Endoscopic Carpal Tunnel Release in Western Massachusetts
Endoscopic Carpal Tunnel Surgery Q & A
Carpal Tunnel Surgery is one of the most common operations done today. Of course there are many questions that arise. While a lot has been written about what carpal tunnel is, it is rare to get a surgeon's answers to these questions. Here are some common questions that we at the Hand Center of Western Massachusetts gets asked by our patients and their answers.
The PHYSICIANS at the HAND CENTER who use this method have the most experience in performing this procedure in Western Massachusetts and the surrounding region.
Will my sensation come back or be normal after surgery?
While the goal of carpal tunnel surgery is to relieve the pressure on the nerve not everyone will respond the same to surgery
Some patients will have immediate return of sensation while some will take longer. Some will notice an improvement right away but still feel tingling and will describe this as "numb" The return of sensation is dependent on many factors including age, general health, duration of symptoms, circulation and the actual mechanical severity of compression.
In very severe cases while decompressing the nerve stops the carpal tunnel syndrome from getting worse, full recovery of sensation may not be possible. Often this is seen in patients who have muscle wasting noted prior to surgery and in those with longstanding complete numbness and elevated two-point discrimination. Of course there are many in these categories that improve despite having very severe cases.
Having a severe case where you are not sure if you'd have full recovery is not a reason to put off surgery, as progression is likely if nothing is done.
How about my strength?
This is a very difficult question as there are many reasons why a hand with carpal tunnel may not feel as strong. It may be that the decreased sensation in the fingers prevents someone from knowing how tight to hold and object and that object is dropped more easily. With return of sensation or even a slight improvement in sensation, dropping objects becomes less of a problem. Some severe cases of Carpal Tunnel can be associated with atrophy in the muscles of the hand. In some severe cases, this muscle will never fully recover. However despite loss of muscle, function can still be preserved. In very severe cases a suregon may recommend a tendon or muscle transfer to improve function.
What do you actually do?
What is actually "released" is the hard ligament in your palm that covers the median nerve. Together with the bones in your wrist this ligament forms a ring or tunnel that surrounds the median nerve and the tendons to your fingers and thumb. When this "release" is done it is much like making a ring bigger and there is less pressure on the median nerve. The body heals the cut in this enlarged ring. But it takes time until your palm feels comfortable. With the pressure reduced on the nerve, healing can occur. How the nerve heals is different in everyone.
Is there more than one way to have carpal tunnel surgery?
There are two methods that are in use here in Western Massachusetts. One method is the traditional open palm method and the other is an endoscopic limited incision method.
What is the difference between these two methods?
In a standard open carpal tunnel release the surgeon carefully makes an incision in the proximal portion of the palm. Exposing the tough tissue in the palm called palmar fascia which is then released. Deeper down is the transverse carpal ligament which is then released to take pressure off the median nerve.
Endoscopic carpal tunnel release uses an endoscope, an instrument attached to a video monitor to visualize the undersurface of the transverse carpal ligament. This avoids the need to make an incision in the palm. Instead the surgeon makes the incision in the wrist crease near the base of the palm.
The endoscopic carpal tunnel view gives the surgeon performing carpal tunnel release a detailed magnified high resolution view. Here, to the right, a simple gauze bandage as viewed through the endoscope. The surgeon has control over variables to allow a full release under direct visualization.
The surgeon essentially releases the ligament from the inside out, avoiding damaging the tough tissues called fascia in the palm that give the palm its shape and contour. In addition the palm skin incision is avoided. For many this reduces the immediate problem of using the hand more fully in the early post operative period. It does not mean that there will be absolutely no discomfort but many feel it is less. Typically however one must realize that there are many people who undergo so called regular open carpal tunnel release who have very little pain and many do not need to take pain medicine at all. However those who have endoscopic release who do well, do well a little bit sooner.
On the right is a series of pictures from inside the carpal canal as the endoscope is used to divide the transverse carpal ligament. Here the fibers of the transverse carpal ligament form the roof of the carpal tunnel. Note the partial release in the first three frames going clockwise and the full release in the last frame. The cut edge of the ligament is seen.
Can I see a demonstration of the endoscopic method?
You can watch this embedded video from You tube.
What happens to the cut ligament?
The cut ligament heals. The gap fills in with new tissue. It is a lot like taking a ring or in this case because it your wrist, a bracelet, and making it bigger. By preserving normal tissue in the palm, less tissue has to fill in, in order for your palm to feel like it hasn't had surgery. A number of studies have shown that palm pain in the early postoperative period is reduced.
Can I use my hand right away?
After surgery you may be able to use your hand right away, especially your fingers to do light things. You must keep your dressing dry until it is changed or removed in the office. For showers or baths keep your dressing covered with a plastic bag. Using your fingers to do light things right away is important. While the dressing will cover your palm, your fingers will be free to use.
How long will it take to heal?
The time for healing is variable as no two people are alike and no one heals exactly the same. However most feel comfortable doing light activities UNSPLINTED and UNPROTECTED that require palm pressure in 1-2 weeks and very heavy activities 4 -5 weeks. Those with lighter sedentary jobs can often go back sooner. Those with very heavy jobs may take longer. Some with office positions even go back to work in the time period between having the opposite hand done. The minimum that most people take off from work is a few days. Of course, other conditions such as arthritis, tendonitis, and fibromyalgia may prolong discomfort after surgery. Sometimes you do not complain of or notice other problems until after your carpal tunnel is better!
While 6 weeks down the line most patients with either an open or endoscopic release are at nearly the same place with respect to activities, the endoscopic released hands seem to be more comfortable sooner. While endoscopic release may feel better earlier it is still advisable not to overdo it. Doing too much too early can delay full recovery, while not doing enough with hand can have the same effect. It is important to use your hand but not overdo it.
Do I need to go to sleep to have the surgery?
The type of anesthesia used is typically is known as "local with monitored anesthesia care "(or IV sedation). This means that you get an intravenous dose of medicine to relax or lightly sedate you. An anesthesiologist, a physician, who is in charge of this part of your operation, gives the sedation. Then the surgeon injects your palm to "numb it up". The sedation usually makes you forget that you had the palm injection. When the surgery starts you do not feel the incision but you know that something is going on because the back of your hand and your fingers still are awake. Some patients fall gently asleep at this point but many stay awake and are indifferent to what is happening. Some patients prefer to be more alert while others prefer to be “totally out.” Although the anesthesiologists are very good at giving just the right amount of sedation to make you comfortable, you may indicate your preference to them.
Does it have to be done in the hospital?
Most carpal tunnel is done as day surgery and most patients can have it done at the surgicenter without the need to go to the hospital. It is usually a 20 -25 minute procedure with total time in the surgery center about 2 hours. You need to have a ride from surgery and cannot drive for 24 hours. After 24 hours you may drive as long as you feel safe and are not taking pain medicine, which can impair your judgment. The requirement of insurance carriers and some people because of other medical problems or sometimes because of scheduling need to go to the hospital for surgery. Then you would expect to spend about 4 - 5 hours at the hospital. The surgicenter has you arrive 80 minutes prior to your scheduled surgery time while at the hospital you need to get there 2 hours ahead of the surgical time.
Will I be in a lot of pain?
While typically everyone who has carpal tunnel surgery gets a prescription for pain medicine, most state that they did not need it or used it minimally. Many get by with Tylenol, Advil, Aleve or a similar over the counter medication. Others feel the need to take pain medication such as codeine or Percocet or Vicodin for a few days. Remember that everyone will not respond to surgery the same way with respect to pain after the surgery. Although it is not unusual for patient to report that they didn’t use the prescribed pain medication. NEVER drive if a taking pain medication.
Overall carpal tunnel surgery can work well. While these answers do not apply to everyone and everyone will not react the same way to surgery, they represent a more common experience. For more information you can come to our website at http://www.handctr.com.
AFTER SURGERY, Therapy, Exercise, Splint and Return to Work
Will I need therapy?
Therapy is rarely used. Most get moving quickly and don’t need therapy. Occasionally finger stiffness or palm discomfort is a need for therapy. Other hand conditions also may require therapy if taken care of at the same time as carpal tunnel syndrome, for example thumb arthritis, finger joint problems, or tendon stiffness.
How about after surgery, can I use my hand?
Yes. You can use your hand and fingers right away.
Yes. You should use your fingers right away.
Yes. Using your fingers is better for you.
After surgery a surgical dressing with a small piece of a reinforcing plaster splint is placed upon the wrist but most of the palm and the fingers are free. You should move and use your fingers right away, even if you are apprehensive and feel tugging or pulling, you need to move to keep your fingers loose. You can shower but cover the surgical dressing with a plastic bag.
The goal should be to have full motion in your fingers before you return for the first postoperative visit.
What happens after surgery?
At 4-7 days after surgery the dressing is removed. The few stitches placed are either dissolving and under the skin or are nylon and will be removed at your first visit. After the dressing is off you may wash your hand and incision gently.
A band aid may be placed on the incision, or the incision may be left open to air. If a band aid is used it should be changed everyday for the next 5-7 days. Then stop using one.
Do not put cream, lotion, ointment, or gel on the incision until 3 weeks out from the surgery. After that if the skin is dry you can use something to moisten the skin if you like.
Hand Exercise ?
You will be given a stress ball or similar object at your first postoperative visit. Use it sparingly at first and do not overdo it; gradually increase your tolerance for gripping and squeezing. Make sure you move your fingers fully into the palm without the ball as well: make a fist, straighten your fingers, spread them apart and stretch out your wrist as well. The goal is to maintain the motion that you had prior to the surgery.
Wrist Splint or Bikers Glove or Neoprene Splint?
Some patients who also may benefit from a comfort cool splint or something similar to protect the basilar thumb joint and the palm in the post operative period.
An alternative to a splint for activity after surgery is to purchase a biking glove or weightlifting glove from a sporting goods store. These gloves have a padded palm and leave the fingers free. Many patients find them useful for various activities in the early weeks after surgery.
Finally, a wrist splint may be worn optionally while sleeping for the first week after the dressing is removed to prevent irritating the nerve while sleeping. After the first week, it is usually stopped when sleeping however those patients with more severe cases or persistent nighttime symptoms, may want to use the splint at night for longer. If you find the splint is bothersome, and feel it’s not helping at night after surgery then you need not wear it at night.
WHile a splint or biking glove may be used for heavier, tougher activities many light sedentary activities can often be done without a splint.
The main thing is to use your judgment. Many never wear a splint or glove after the dressing is off, others use it for a few weeks gradually eliminating it from their activity and then stopping.
How long will pain last after surgery?
It is normal for some patients to have a little discomfort 4-5 weeks after surgery if you push hard right in line with the ring finger in the palm. This is where the surgery took place in the palm thus if you hit it just right you’ll feel something; this area may still feel a little hard and swollen. Gentle massage or rubbing the area helps to soften and desensitize the tissues in the palm. Remember every patient is different and will experience pain to a different degree.
What about work?
Return to work is a complex issue as there are many factors that determine when and why someone chooses to or feels comfortable returning to work. Speak with your surgeon BEFORE surgery regarding your specific situation.
The time for healing is variable as no two people are alike and no one heals exactly the same. However most feel comfortable doing light activities UNSPLINTED and UNPROTECTED that require palm pressure in 1-2 weeks and very heavy activities at 4 -5 weeks. Those with lighter sedentary jobs can often go back sooner. Those with very heavy jobs may take longer. Some with office positions even go back to work in the time period between having the opposite hand done. The minimum that most people take off from work is a few days. Of course, other conditions such as arthritis, tendonitis and fibromyalgia may delay comfort after surgery.
Overall carpal tunnel surgery can work well to help the nerve in your hand recover. While these answers do not apply to everyone and everyone will not react the same way to surgery, they represent a more common experience. For more information you can come to our website: www.handctr.com.