Health Society of South Africa

ENDOSCOPIC CARPAL TUNNEL RELEASE
Surgery to restore comfort and function

Help for a Painful Problem

Do you have numbness and tingling in your hand? Aching pain in your wrist? If you've been diagnosed with carpal tunnel syndrome (CTS), you probably know these symptoms all too well. CTS can also cause weakness that makes using your hand difficult or impossible. The good news is that CTS can be treated with endoscopic surgery - a procedure that allows your doctor to see and operate inside your palm and wrist through very small incisions.

What is Endoscopic Surgery?
Endoscopic surgery is done through one or two small incisions using a thin, telescope-like instrument called an endoscope. A video camera attached to the endoscope records images that your surgeon can view on a monitor. Specially designed surgical tools allow your surgeon to operate through the small incision(s). Because a large incision is avoided, endoscopic surgery may cause less pain and allow for faster healing than traditional (open) surgery.

The Surgical Decision
To confirm the diagnosis of CTS, your doctor has thoroughly examined your wrist and hand and possibly ordered tests. You and your doctor may have explored nonsurgical options, including medications or injections to help reduce swelling, splints to keep your wrist in a neutral position while you work or sleep, or changes in the way you use your hand. If nothing has fully relieved your symptoms, endoscopic surgery may be the best option for you.

Inside the Wrist: Your Carpal Tunnel

Your carpal (wrist) tunnel is formed by bones and the transverse carpal ligament. The median nerve runs through the centre of the tunnel. CTS develops when the median nerve presses against the transverse carpal ligament, leading to symptoms in your wrist, hand and fingers. Endoscopic surgery helps relieve these symptoms by releasing the ligament to ease the pressure on the median nerve.

Transverse carpal ligament. This very strong ligament forms the "roof" of the carpal tunnel.
Median nerve. This nerve carries sensation to and from the fingers and powers the movement of the thumb.
Carpal tunnel. The space in the centre of the wrist containing the flexor tendons and the median nerve.
Carpal bones. A U-shaped cluster of eight bones at the base of the palm forms the floor and two sides of the tunnel.
Flexor tendons. These tendons encircle the median nerve and form the major contents of the tunnel.

When You Have CTS
Due to a problem such as swelling or injury, the contents of the carpal tunnel may take up too much space. When this happens, the median nerve may press against the transverse carpal ligament, causing CTS. Symptoms of CTS include pain, numbness and tingling, and weakness in the hand and fingers. These symptoms may make it difficult to use your hand and disrupt your daily activities or nighttime sleep.

Surgery Can Help
During surgery, the transverse carpal ligament is cut (released). This increases the tunnel space so the median nerve is no longer under pressure. If CTS hasn't caused permanent nerve damage, releasing the ligament can help relieve CTS symptoms. However, this surgery won't treat other hand problems (such as arthritis, cysts or tendinitis). Your doctor can discuss types of treatment if you have any of these other problems.

Your Endoscopic Surgery

Your surgeon will discuss your endoscopic surgery with you, including how to prepare for it and the possible risks and complications. If for any reason the endoscopic procedure can't be continued once begun, a traditional open procedure will be done. Endoscopic surgery is performed in the hospital or in an outpatient surgery centre. You'll probably go home the same day.

Preparing for the Procedure
Your surgeon may ask you to visit your primary care doctor for a medical evaluation. This may include a physical, laboratory tests and other tests such as an ECG (eletrocardiogram) which measures your heart's electrical signals. Be sure to tell your doctor about any medications you're taking. You may need to stop taking certain medications, especially aspirin, anti-inflammatories and anticoagulants. If you smoke, quit at least two weeks before surgery to improve your circulation and healing. Unless advised otherwise, don't eat or drink anything after midnight the night before surgery, to prevent problems with the anaesthetic.

Your Anaesthetic
The anaesthetist will discuss the type of anaesthetic you'll be given to keep you free from pain during surgery. Local or regional anaesthetic numbs your arm and hand. You may also be given medication to help you relax. General anaesthetic makes you sleep during the procedure. During surgery, an intravenous (IV) line may provide you with fluids.

Risks and Complications
Your doctor will discuss the possible risks and complications of carpal tunnel surgery with you. They include:

Damage to blood vessels, leading to bleeding
Infection
Unrelieved symptoms
Nerve damage leading to temporary or permanent numbness (rare)
Tendon damage (rare)

The Surgical Procedure
The entire surgical procedure generally takes less than an hour. First a tight cuff (tourniquet) may be placed around your arm to stop blood flow to your hand. Then your surgeon makes one or two small incisions (portals) in your palm or wrist. The endoscope and surgical instruments are inserted through the portal(s). A video camera attached to the endoscope sends images of your carpal tunnel to a video monitor. This allows your surgeon to view the ligament and guide the surgical instruments. The ligament is released, the instruments are removed and the portal(s) is closed with sutures. A sterile dressing is then applied. You may also receive a temporary splint to keep your wrist straight after surgery.

If You Need Open Surgery
If for any reason your surgeon decides that the endoscopic procedure can't be continues safely, the endoscope will be removed and your surgeon will perform an open procedure. This requires making a larger incision on the palm of your hand.

After Your Surgery

You'll spend a brief time recovering in the hospital or surgical centre after your surgery. Before you go home, you'll receive instructions on how to care for your hand. Once you're home, take an active role in your recovery as you heal and return to normal activities. Also, keep regular follow-up visits with your doctor.

Immediately After Surgery
After the procedure, you'll stay in the recovery room while the anaesthetic wears off (about an hour). While in the recovery room, the circulation and nerve sensation in your hand will be monitored for possible problems. The nurse can instruct you on incision care and what you should and shouldn't do while your hands heals. You may be given prescription pain medications if you need them. When you're ready to leave, have someone drive you home.

Recovering at Home
For the first several days after your surgery, keep your hand elevated above the level of your heart to reduce swelling and pain. You may notice that your palm and the back of your hand are black and blue for a few days - this is normal and nothing to worry about. If you have discomfort in your wrist or palm, take your pain medications as directed. An ice pack may also help relieve discomfort. Keep your dressing clean and dry - ask your doctor about showering and bathing. Your doctor will tell you when you can remove your dressing (and your splint if you have one).

When to Call the Doctor
Call your doctor if you notice any of the following symptoms:

White or pale blue hand or nails
Increasing pain not relieved by pain medications
Loss of sensation in fingers
Excessive swelling
Fever over 37.8�C

Getting Stronger
To keep your hand flexible as it heals, it's best to begin moving your fingers right after surgery. Certain exercises may be recommended to help maintain circulation in your hand, improve your flexibility and increase your strength. To protect your healing skin and ligament, avoid bending your wrist very far forward (flexion) or backward (extension).

Returning to Activities
Within a day or two after surgery, you can begin to use your hand for light activities. Your hand will probably be weak at first, but it will get stronger as you use it. Follow your doctor's instructions regarding bandaging and avoid bumping or hitting the area around your incision(s). Talk to your doctor about when you can return to work. Also ask your doctor about driving. In many cases, you'll be able to resume driving when you stop taking prescription pain medications, usually in about a week.

Following Up with Your Doctor
You'll need to return to your doctor for a follow-up appointment about a week after your surgery and then periodically while you heal. During these visits, your doctor monitors how your hand is healing and checks for problems. You and your doctor can discuss the results of your surgery. If your CTS was due to repetitive strain, you may need to make some changes in how you use your hands to avoid future problems. With care, you may regain full use of your hand and remain free from painful symptoms.

Your Surgical Checklist

Listed below are some recommendations you may need to follow before and after surgery. Discuss them with your doctor.

Before surgery:
Your schedule for examinations, surgery and stopping taking medications.
Arrange to have someone drive you home from the hospital.
Don't eat or drink anything after midnight the night before surgery.

After surgery:
Keep your wound clean
Don't get your incision wet until after your first visit to your doctor.
Elevate your hand above your heart as often as possible for the first week.
Use ice to relieve any discomfort in your palm.
Avoid bumping or hitting the incision site.
Avoid using your operated hand for heavy lifting.
Move your fingers - grip and straighten to restore flexibility.
Avoid bending your wrist too far up or down.

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