Carpal Tunnel Decompression

What is Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome is when the nerve that runs through the wrist to the hand is compressed. This nerve is called the median nerve. The median nerve supplies the muscles of the thumb and fingers for gripping and sensation to the outside or lateral part of the palm. It runs under the flexor retinaculum ligament. 

The flexor retinaculum forms the roof of the tunnel. When this becomes thickened, it causes pressure on the underlying median nerve causing pain, tingling, numbness and weakness in the hand. 

Carpal Tunnel Syndrome is commonly seen in people who use their hands for heavy manual work, repetitive computer use, or repetitive hobbies such as crafts or knitting. Other causes are pregnancy & hormone disorders, such as acromegaly and diabetes.

What is Carpal Tunnel Decompression?

Carpal Tunnel Decompression is a surgical procedure that is performed to relieve the symptoms of carpal tunnel syndrome.

The decompression procedure involves cutting the ligament that forms the carpal tunnel's top, relieving the pressure on the median nerve and alleviating symptoms.

Who is Suitable for Carpal Tunnel Decompression?

Weakness and altered sensation in the thumb and finger gripping muscles. There is numbness and pain in the fingers, worse at night, that wakes the patient from sleep, relieved by shaking the hand. The patient has problems holding objects with frequent dropping.

If pain and numbness in the hand worsen and do not respond to a hand splint or local steroid injections, then operative intervention is indicated.

Carpal Tunnel Diagnosis

Carpal tunnel syndrome is diagnosed by special electrophysiological tests called nerve conduction studies. This is when a nerve impulse is measured across, running from the neck to the fingers. The nerve impulses are slowed and reduced as they cross through a narrowed carpal tunnel. A Neurologist performs the nerve conduction study.

Carpal Tunnel Symptoms

Patients can have symptoms in both hands, usually with the dominant hand displaying worse symptoms.

Benefits of Carpal Tunnel Decompression

Carpal Tunnel Decompression can significantly reduce the pain, numbness, and tingling associated with carpal tunnel syndrome. It can also help restore muscle strength and normal function in the hand and fingers if carpal tunnel syndrome is causing weakness or loss of function. The surgery may also prevent further nerve damage and the resultant loss of hand function.

Types of Carpal Tunnel Decompression

There are two main types of Carpal Tunnel Decompression surgery:

• Open Decompression Surgery: This is the traditional method where the surgeon makes an incision in the wrist and palm to access the carpal tunnel and cut the transverse carpal ligament.
• Endoscopic Surgery: This is a less invasive method where the surgeon makes one or two smaller incisions and uses a tiny camera (an endoscope) to guide the surgical tools. The transverse carpal ligament is cut this way.

Both types of surgeries are generally effective, but recovery may be faster with endoscopic surgery.

Alternative Options to Carpal Tunnel Decompression

Before resorting to surgery, several less invasive treatments for carpal tunnel syndrome are usually tried. These include:

• Splinting or Bracing: This keeps the wrist in a neutral position, particularly during sleep, which can reduce pressure on the median nerve.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter drugs like ibuprofen can help reduce inflammation and pain.
• Corticosteroids are powerful anti-inflammatory medicines that can be taken orally or injected directly into the wrist to reduce inflammation and swelling.
• Physical Therapy: Specific hand and wrist exercises may be recommended. Some physical therapists may also use ultrasound therapy to reduce symptoms.
• Lifestyle Changes: Modifying certain activities or work practices to reduce unnecessary strain on the wrist.
• Ergonomic Adjustments: This might involve changing the setup of a computer workstation or using ergonomic tools.

What to do Before a Carpal Tunnel Decompression?

Tell Mr Malham about any medical conditions or previous operations. Suppose you have a medical condition such as diabetes, heart problems, high blood pressure or asthma. In that case, Mr Malham may arrange for a specialist physician to see you for a pre-operative assessment and medical care following the neurosurgery. 

Inform Mr Malham of the medication you are taking and/or have allergies to medications. You must stop using the following 10 days pre-operatively: 

• Aspirin
• Plavix
• Isocover
• Asasantin

You must stop using blood thinning medication (such as Warfarin) 3-5 days pre-operatively. 

Carpal Tunnel Decompression Surgery

Here's a basic overview of the Carpal Tunnel Decompression procedure:

• You will be admitted as a day case to the hospital. You will go home the same day. You must not drink or eat for 6 hours before the procedure.
• Carpal tunnel decompression/release can be performed under sedation with a local or general anaesthetic. You will be lying on your back on the operating table with your hand outstretched and resting on a special arm table. A local anaesthetic will be injected into the palm where the skin incision is made. Your arm and hand will then be washed with an antiseptic solution; then your arm will be covered with drapes. 
• A 2 cm incision is then made in the middle palm of your hand from the wrist crease. The fat below the skin is separated, and the thickened flexor retinaculum is carefully opened. The flexor retinaculum is then fully decompressed along its entire length to free the compressed median nerve. All small bleeding points will be coagulated. 
• The wound is washed, and the skin is carefully sutured with fine nylon sutures. A wound dressing is placed over the wound, followed by a cotton wool pad. A crepe bandage is wrapped around the wrist and hand. 
• You will then be taken to the recovery room.

What to Expect After a Carpal Tunnel Decompression?

Your hand will be elevated on a pillow in the recovery room, with nurses checking your finger sensation and movements. They will also check your breathing, blood pressure and heart rate. 

You usually are given pain relief in the form of tablets. A small arm sling is given to keep your hand elevated. 

You will go home 3-4 hours after drinking and eating light food. It is essential that a relative/friend collects you from the hospital and drives you home. 

Keep your hand elevated above your heart for 24 hours following the operation. The crepe bandage can be removed 3 days after surgery. The skin sutures are to be removed 10 days after your operation by your GP/nurse. 

Carpal Tunnel Decompression Recovery Plan

The recovery process post-surgery varies from person to person, but a typical recovery plan may look like this:

• Pain Management: You may experience pain and discomfort after the anaesthesia wears off. Your doctor will provide a pain relief plan, including over-the-counter medications.  Prescription painkillers are usually not required.
• Physical Activity: You'll be encouraged to gently move your fingers and hand to promote blood circulation and prevent stiffness. Avoid heavy lifting and strenuous activity with the affected hand for a few weeks.
• Physical Therapy: Most people do not require physical therapy after carpal tunnel Decompression.
• Follow-up Visits: Mr Malham will review you in the consulting rooms 4 weeks following the operation to assess your progress. Return to work timing will be discussed.

Carpal Tunnel Decompression Prognosis

The prognosis for carpal tunnel decompression surgery is generally good, with an 80 - 90% success rate for improvement in pain, strength, sensation and sleep. 

For some individuals, particularly those with severe or long-standing carpal tunnel syndrome, symptoms like numbness or weakness may persist even after surgery. 10% of patients will experience no change in symptoms. Also, while rare, symptoms can recur in some people, requiring additional treatment.

Carpal Tunnel Decompression Risks

While carpal tunnel Decompression is generally a safe procedure, as with any surgery, there are potential risks and complications. There is a 2% risk of the following:

• Infection, usually a superficial skin infection requiring antibiotics; 
• Bleeding with bruising in the palm;
• Damage to the median nerve or its recurrent branch with weakness of the thumb; Ongoing pain along the incision site;
• Failure to improve symptoms of pain, weakness and tingling needing redo surgery

If your symptoms do not improve following the operation, you will be carefully reviewed for approximately 3 months after the operation. 

You may require repeat nerve conduction studies to assess if there is any residual compression/ nerve damage. It is rare for patients to require repeat decompression to satisfactorily relieve pressure on the underlying median nerve to improve symptoms.

What if Carpal Tunnel Decompression is Delayed?

Delaying carpal tunnel Decompression surgery can result in worsening symptoms and permanent damage to the median nerve. This can lead to persistent numbness, loss of strength, and loss of hand function. Therefore, if non-surgical treatments aren't relieving symptoms, timely surgical intervention is crucial to prevent irreversible damage. As always, the decision to proceed with surgery should be made in consultation with your orthopaedic surgeon, weighing the potential benefits and risks.