Orthopedic Surgery for Carpal Tunnel Syndrome Treatment & Management

Updated: Aug 13, 2018
  • Author: David A Fuller, MD; Chief Editor: Harris Gellman, MD  more...
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Treatment

Approach Considerations

Acute carpal tunnel syndrome (CTS) can be thought of as a compartment syndrome of the carpal canal. Decompression should be performed as soon as possible, provided that reduction of associated fractures or dislocations or removal of tight splints does not relieve the symptoms. Other medical and surgical factors may impact the opportunity to operate on an emergency basis, but relieving pressure on the median nerve is a priority in order to reduce the risk of permanent nerve injury.

Acute CTS can be diagnosed through history and physical examination alone. Electrophysiologic studies are not required. Sometimes, carpal canal pressure measurements are made to help support the diagnosis of acute CTS, with pressures greater than 30 mm Hg being consistent with the diagnosis.

Chronic CTS presents over time and is treated by means of both operative and nonoperative approaches. Patients with milder symptoms and shorter nerve conduction delays on electrodiagnostic studies respond most favorably to nonoperative treatment. Patients with more severe symptoms—duration longer than 1 year, weakness, atrophy, radial-side hand numbness, two-point discrimination greater than 6 mm, and longer nerve conduction delays—often do not benefit from nonoperative care. Surgical treatment is indicated if nonoperative treatment fails or if findings predictive of failure are noted.

In a systematic review assessing the effectiveness of surgical and postsurgical treatments for CTS, Huisstede et al found that surgical treatment appeared to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short, medium, or long term, but that there was strong evidence favoring local corticosteroid injection over surgery in the short term, as well as moderate evidence favoring manual therapy over surgery in the short and medium term. [28] No surgical treatment was found to be unequivocally more effective than another.

There are no specific contraindications for surgical treatment of CTS. Medical conditions should be stabilized before surgery. Pregnancy should be allowed to proceed to term, because CTS often resolves after the pregnancy.

Unrealistic expectations can influence surgical outcomes, and risk factors for poor outcomes should be sought preoperatively. Individuals with severe CTS should be cautioned that their numbness may persist, at least to some degree, despite a complete surgical release. Patients receiving worker's compensation have a lower return-to-work rate. A greater preference for improved strength preoperatively also has been associated with lower satisfaction. [29]

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Medical Therapy

Steroid injection and wrist splinting have been used effectively in patients with milder symptoms of CTS. [21] A study reported complete relief of all symptoms in 76% of hands at 6 weeks after treatment, but by more than 12 months after treatment, the proportion of hands experiencing complete relief had deteriorated to only 22%. [30] Similar results were reported with steroid injection alone in a double-blind, placebo-controlled trial. [31]

Other nonoperative treatments have been proposed, but they have not been studied as rigorously; they include nonsteroidal anti-inflammatory drugs (NSAIDs), [32] vitamins (B complex), workstation redesign, ergonomic tool modification, acupuncture, [33] and yoga.

Ultrasound-guided platelet-rich plasma (PRP) infusions have been studied as well in this setting. In a systematic review including five studies, the bulk of the findings suggested that PRP infusion improved patients' clinical condition and was beneficial for those with mild-to-moderate CTS; however, further study is required before definite recommendations can be made. [34]

A systematic review of nonsurgical treatments for CTS by Huisstede et al found strong and moderate evidence for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads. However, the only treatment for which long-term results were reported was steroids, and there was no evidence for the long-term effectiveness of these agents. [35]

A subsequent updated systematic review by Huisstede et al that examined studies of physical therapy and electrophysical modalities for CTS found moderate evidence for the effectiveness of myofascial massage therapy and several electrophysical modalities in the short term, as well as moderate evidence for radial extracorporeal shockwave therapy (ESWT) plus a neutral wrist splint, ESWT alone, and ultrasound in the medium term. [36] No randomized controlled trials on the long-term effects of physical therapy and electrophysical modalities were found by the authors.

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Surgical Options

Open and endoscopic surgical techniques have been described for treatment of CTS. Both approaches are effective for chronic CTS. Potential benefits of endoscopy, including quicker functional recovery, must be weighed against the technique's increased cost and higher complication rate. The reliability of the open technique and the good visualization it provides continue to make it the preferred operation for many hand surgeons. Open release with an extended surgical incision is recommended for acute CTS. [37, 38, 39]

A realized goal of the less invasive endoscopic approach to carpal tunnel release is to return individuals to work sooner. To date, however, concerns over safety and cost have been an obstacle to wider acceptance and use of endoscopic techniques in this setting. It is hoped that this picture will be changed by the development of safer endoscopic methods and less invasive or nonoperative techniques that provide safe and lasting treatment for CTS.

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Open Carpal Tunnel Release

General, regional, or local anesthesia can be used for open carpal tunnel release. The procedure is performed with a tourniquet inflated around the arm to control bleeding in the operative field. (See the videos below.)

Carpal tunnel release (part 1). Skin incision and retraction. Procedure performed by Deepak Kapila, MD, Broward Health, Fort Lauderdale, FL. Courtesy of BroadcastMed (http://ortho.broadcastmed.com/4229/videos/carpal-tunnel-surgery).
Carpal tunnel release (part 2). Exposure of palmar aponeurosis and transverse carpal ligament; entry into carpal tunnel. Procedure performed by Deepak Kapila, MD, Broward Health, Fort Lauderdale, FL. Courtesy of BroadcastMed (http://ortho.broadcastmed.com/4229/videos/carpal-tunnel-surgery).
Carpal tunnel release (part 3). Division of transverse carpal ligament, removal of tenosynovium, and release of median nerve. Procedure performed by Deepak Kapila, MD, Broward Health, Fort Lauderdale, FL. Courtesy of BroadcastMed (http://ortho.broadcastmed.com/4229/videos/carpal-tunnel-surgery).
Carpal tunnel release (part 4). Completion. Procedure performed by Deepak Kapila, MD, Broward Health, Fort Lauderdale, FL. Courtesy of BroadcastMed (http://ortho.broadcastmed.com/4229/videos/carpal-tunnel-surgery).

A longitudinal incision in the base of the palm is used (see the image below). The incision is made in line with the flexed ring finger. The intersection of this longitudinal line with the Kaplan line (a line parallel to the ulnar aspect of the extended thumb) marks the distal extent of the incision. Proximally, the incision ends a few millimeters distal to the distal wrist flexion crease.

Surgical incision for open carpal tunnel release. Surgical incision for open carpal tunnel release. Incision can be extended proximally across wrist flexion crease for more extended exposure.

Next, the subcutaneous fat is retracted radially and ulnarly, exposing the superficial palmar fascia. The superficial palmar fascia is divided sharply in line with the skin incision. Retractors are placed deeper to expose the transverse carpal ligament (TCL).

A blunt, curved hemostat clamp or similar instrument can be passed deep to the distal edge of the TCL to help confirm its position and to protect the contents of the carpal canal. The TCL is divided sharply along its ulnar aspect. Distally, the superficial palmar arch marks the end of the TCL and must be protected. Proximally, the ligament is transected to the level of the distal wrist crease under direct vision.

Blunt dissecting scissors are used to spread superficial and deep to the antebrachial fascia. Angled retractors are placed proximally under the skin flap so that the antebrachial fascia can now be divided for 2-3 cm proximally under direct vision, with the blunt scissors used partially open in a pushing fashion.

If visualization is poor, the skin incision may have to be extended proximally. If the incision must extend across the distal wrist crease, it should be angled.

Tenolysis, neurolysis, synovectomy, or reconstruction of the TCL is not routinely performed.

Before closure, the tourniquet is deflated, and hemostasis is obtained with bipolar electrocautery. No deep sutures are used. The skin is closed with 4-0 nylon. A soft, sterile dressing is applied.

Postoperative splinting has been recommended to prevent prolapse of nerve, entrapment of nerve in scar tissue, or tendon bowstringing. However, splinting has not been demonstrated to have any beneficial effect and can increase pain and scar tenderness.

A mini-incision approach to carpal tunnel release has been described, with good results reported. [40, 41]

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Endoscopic Carpal Tunnel Release

Endoscopic carpal tunnel release may be performed with either a one-incision or a two-incision technique. [19, 42]  In both techniques, the first incision is made transversely, just proximal to the wrist flexion crease between the palmaris longus and the flexor carpi ulnaris (see the image and video below).

Surgical incisions for endoscopic carpal tunnel re Surgical incisions for endoscopic carpal tunnel release (one- and two-incision techniques). Precise location of incisions is critical and depends on individual anatomy.
Minimally invasive endoscopic carpal tunnel release. Procedure performed by Marc Tanner, MD, Bon Secours Health System, Greenville, SC. Courtesy of BroadcastMed (http://ortho.broadcastmed.com/4120/videos/minimally-invasive-endoscopic-carpal-tunnel-release).

In the one-incision technique, the blade assembly and viewing device are inserted into the carpal canal in an anterograde fashion through the incision. With the wrist in extension, the device is advanced to the distal edge of the TCL. Video images, ballottement, and transillumination can be used to confirm the position.

When correct positioning is assured, the cutting blade is elevated, and the device is withdrawn, cutting the distal half of the ligament. The device is then reinserted to inspect ligament division, and additional passes are made to complete the division of the remaining proximal portions of the ligament. The skin incision is sutured closed.

In the two-incision technique, the second incision is made transversely in the palm on a line bisecting the angle formed by lines drawn along the distal border of the fully abducted thumb and the third webspace (see above). Blunt dissection is performed in the palm to identify the superficial palmar arch, the common digital nerves, and the distal edge of the TCL. Following the axis of the forearm, a blunt, curved instrument is inserted into the carpal canal through the proximal incision to free soft tissues from the undersurface of the TCL.

A trocar-and-sheath assembly is passed in an anterograde manner from the proximal incision to the distal incision through the carpal canal. The fingers and wrist are then extended and secured in a custom holder. The trocar is removed, and the endoscope is inserted into the sheath through the proximal incision.

The distal half of the ligament is then divided with special upward and reverse cutting knives placed in the distal sheath while being viewed through the endoscope.

The endoscope then is removed and reinserted into the sheath through the distal incision, and the reverse cutting knife is inserted into the sheath through the proximal incision. By withdrawing the reverse cutting knife, the proximal half of the ligament is released. Skin incisions are sutured closed.

With either technique, if visualization is not satisfactory, the procedure should be abandoned and conversion to open carpal tunnel release initiated.

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Complications

Complications are not common after either open or endoscopic carpal tunnel release. [43] Major complications with either approach can include nerve laceration, vessel laceration, and tendon laceration. Laceration of the palmar cutaneous branch of the median nerve with painful neuroma formation is reported to be the most common complication of open carpal tunnel release.

Incomplete release of the TCL is reported to be the most common complication of endoscopic carpal tunnel release. Loss of grip strength and tenderness of scars after open carpal tunnel release tend to resolve with time.

The general consensus among surgeons is that nerve injuries occur more frequently with endoscopic release than they do with open release. A 2014 meta-analysis of randomized, controlled trials lent support to this view. [44] Nerve injuries with the endoscopic technique are not necessarily related to the skill and experience of the surgeon but may be associated with the nature of the procedure, the anatomy of the carpal canal, and the device used.

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