nuance and detail to carpal tunnel release surgery. But hopefully, this provides you with the basics so you can arm yourself with a ‘doctor’s knowledge’ about your hand and your body!
Next time, in our final segment of this series, I discuss special cases where treatment options go beyond just bracing or surgery (here).
