Repetitive stress injuries
Every year more than 500,000 people in the US undergo surgeries for carpal tunnel syndrome. Surgery for CTS is among the most common hand surgeries. In various trials, 70 - 90% of patients who underwent surgery were free of nighttime pain afterward.
Although evidence strongly suggests that surgery is more effective than conservative approaches (at least in patients with moderate-to-severe CTS), the decision about whether to have surgery to correct CTS, and when to have it, is a troubling one for patients. Electrodiagnostic and other tests used to confirm the presence of CTS are not very useful in determining the best candidates for surgery. Severe CTS may not relate at all to surgical success or the lack of it.
In general, patients with the following characteristics are less likely to respond to conservative treatment and, therefore, might benefit from surgery:
Surgery does not cure all patients, and because it permanently cuts the carpal ligament, some wrist strength may be lost, but it rarely has any effect on function. A number of experts believe that release surgery is performed too often. They recommend aggressive conservative treatment (such as splints, anti-inflammatory agents, and physical therapy) before choosing surgery. Nevertheless, other experts argue that CTS is often progressive and will worsen over time without surgery. Furthermore, evidence now shows that surgery is better than splints and conservative measures for the relief of pain.
Factors that may increase the chances for successful surgery:
Factors that may reduce the chances for success:
Open Release Surgery. Traditionally, surgery for CTS entails an open surgical procedure performed in an outpatient facility. In this procedure, the carpal ligament is cut free (released) from the median nerve. The pressure on the median nerve is therefore relieved. The surgery is straightforward.
The Mini-Open Approach. In recent years, more surgeons have adopted a "mini" open -- also called short-incision -- procedure. This surgery requires only a one-inch incision, but it still allows a direct view of the area (unlike endoscopy, which is viewed on a monitor). The mini-open approach may allow for quicker recovery while avoiding some of the complications of endoscopy, although few studies have investigated its benefits and risks. The recovery time in patients receiving the mini-open approach may be shorter than with the open approach, and results are generally the same.
Endoscopy. Endoscopy for carpal tunnel syndrome is a less invasive procedure than standard open release.
Patients report less pain than those who had the open release procedure, and return to normal activities in about half the time. Nevertheless, at this time the best evidence available does not show any significant long-term advantages of endoscopy over open release in terms of muscle, grip strength, or dexterity. The endoscopic approach may even carry a slightly higher risk of pain afterward. This may be due to a more limited view of the hand with endoscopy. (In the open release procedure, the surgeon has a full view of the structures in the hand.) Concerns of irreversible nerve injury with endoscopic carpal tunnel release, when compared with open carpal tunnel release, exist because of this reduced visibility. However, larger studies have shown an extremely low number of complications following the procedure, when performed by physicians experienced in the technique.
Timing for Recovery. Patients should expect the following course:
For some patients, release surgery relieves CTS symptoms of numbness and tingling immediately.
Physical Therapy. Physical therapy following surgery has not been shown to speed up recovery or affect the final outcome of CTS surgery.
Treatment failure and complication rates of CTS surgery vary.
Complications after surgery may include the following:
If pain and symptoms return, the release procedure may be repeated.
Reasons for procedure failure include:
Patients who had open release surgery appear more likely to require repeat operations compared with those who have had endoscopic surgery.
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