Carpal Tunnel Syndrome FAQs

All surgical procedures, including Carpal Tunnel Release Surgery, are accompanied by a certain degree of risk, whether the procedures are traditional or endoscopic.  Dr. Volshteyn and our surgical team are dedicated to making sure that your operation will go smoothly. 

We careful review your medical history and current health condition before deciding if it is safe for you to proceed with surgery.  It is important that you fully disclose all pertinent information so that we are able to make an accurate assessment of the risks involved.  We will take every precaution necessary to reduce the possibility of any complications.

The carpal tunnel is a channel located at the level of the wrist.  It is formed by carpal bones and the transverse carpal ligament.

The carpal or transcarpal ligament is a fibrous band which makes up the roof of the carpal tunnel.  10 main structures pass through the tunnel.  One median nerve and 9 tendons run through this tunnel together with smaller vascular and connective tissue structures.

The most frequent cause for Carpal Tunnel Syndrome development is occupational.   It is associated with association with repetitive tasks and activities.

Repetitive and prolonged wrist flexion and extension movements (finger flexion and extensions to a lesser degree) can provoke increased pressure within the carpal tunnel due to inflammation and swelling.   The continuous movement and stretching of the nerves and muscle tendons in the tunnel can bring about an inflammation and swelling which reduce the carpal tunnel dimensions.  Being the “weakest link” amongst the structures, median nerve gets compressed.

Other systematic illnesses and conditions can be associated with Carpal Tunnel Syndrome.  Diabetes, rheumatoid arthritis, Mixedema, Amiloidosis,  Pregnancy, use of oral contraceptives, menopause, traumas (with or without wrist bone fractures), arthritis and deforming arthrosis are among the conditions that can precipitate Carpal Tunnel Syndrome.

In the initial stages Carpal Tunnel Syndrome (CTS) presents with “pins and needles” sensation, numbness or swelling of the hand, mostly to the first three fingers (thumf, index and middle) and partly the fourth finger.   The pain usually worst in the morning or during the night or while driving or using vibrating instruments: drills, massagers, reciprocating saws and jack hammers. 

Commonly, the patients report waking up at night with the feeling that they need to rub or squeeze their hand.  In happens because when we sleep, we have a tendency of keeping our wrists flexed.   This position decreases the size of the Carpal Tunnel and produces the worsening of symptoms. 

Wearing a night time wrist splint prevents this posture and allows patients to have a better night sleep.  Alternatively, some patients report that they sleep on their stomach with the wrists locked flat on the mattress by the pillow and their body weight. 

The pain can  also radiate also to the forearm, and these symptoms are defined better as "irritating". If the Carpal Tunnel Syndrome worsens, the feeling in the fingers, the strength in the hand can be lost and local atrophy of the thumb muscles (thenar eminence) can be seen.  

Carpal Tunnel Syndrome is significantly associated with some occupations. Those hit more are workers in manufacturing and assembly lines, electronics, textiles, food industry, shoes, leather industry and also workers in packing departments, hotel chefs and workers in Public sectors.  A new group of computer related occupations is rapidly climbing too.

Generally, post-operative instructions call for rest and limited movement in order to speed up the healing process and recovery time.  The length of recovery varies with each procedure and is different for each individual.  Bruises usually disappear within a few days, and most swelling is gone in a matter of weeks. 

If you follow our post-operative instructions carefully, you will be able to enjoy activities within 2-4 weeks.  Functional Recovery is shorter with endoscopic procedures.  Your scars will fade over time but are permanent.  We take care to conceal any scars so that they are barely visible, if at all.  When you come in for your consultation we can discuss your expected recovery period and any post-operative instructions in detail.

Insurance providers generally cover costs for reconstructive surgery.  If your surgery is covered by insurance, pre-certification is required.  We will be happy to assist you with the process.

There is no universally correct opinion.   During the night the wrist may be in flexed position.  This position can decrease the size of the Carpal Tunnel and increase the pressure on the nerve.   The other theory is that  the lying position may redistribute body fluids and increase in the pressure in upper limbs and hands and therefore within the carpal tunnel with increase of pressure.  The third theory is that the actual hand resting does not allow fluid drainage from within the carpal tunnel.

The incidence of Carpal Tunnel Syndrome is 0.1% to 0.5% with average of 0.2-0.3%.  It is estimated that  about 200,000 carpal tunnel surgeries performed every year.   It is about three to four times (some studies show up to 6 times) higher in women. In about 70% of the CTS cases, it is bilateral and is more common in the dominant hand.

If the patient comes in with classic complains of tingling (paresthesias) and/or pain, often radiating to the forearm, mostly at night or early in the morning, radiating to the thumb, index and middle finger (occasionally to the fourth finger also), the symptoms are most probably due to Carpal Tunnel Syndrome.

Some feel that, it is necessary to carry out a neurological test and EMG/ENG (electromyography / electroneurography) nerve conduction study.  The objective neurological test examines the strength, the reflexes, and sensitivity, and can help in diagnosing additional areas of compression.

The most common clinical tests are the Tinel and Phalen tests. In the first case, the carpal tunnel is tapped with a reflex hammer or a finger and the patient must feel an electric shock type feeling in the median nerve distribution area.   The second test consists in bending or stretching the hand over the forearm (flexing the wrist) for up to one minute; the patient must feel a tingling sensation or the tingling sensation must worsen.  The faster the symptoms occur or warsen, the more severe the Carpal Tunnel Syndrome is.

However the tests can often give negative false or positive false results.  It is estimated that up to 15% of patients with negative results actually suffer from carpal tunnel.   It is recommended to base the treatment on overall impression and not necessarily single test results.  

Usually without proper treatment or change of job, Carpal Tunnel Syndrome tends to get worse over the years.  If initially the patient complains of pins and needles, depending on cause and severity, over weeks, month or years Carpal tunnel syndrome can progress to complete loss of sensation and very severe decrease in strength.  At that time even having surgery will not restore original function any more.  However some patients report having no change for a while.

Carpal Tunnel Syndrome therapy can be conservative or surgical. Conservative treatment is can be used if there is no deficit of strength or sensation or severe changes in EMG/ENG tests.

It is important, however not to operate on the patient too late, in as much as results and disability may be permanent. Conservative treatments include changing working schedule or conditions to achieve an improvement.   Other therapeutic modalities include: physical therapy, stretching, ultrasound, ionophoresis, laser.   

Non steroid anti-inflammatory medications also have beneficial temporary effect as steroid drug injections.

Unfortunately, commonly with all the conservative treatments available, while the patient is trying various modalities, the disease progresses and the potential recovery of sensation or strength decreases progressively.

Wrist splints are efficient but not well tolerated, usually used at night only and therefore have no effect on the cause of the syndrome.   

Surgery is one of the most reliable methods of carpal tunnel treatments.  The operation is quite simple and involves cutting the carpal ligament. The pressure is relieved and the nerve compression resolved.  Recovery of the nerve function may take up to 12 month.  Temporary decrease in grip strength is common.   It can also be done endoscopically. There are no univocal criteria for the choice of surgical method. Recovery is usually between 2 –4 weeks.  It may be a bit shorter with endoscopic method.

For more information on carpal tunnel syndrome, the following organizations:

National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse, NIAMS, NIH, HHS
Phone: (301) 495-4484, (301) 565-2966 TTY, (301) 881-2731 Faxback System,
(877) 226-4267
Internet Address: http://www.niams.nih.gov/

National Institute of Neurological Disorders and Stroke, NIH, HHS
Phone: (301) 468-5981 TTY, (301) 496-5751 (Information Office),
(800) 352-9424
Internet Address: http://www.ninds.nih.gov/

National Institute for Occupational Safety and Health (NIOSH) Publications Office
Phone: (513) 533-8471, (800) 356-4674
Internet Address: http://www.cdc.gov/niosh/pubs.html

American Academy of Orthopaedic Surgeons
Phone: (847) 823-7186, (800) 346-2267, (800) 999-2939 (Fax on Demand)
Internet Address: http://www.aaos.org/

American Chronic Pain Association
Phone: (916) 632-0922
Internet Address: http://www.theacpa.org/

American Society for Surgery of the Hand
Phone: (404) 523-8821 Fax on Hand, (800) 905-4263 Fax on Hand
Internet Address: http://www.hand-surg.org/

For your convenience we include the information available elsewhere.

The Following information is provided by American Society for Hand Surgery

1) What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is a disorder that causes pain,

weakness and numbness in the hand and wrist.

Patients oftencomplain of symptoms during activities such as driving a car,

holding a telephone, and reading the newspaper. It occurs due

to increased pressure on the median nerve at the wrist. The

associated pain occurs most often about the palm side of the

wrist and hand but may be diffuse. The pain may radiate to the

forearm and shoulder but rarely to the neck. The median nerve

provides sensation to the thumb, index, long and half the ring

fingers and therefore patients with carpal tunnel syndrome will

classically note numbness and tingling in this distribution.

Some patients may note numbness about the entire hand.

These symptoms may occur with activities during the day or

while at rest during the night. In addition to numbness and

pain, patients may complain of weakness of the hand and

dropping objects. With a more severe carpal tunnel syndrome,

atrophy of the muscles at the base of the thumb may be noted.

2) What is the carpal tunnel?

There are eight carpal bones of varying shape and size that

make up the wrist. These carpal bones form a “C” shaped ring

that is covered by a ligament, the transverse carpal ligament.

The ligament and bones form the carpal tunnel through which

pass the median nerve and nine tendons that flex the fingers

and thumb. Any condition that decreases the size of the tunnel

or increases the size of the contents can cause carpal tunnel

syndrome.

3) What causes carpal tunnel syndrome?

There are numerous factors that may cause carpal tunnel

syndrome. It may be related to strenuous repetitive use of the

hands or occur after trauma such as a wrist fracture. The nerve

can be compressed from something extra within the canal.

This includes a mass, an anomalous muscle, or a hematoma

which can occur particularly in patients taking anticoagulation

medication after a fall on the hand. Other disorders associated

with carpal tunnel syndrome include diabetes mellitus,

hypothyroidism, alcoholism, severe infections, and arthritic

diseases such as rheumatoid arthritis, and gout. Carpal tunnel

syndrome is also associated with pregnancy as well as patients

on hemodialysis.

4) How does the doctor make the diagnosis of carpal

syndrome?

The physician can often make the diagnosis after the patient

has explained their symptoms and the extremity has been

examined. During the examination the physician may perform

certain provocative maneuvers to determine if carpal tunnel

syndrome is evident. By tapping over the nerve at the wrist,

termed Tinel’s sign, a patient with carpal tunnel syndrome may

note a tingling sensation in the digits innervated by the median

nerve. Similar findings may be noted while holding the wrist

fully flexed or extended, termed Phalen’s and reverse Phalen’s

signs respectively. The strength of the muscles of the hand

are evaluated as well as the sensation. An EMG / NCV,

electromyography and nerve conduction velocity, is often

performed to confirm the diagnosis and determine severity. Xrays

are not routinely obtained.

5) How is carpal tunnel syndrome treated?

Patients with carpal tunnel syndrome due to a specific medical

condition such as diabetes or a thyroid disorder should have

the associated medical disorder treated appropriately. Wrist

splints are used at night and during the day during activities that

may exacerbate the symptoms. Non-steroidal antiinflammatory

medications may be of benefit but have the risk of

gastritis. Alteration of activities is important. This includes

taking frequent breaks from repetitive activities, and stretching

before and after activities. A therapist may be helpful in

reviewing ergonometric tips or performing a work place

evaluation. A corticosteroid injection of the carpal canal often

provides temporary relief. Approximately 25% of patient treated

with an injection will have long-term relief of their symptoms.

Non-operative treatment modalities are tried for months and if

the symptoms persist or progress surgical treatment is

considered. Those patients with a severe carpal tunnel

syndrome are considered for surgery more promptly since the

non-operative modalities typically are not helpful at this stage.

6) What is involved in the surgery for carpal tunnel

syndrome?

Carpal tunnel release is the most common procedure

performed in the upper extremity. In general surgical

procedures for carpal tunnel syndrome cut the ligament over

the canal to take the pressure off of the median nerve. The

surgery is performed on an outpatient basis under local

anesthesia and often in conjunction with intravenous sedation.

The procedure may be performed using the open technique in

which an incision is made in the palm to cut the ligament. The

nerve and canal is inspected to confirm that there is no other

process compressing the nerve. The skin is sutured and a

sterile dressing and often a splint are applied. The sutures are

removed in 5 to 10 days and an exercise program in started.

An alternative surgical procedure is the endoscopic carpal

tunnel release in which one or two smaller incisions are made

at the palm and or wrist and the ligament is cut while keeping

the skin above the ligament intact. The benefit of the

endoscopic release is less postoperative pain, earlier return of

grip strength, and earlier return to work.

7) What are the results of surgery for carpal tunnel

syndrome?

The majority of patients undergoing carpal tunnel release note

an improvement in their symptoms. Some patients may notice

persistent numbness and tingling. This will occur particularly in

patients that have a more severe carpal tunnel syndrome. At

this stage more permanent changes may have occurred within

the nerve due to longstanding compression. Other patients

may notice persistent or recurrent symptoms due to other

factors for example nerve compression in the neck (cervical

radiculopathy), or a polyneuropathy due to diabetes.

Most patients are capable of performing their activities of daily

living soon after the procedure. Pain about the about the palm

is often noted initially that is treated with scar massage. This

scar pain is one reason full grip strength often does not return

until three months after the procedure.

8) What are the risks of surgery for carpal tunnel syndrome?

There is a small risk of nerve injury since the procedure is

performed adjacent to the nerve. The endoscopic release has

a higher risk of nerve and blood vessel injury as compared to

the open procedure. There is a low risk of infection and

bleeding during the procedure is minimal. Hand and wrist

stiffness is a potential risk but is uncommon if the postoperative

exercises are performed.

The type of the anesthesia varies with each procedure. 

For some Carpal Tunnel Release procedures, only local anesthesia or local anesthesia with intravenous (IV) sedation is needed.  This method will allow you to be awake, but insensitive to any pain. 

In more complex Carpal Tunnel Release procedures, general anesthesia is needed and you will be asleep during the entire procedure.  The anesthesia used in your operation will depend on the type and extent of the procedure(s), your age, and the surgeon’s preference.