Carpal tunnel syndrome (CTS) is a common condition affecting the hands, wrists, arms, and including the neck region of many patients. Swelling, injury or pressure within the tunnel impacts the median nerve (the nerve in the forearm), resulting in pain or discomfort. Therefore, surgery to correct CTS focuses on reducing pressure on the median nerve.

Diagnosing Carpal Tunnel Syndrome

The most important goal of the diagnostic and imaging exams is to diagnose the carpal tunnel syndrome (CTS) itself. There are conditions such as pregnancy, arthritis, thyroid disease, or diabetes, which can cause symptoms similar to CTS.

As part of the diagnostic process, your doctor will likely perform a full range of diagnostic tests for CTS and the appropriate imaging studies (X-rays, MRI). The doctor will also do a full physical exam, looking closely at the wrist area for pain or swelling.

The main purpose of surgery for CTS is to “release” the band of tissue, known as the transverse carpal ligament, surrounding the median nerve. The transverse carpal ligament acts like a rubber band holding around the tendons of the arm and hand as well as the median nerve. If there is swelling within the carpal tunnel, the transverse carpal tunnel ligament tightens, putting pressure on the median nerve and causing pain. The surgery is therefore called “release” surgery because by cutting the transverse carpal tunnel ligament, it can help release pressure on the median nerve.

Surgery may be an option for patients whose pain or discomfort from CTS has lasted several months, even up to a year. Surgery will be considered for those patients in whom conservative (non-surgical) therapies have not been effective or are unable to provide long-term relief. Non-surgical options for CTS may include: 

• The use of a splint or wrist brace 
• Activity modification 
• Medical management, such as through the use of non-steroidal anti-inflammatory drugs (NSAIDs) 
• Physical therapy 
• Steroid injections

The difference between conservative and surgical methods is that while conservative methods may reduce the symptoms associated with CTS, surgery can help treat the underlying cause of CTS: pressure on the median nerve.

Surgical Procedures

There are two main types of surgery available for CTS. One type uses traditional surgical methods and is known as open carpal tunnel release surgery (OCTR). The other type of surgery uses specialized endoscopic instruments and is known as endoscopic carpal tunnel release surgery (ECTR). The goal of both types of surgery is to cut the transverse carpal tunnel ligament in order to open up the space inside the carpal tunnel area. 

• Open Carpal Tunnel Release (OCTR): In surgical terms, “open” refers to traditional surgery, and involves making a 1-2 inch incision in the wrist. The incision, or opening, allows the surgeon to directly see and then cut the transverse carpal ligament. The “release” is immediate and helps reduce pressure on the median nerve. The incision is then closed with stitches. 
• Endoscopic Carpal Tunnel Release (ECTR): The word “endoscopic” refers to the use of specialized instruments and cameras to indirectly approach and then sever the transverse carpal tunnel ligament. The surgeon may make one or two small incisions in the wrist near the transverse carpal ligament. A small tube is temporarily inserted into the operation area for housing the other instruments during the surgery. The instruments are used to see and then to cut the transverse carpal ligament. After the ligament has been “released,” the tube and other instruments are removed, and the incision site is closed with stitches. Endscopic surgery is also called laparoscopic or keyhole surgery.

Because the incision is smaller for the ECTR technique compared to the OCTR, the endoscopic surgery may have faster recovery times. However, if the surgeon is not able to see the entire transverse carpal ligament using the endoscopic equipment, or if it is a repeat procedure, OCTR may be recommended.

Both OCTR and ECTR are typically done under local anesthesia (numbing the wrist area) on an outpatient basis, not requiring a hospital stay. Both types of surgery allow for recovery within a few weeks with minimal scarring. Your doctor can help you decide which surgical option is best for you and your particular case of CTS.

Recovery

After the surgery, the entire wrist and forearm will remain bandaged for a few days. Driving is not recommended immediately following surgery, though you may still have limited use of your thumb and fingers. Most patients need some assistance with daily activities, but are able to still do basic tasks such as getting dressed or eating.

If a small tube or drain is placed into the surgery site to help remove excess fluids, you will need to return to the doctor’s office to have the drain removed. Your wrist will then be placed into a plastic splint to prevent motion near the surgical site. You may have to wear have a splint for at least a week or two, or for as long as your doctor advises. At this time, you may also be prescribed some exercises to help with the recovery process.

Depending upon the speed if your recovery, you may be able to return to most normal activities in 6-8 weeks. Your doctor may prescribe physical therapy or other specialized exercises. Some patients experience some tingling or numbness up to several months after the surgery that reduce over time.

Your doctor may also prescribe pain or anti-inflammatory medication. You may also be able to use over-the-counter (OTC) medications like NSAIDs (acetaminophen, ibuprofen, or naproxen).

If you have discomfort due to CTS in both hands, you may choose to have both wrists operated on at one time. Though this means that you will only have to go through the recovery process once, you will have limited use of both of your hands for several weeks. Therefore, assistance is recommended for daily tasks, including household chores. Talk to your doctor to see if a dual surgical option is right for you.

Carpal tunnel release surgery is an effective surgery. After recovery, patients experience minimal scarring and rarely have to have the surgery repeated.

After recovery from surgery, you may also want to try and reduce the activities that caused the CTS initially, such as any repetitive motions or overuse of the hand or wrist.

As with any surgical procedure, the risks include the possibility for infection or nerve damage.

More importantly, patients may require assistance in completing daily chores, including self-care, for some time after the surgery. There may also be some lingering weakness or numbness, which should get better over time.

Be sure to address any questions or concerns you have with your doctor.

If left untreated, severe cases of CTS can lead to permanent numbness or weakness over time. Patients may lose strength or grip in their hands or arms, causing them to drop objects or lose sensation. Treatment for CTS can help restore normal function.

CTS may take many months or years to develop. Untreated CTS can lead to long-term nerve and muscle injury, weakness, or other disability.