Treatment of Carpal Tunnel Syndrome

Conservative Treatment

Conservative treatment of Carpal Tunnel Syndrome involves removal from exposure, physical therapy, anti-inflammatory medication, and application of splints at night. Splints eliminate the awkward nighttime postures that can make CTS worse. Splints should not be worn at work.

The most important part of conservative treatment is activity modification. For workers in high risk jobs, activity modification would involve time away from jobs with risk factors, work restrictions and work station redesign. When symptoms first occur, workers should report them to their health and safety rep. and plant medical department. The jobs that make symptoms worse should be evaluated for risk factors.

Through conservative treatment and the reduction of risk factors at work, carpal tunnel surgery may be avoided.

Surgical Treatment

Carpal tunnel syndrome (CTS) is a very common condition. It is estimated that 400,000 to 500,000 surgeries for CTS are performed each year in the United States alone, making it one of the most common orthopedic procedures. Surgery for CTS was proposed in 1913, and the first recorded surgery for CTS was performed just over 70 years ago. And yet, somewhat amazingly, the study by Gerritsen et al., (2002) is the first randomized control trial (RCT) to assess the efficacy of carpal tunnel release surgery in comparison to ‘conservative’ therapy. (see article on page 2)

The randomized control trial is generally regarded the most rigorous scientific method used by the research community. In classic carpal tunnel surgery an incision is made at the base of the palm. The trans-carpal ligament is cut and the condition of the tissues within the tunnel (the nerve, tendon, tendon sheath) are examined. If all the tissues are intact, carpal tunnel surgery is usually limited to the cutting of the trans-carpal ligament to relieve pressure on the median nerve. Several millimeters of the ligament may be removed to prevent the ligament from taking up space in the carpal tunnel during the healing process.

Other procedures may be performed in conjunction with carpal tunnel release. Such extreme procedures are rare. Sometimes thickened synovial tissue and scar tissue around the flexor tendons is cut away.

This is known as flexor tenosynovectomy. Another possible procedure is the removal of the nerve covering which may have scarring. When scarring occurs it can contract and squeeze the nerve. The nerve covering is called the epineurium. Removal of the epineurium is called an epineurotomy. In severe cases the nerve bundle itself can be damaged. A procedure used in this case is internal neurolosis. In this procedure the surgeon spreads the nerve bundles apart and removes scar tissue from neuron fibers.

Some surgeons use a technique called endoscopic carpal tunnel surgery. An incision is made at the base of the palm. The doctor uses miniature video and surgical tools to cut the transcarpal ligament from the inside. This surgery may be more expensive because it takes longer and requires specialized equipment. Since the incision is much smaller in endoscopic surgery, the time away from work may be reduced because less time is needed for sutures to heal.

Figure 2. Cross section of the carpal tunnel. In both endoscopic and open carpal tunnel surgery the transverse carpal ligament is cut to create room within the carpal tunnel. This releases pressure on the median nerve.

One disturbing feature of endoscopic surgery is the increased risk of cutting into or severing the ulnar or median nerve, the flexor tendons, or the arteries in the palm. The endoscopic surgery takes place in a very cramped space; the surgeon has a very narrow field of view. In the more common open tunnel release with a larger incision the surgeon peels back the tissue and can see where he is and what he is cutting.

A primary reference for orthopedic surgeons states, while studies show that endoscopic surgery can be done safely by experienced well trained surgeons, “it is doubtful whether this procedure should be used for every patient with carpal tunnel syndrome. Consideration should always be given to an open technique if the endoscopic release cannot be performed safely”. 1

After surgery is performed a period of rest is required to let the tissues heal. Patients might still have symptoms of tingling after surgery. The strength of the hand may be reduced after the transverse carpal ligament is cut. It is important to reduce or eliminate the risk factors associated with CTS for workers who have had surgery. Workers returned to unabated jobs will likely develop CTS again. Problem jobs should be evaluated and redesigned to eliminate risks.

1. Campbell’s Operative Orthopedics, Volume 4, Microsurgery, the Hand and Nervous System Disorders. 9th ed. 1998 edited by S. Terry Canale p 3689. For discussion of the endoscopic surgery see pp 3688-3691