A Patient's Guide to Endoscopic Carpal Tunnel Release
This guide will help you understand
Document Link: A Patient's Guide to Carpal Tunnel Syndrome AnatomyWhat part of the wrist is treated during surgery?The carpal tunnel is an opening through the wrist into the hand that is formed by the bones of the wrist on the bottom and the transverse carpal ligament on the top. (Ligaments connect bones together.) This opening forms the carpal tunnel.
View other anatomy features of the carpal tunnel. RationaleWhat does the doctor hope to achieve with surgery?The surgery releases the carpal ligament, taking pressure off the median nerve. By using the endoscope, surgeons can accomplish this without disrupting the nearby tissues. Proponents of the procedure feel that patients heal faster, are able to use their hand faster, and have fewer problems of tenderness in the palmar incision. Other physicians are not convinced that this procedure is better than the open incision technique. The endoscopic method is more technically demanding and can be more expensive in most hospitals. There may be a higher complication rate with this procedure due to the possibility of injury to the nerves in the carpal tunnel. As more and more surgeons choose to use this method, these questions will probably be resolved. Pre-Intervention InstructionsWhat should I do to prepare for surgery?The decision to proceed with surgery must be made jointly by you and your doctor. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your doctor. Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation. On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn't eat or drink anything after midnight the night before. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day. ProcedureWhat happens during the operation?The surgery can be done using a general anesthetic (one that puts you to sleep) or a regional anesthetic. A regional anesthetic blocks the nerves going to only a portion of the body. Injection of medications similar to novocaine are used to block the nerves for several hours. This type of anesthesia could be an axillary block (only the arm is asleep) or a wrist block (only the hand is asleep). The surgery can also be performed by simply injecting novocaine around the area of the incision. Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ killing solution.
The procedure using a single incision is becoming more popular. The incision allows the surgeon to open the carpal tunnel just below the transverse carpal ligament. Once the surgeon is sure that the instruments can be passed into the carpal tunnel, a metal or plastic cannula (a tube with a slot on the side) is placed alongside the median nerve. View insertion of cannula and endoscope. The endoscope can be placed into the tube to look at the underside of the transverse carpal ligament, making sure that the nerves and arteries are safely out of the way. A special knife is inserted through the cannula. This knife has a hook on the end that cuts backwards when the knife is pulled back out of the cannula. The slot in the cannula allows the hook to cut only in the direction the slot is facing. The nerves in the carpal tunnel are protected by the tube everywhere else. Once the knife is pulled all the way back, the transverse carpal ligament is divided, without cutting the palmar fascia or the skin of the palm. View of knife dividing the transverse carpal ligament. Once the transverse carpal ligament is divided, the median nerve is no longer compressed and begins to return to normal. View of the transverse carpal ligament after being divided. ComplicationsWhat might go wrong?This surgical procedure poses some risk of injury to the tendons, arteries, and nerves within the carpal tunnel, including the median nerve. It is possible, though uncommon, that these structures can be injured during surgery. Infection of the incision is another possible complication after surgery. Therefore, check your incision every day as instructed by your surgeon. If you think you have a fever take your temperature. If you have signs of infection or other complications, call your surgeon right away. These are warning signs of infection or other complications:
Some patients report having pain along the palm incision, but this happens less than when people have an open carpal ligament release. Sometimes people still feel some numbness and tingling after surgery, especially if they had severe pressure on the median nerve prior to surgery. When the thenar muscles are notably shrunken (atrophied) from prolonged pressure on the median nerve, strength and sensation may not fully return even after having this type of surgery. There is a small chance that problems of carpal tunnel syndrome can come back after having the endoscopic release surgery. Though it doesn't happen often, the likelihood is greater in workers who have to go back to a job where they hold on to vibrating tools for long hours. The strength to squeeze and grip with your hand may always be a little less once this surgery is done. During normal gripping, the tendons of the wrist press outward against the transverse carpal tunnel ligament. This allows the transverse carpal ligament to work like a pulley to improve grip strength. After the transverse carpal ligament has been released, the tendons lose this mechanical advantage. When the tendons try to press out, they do not have this pulley because the ligament has been released. Thus, grip strength is generally a bit less after a person has this surgery. Post-Intervention InstructionsWhat happens immediately after surgery?After surgery, the incision is wrapped in a soft dressing or simply covered with a bandage. Your doctor may splint and wrap the wrist. In the days following surgery, keep twenty-four hour phone numbers handy. Call your surgeon's office if you feel your hand is not healing as it should. RehabilitationWhat should I expect after surgery?You'll be scheduled to see your doctor in ten to twelve days for a follow-up. Your doctor may need to take out one or two of the stitches if they haven't already been absorbed into your body. Finger motions are safe to begin within one day after surgery. But you need to avoid heavy grasping or pinching with your hand for six weeks. These actions need to be avoided to keep the tendons from pushing out against the healing transverse ligament. After six weeks, you should be safe to resume gripping and pinching without irritating the wrist. Your doctor may have you work with a physical or occupational therapist for four to six weeks after the surgery. You'll begin doing active hand movements and range of motion exercises. Therapists also use ice packs, soft-tissue massage, and hands-on stretching to help with the range of motion. When the stitches are removed, you may start carefully strengthening your hand by squeezing and stretching special putty with your hand and fingers. Therapists also use a series of "fist" positions to encourage the finger tendons to slide within the carpal tunnel. As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you'll do are designed to get your hand working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your hand and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems. |
The median nerve and the flexor tendons pass through this tunnel. The median nerve rests on top of the tendons, just below the transverse carpal ligament. Between the skin and the transverse carpal ligament is a thin sheet of connective tissue called the palmar fascia.
An incision will be made in the wrist just below the crease where the palm starts. This incision allows the surgeon to place the endoscope into the carpal tunnel. Some surgeons make a second incision within the palm of the hand.
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