Carpal Tunnel

What are the symptoms?

Prolonged pressure on the Median nerve in the carpal tunnel will damage the nerve and can cause a number of symptoms:

• Numbness and tingling - this typically occurs in the thumb, first, middle and half of the ring finger and may be painful or not. In mild cases it only comes on when the wrist is held bent in one direction for a long period of time or at night time. Patients may wake up with a tingling, dead hand. In severe cases the fingers and thumb can be permanently numb.
  
  
• Aching and pain – this is often in the hand and comes on with tingling. It may also start at the wrist and cause pain up the arm.
  
  
• Clumsiness and weakness – patients often drop things due to the reduced feeling or weakened grip in more severe cases.

What are the causes of this condition?

Most often there is no cause for CTS although risk factors include:

• Diabetes
• Repetitive manual work
• Hypothyroidism
• Previous trauma
• Rehumatoid arthritis
• Obesity
• Kidney failure
• Pregnancy
• Neck arthritis
• Menopause
• Vitamin D deficiency
• Vitamin B deficiency can also “mimic” the symptoms of CTS
• In some cases, there may be a genetic link.

Sometimes your GP or surgeon may arrange a test called a Nerve Conduction Study to confirm the diagnosis: This test is not always sensitive at picking up this problem, and in fact even if the test is negative, you may still be having CTS. However, the test can give an indication about the severity of the condition or even diagnose other conditions which may be confused with this.

What treatments are available for CTS?

Postural adaptations

Avoiding prolonged periods with the wrist bent may help to relieve the symptoms. Splinting the wrist at night using a ‘futura splint’ (cheaply available to buy from the internet or your chemist) helps many patients: if this is effective no further treatment may be necessary. Some patients may choose to live with the pins and needles and decide not to have an operation. 

Painkillers

In mild cases of CTS, Ibuprofen or similar drugs can provide some short-term relief from symptoms. Nerve symptoms may be relieved by specific nerve painkillers from your GP however they do not treat the underlying cause, and some patients find the side-effects of these problematic.

Injection

Injection of steroid into the carpal tunnel can provide a good relief of symptoms for up to 1 year. Steroid injections can be used as a nonoperative treatment method, but also as a diagnostic tool when there is any doubt as to where the patient’s symptoms originate from. In patients who have diabetes, steroid injections can cause elevation of blood glucose for one to two days that doesn’t require further intervention.

Steroid injections are not routinely repeated when the patient’s symptoms recur, and should not generally be given to the same wrist more than twice.

Carpal Tunnel Surgery

The operation is meant to relieve the pressure off the nerve, and by doing so, you should get improvement in the pins and needles in the fingers. You may also get improvement in the strength in the muscles of the hand. This improvement may be instant or gradual over 12-18 months. However, in cases of advanced compression, the nerve may not recover fully even after release, but in those cases, surgery is done to prevent further damage.

Surgery for Carpal tunnel syndrome is a worthwhile operation which usually relieves your symptoms if they are intermittent and improves them to some extent in more severe cases. Treatment can improve your hand's function and reduce the stress and sleep interference of symptoms. Surgery is usually safe, but as with any procedure, there is always a small risk of complications happening.

What happens on the day of surgery?

Admission

On the day of surgery, you will be admitted by a nurse who will check your details, medications and past medical conditions and put a wrist band with your details on the arm we are not operating on (if we are operating on both hands this band is put on your ankle).

Remove any rings before you come to hospital and if you are unwell or have any cuts on your hand or arm then please inform us before the day as this may require your operation to be delayed.

Open Carpal Tunnel Decompression (CTD): Local Anaesthetic

A local anaesthetic will be used where you will be awake for the operation, but the area will be numb. In some cases, a general anaesthetic may be required, or you may also be given a sedation during the local anaesthetic or even an ‘axillary nerve block’ where you will be awake but the whole of your arm will be numb for 12 hours.

If staying awake for your surgery, there is the option to listen to music or watch a video on the tablet screens and headphones we have in theatre. Alternatively, you can bring your own device to listen to music on, but you must have headphones.

Endoscopic Carpal Tunnel Decompression (Endo-CTD): General Anaesthetic

If you are having anything more than just local anaesthetic, such as with an endoscopic CTD, you will have to starve for your surgery.

(You will be advised before your admission whether you will have to starve or not.)

Surgical Time

Surgical procedure time varies from 10-30 minutes per operated hand, however it is normal that you will be in the operating theatre for almost an hour due to necessary theatre turnaround time.

Once anaesthetised, the surgeon will release the tight ligament either

• Open CTD: Via an approximately 5cmcut in the midline of your palm just past where the wrist creases Occasionally a larger incision is needed extending down your forearm (Extended-open CTD).
• Endo-CTD: Via a small (~1cm) cut in the forearm, through which the endoscope ‘camera’ is inserted together with the endoscopic blade to release the ligament internally under direct camera vision. Occasionally the view is insufficient under the camera approach alone and so your surgeon will then convert to an ‘Open CTD’ procedure.

 Your incision will be stitched and dressed with either just plasters +/- skin glue, or with a simple bulky bandage.

After Surgery

Almost all patients will go home on the day of surgery. Very occasional, social or medical conditions require an overnight stay.

What are the possible complications from this operation?

Whilst the surgical team makes sure that the operation is carried out with utmost safety, complications may still happen. Your surgeon should have discussed these with you. The percentage of values given cover a range from simple to complex cases. If you need anything more than local anaesthetic alone there may also be additional risks with the anaesthesia that your anaesthetist will discuss them with you.

• Bleeding – often this operation is carried out under a tourniquet, bleeding may happen after the operation is finished causing marked bruising and wound oozing (2-5%). Very rarely if a blood clot collects under the skin you may need an operation to remove it and stop the bleeding.
• Infection – this is rare (1-5%) following this operation but if it happens, you may need to have antibiotics. In very rare cases another operation.
• Scar - the scar will normally be tender for 6 weeks however in up to 19% of cases this may last longer and could be 3-6 months.
• Pain – persisting nerve pain can occur in 2-5%. Pillar pain which is pain either side of the scar and deep in the wrist is very common for 4-6 week. In some cases (1-18%) it can persist for many months.
• Nerve injury - the risk of injury to the main nerve, a small skin nerve which supplies part of the palm or a branch which supplied the muscles of the thumb is rare (less than 1%). If this happens you may have permanent numbness to your fingers and weakness to your hand.
• Continued symptoms - your symptoms usually improve within a few weeks after the operation but in some cases, often those with more severe nerve damage, it may not improve. There is a small risk that the symptoms may be worse due to dissection around the nerve. Occasional further surgery may be required if symptoms persist (2-18%).
• Weak grip – in less than 1% of patients the operation can make the grip strength worse once recovered.
• Complex regional pain syndrome - Very rarely you can develop a condition called complex regional pain syndrome (CRPS) (less than 1%) which can make your hand red, swollen and painful. This is a difficult condition to treat and may last for several years. Treatment consists of pain killers and hand therapy.
• New problems - occasionally surgery on the hand, if extensive, can cause other problems such as trigger finger (5-32%).

What should I do about my medication?

Let us know about your medication in the clinic. For all procedures other than local anaesthetic procedures you will be seen in the pre-assessment clinic before surgery where they  will advise exactly what to do regarding any medications which you will need to reduce or stop.

What can I do to make the operation a success?

• If you smoke it is best to stop or reduce as much as you can. If you are diabetic, you will reduce your risk of infection and poor wound healing by keeping your blood sugars stable. Please attend all dressing, doctor and hand therapy appointments after surgery. You must follow the hand exercises that you have been given to get the best function and recovery following surgery.

What happens after my CTD surgery?

• Often all or part of your hand will feel numb; this is normally due to the local anaesthetic given and will reduce in the next 12-24 hours. You may experience pins and needles during this process.

• Once you are home you may be too uncomfortable to use your hands for many things. Try to undertake light activities around the home: 

  Any movement of your fingers will help to pump fluid out of your hand and help speed your recovery.

• For pain, start taking over-the-counter painkillers the same day/afternoon/evening, usually at least for the next four days. Eg. Paracetamol 1g (4x a day) AND Ibuprofen 400mg (3x a day)
• If your hands are very swollen and painful, you may benefit from elevating them at rest and on your chest or pillows when you sleep.
• Your stitches are usually dissolvable and may be purely internal. You will typically be given a few simple dressings to go home with. If you have had some bleeding or spotting on the dressing from surgery, you can change this yourself at home, but if not, we suggest you leave the original on for 4-7 days before you change. Your dressing is splash-proof, so you can wash your hand during everyday activities and even have a quick shower, but try not to submerge or soak your dressings.
• You may also have a layer of medical skin glue underneath the dressings which is also water-resistant. It is important you do not pick this, but it usually falls off itself by around three weeks after the surgery.
• If you have stitches that need to be removed, or external ‘dissolving’ stitches that have knots that need to be ‘brushed off’, you should make an appointment to have this done with your GP nurse 12-14 days following surgery, and keep the wound dry until that time

If you have stitches that need to be removed, or external ‘dissolving’ stitches that have knots that need to be ‘brushed off’, you should make an appointment to have this done with your GP nurse 12-14 days following surgery, and keep the wound dry until that time

Outside of these hours, please contact the main hospital number and ask for the Clinical Site Co-ordinator on call via 0121 685 4000.

If you are unable to make your Outpatient appointment, please contact the Appointments department on 0121 812 3200.

CTD - How long will it take to recover?

Typical recovery times:

• Light activities: start the day of surgery, as able, and take painkillers to keep comfortable
• Return to work: You should not work the day following a general anaesthetic. Thereafter, everyone is different, but you may find you are working at a slower pace initially due to pain, so gradually ease yourself into it.
• Heavy manual work: When comfortable. Anticipate at least 4weeks post-op, and when you start, take a gradual return to activity and be guided by any pain you may have. Sometimes “Pillar Pain” aching can take 4 months to fully settle.
• Return to driving: usually 2-4 weeks: You must be able to comfortably grip the steering wheel for emergency manoeuvres/to change gear etc.

In mild cases where the symptoms were intermittent through the night, the numbness will subside within a few days after surgery. If there was weakness or constant numbness before the operation, this can take much longer to subside and the hand might not fully recover.

Improvements can continue up to 1 year. If your symptoms fail to improve your surgeon will assess you during the next appointment and advise you.

Scar management

Once the scar is healed (at least 2 weeks post-op), you can massage the scar using any lotion or oil as a lubricant:

• Starting lightly but gradually apply more pressure
• Aim to build-up to 5 minutes firm massage, 5x a day, for 2 months minimum
• Massage helps desensitise and deep massage helps to break up scar tissue. 
• You should also expose the scar to different textures e.g. towels, cotton wool or tissues and to different temperatures e.g. a warm cloth or a cold tap, to feed your healing scar different sensations. 
• You may also try immersing your hand in a tub of uncooked rice or pasta to vary the textures.

After surgery information

• Elevate your hand in a sling whilst mobilising and on a pillow when sitting or in bed.
• Do not allow your hand to hang down by your side.
• Keep the dressing dry, try not to disturb the dressing until you have been advised to.
• Do not partake in heavy manual work until you have been seen at your next appointment and have been advised it is safe to do so. 
• Take painkillers as prescribed. 
• If you are instructed to wear a sling, please ensure you remove your arm from the sling every 1 to 2 hours and exercise the shoulder and elbow to prevent them from getting stiff. Remember to also wriggle your fingers.

If you experience pain, numbness, tingling, excessive swelling, discharge through your dressing or discoloration of the fingers, in the first instance please contact the Outpatients Department (Mon - Fri, 8:30am - 4:30pm).

Outside of these hours, please contact the main hospital number and ask for the Clinical Site Co-ordinator on call via 0121 685 4000.

If you are unable to make your Outpatient appointment, please contact the Appointments department on 0121 812 3200. 

Post-operative CTD Exercises

• Start these as soon as you are able following your CTD Surgery (Carpal Tunnel Decompression).
• Take regular painkillers to let you start these exercises sooner! 

Finger Exercises

Important to prevent / reduce swelling, and ensure your fingers stay flexible 

Starting from a straight position, do 10 repetitions of each type of fist shown below, 5 times per day (or more):