Carpal tunnel – endoscopic surgery

Definition of carpal tunnel syndrome:

The carpal tunnel syndrome is a compression of the median nerve at the wrist by the flexor retinaculum, also called anterior annular ligament. It manifests itself by tingling in the hand. Compression of the median nerve at the carpal tunnel is a frequent hand pathology that can occur at any age, however carpal tunnel syndrom is more frequent in women between 40 and 55 years old. Hand surgery is necessary in forms that are severe or resist medical treatment; the operation is often performed by a specialized surgeon.

Video of carpal tunnel syndrome treatment:

Video of carpal tunnel syndrome treatment:
Video of hand surgery showing an endoscopic surgical operation on the carpal tunnel / Toulouse specialist 

 

Diagnosis of median nerve compression in the carpal tunnel:

An accurate diagnosis is essential to determine the most suitable treatment: nocturnal bracing, injections or surgery. Several functional signs can occur, simultaneously or separately: tingling (paresthesias) of the hand’s first four fingers, pain in the hand’s heel, loss in strength and fatigability of hand and thumb. In the presence of carpal tunnel syndrome, the clinical examination must focus on measuring the epicritic sensibility (Weber test) of the hand and the fingers and the hand's global grip strength (Jamar®), which will make it possible to evaluate the severity of the carpal tunnel pathology.

The clinical examination will also look for pathologies associated with the carpal tunnel: trigger finger, rhizarthrosis.

Measuring epicritic sensibility for a carpal tunnel syndrome (Weber test)

Measuring grip strength using Jamar® prior to carpal tunnel surgery

 

Carpal tunnel syndrome has several degrees of severity:

  • Stage 1 (early) carpal tunnel syndrome: tingling (paresthesias) is felt in the middle or at the end of the night, grip strength is not diminished. At this stage, a simple injection or even a nocturnal splint will suffice to reduce the discomfort caused by the carpal tunnel syndrome, and hand surgery is not necessary yet.
  • Stage 2 (intermediate) carpal tunnel syndrome: discomfort occurs during the day. The activities that require strength will be affected first, then, gradually, daily tasks. At this stage, medical treatment can be discussed but only surgery (outpatient hand surgery) can ease the carpal tunnel syndrome permanently.
  • Stage 3 carpal tunnel syndrome: hand sensibility is reduced and atrophy occurs on certain muscles of the thumb. All activities are disrupted, the loss in sensibility and strentgh is considerable. At this stage, only surgery can be considered, carpal tunnel surgery is required.

Endoscopic surgery of the carpal tunnel:

Carpal tunnel syndrome can be treated by endoscopic release in all cases, except when the patient has already undergone open carpal tunnel surgery. Endoscopic surgery of the carpal tunnel syndrome is specialized hand surgery; it is a reliable surgical technique that allows a short recovery.

You can read the guidelines of the American Association of Orthopaedic Surgeons here 

 

Carpal tunnel syndrome, anatomical diagram of median nerve compression, ToulouseCarpal tunnel surgery in Toulourse, anatomical markers and line for incision

 

Endoscopic release surgery of the median nerve at the carpal tunnel is hand specialist surgery, it is an outpatient procedure that usually is carried out with the hand under anaesthesia.
A 5 mm incision is performed above the hand, at the wrist’s flexion crease, careful dissection proceeds down to the volar carpal ligament, which is incised. The underside of the transverse carpal ligament is then released using a spatula.

arpal tunnel, endoscopic section of flexor retinaculum, Toulouse 

Carpal tunnel endoscopy in Toulouse, verification of the section of the tranverse carpal ligament (white) and the release of the median nerve (yellow), Toulouse

 

 

The endoscope is then inserted in the carpal tunnel, the whole retinaculum is sectioned up to the fat pad of Kaplan and Milford, palmar aponeurosis is left intact.
At the end of the procedure, the endoscope can be used to verify that the median nerve has been completely released.
The hand’s wound is closed using Steri-strip, this hand surgery requires no stitches.

Recovery after endoscopic carpal tunnel surgery:

Light daily activities and self-care can resume one week after surgery for endoscopic surgical release of the median nerve at the carpal tunnel.
Recovery for this procedure usually involves the following:  paresthesias (tingling) in the hand disappear very quickly. However the hand's heel may be sore in daily activities for a month, and for up to 3 months after surgery in forceful movements of the hand.   This period corresponds to the time required for the flexor retinaculum to heal. When axonal degeneration or sensory or motor deficit exists before surgery, the carpal tunnel's axones may need to grow back up to the fingertips for paresthesias (tingling in the hand) to disappear completely, which can take several months. Driving often resumes at the end of the 3rd week after surgery. The hand recovers its full strength between 3 and 5 months after surgery.

 

Endoscopic carpal tunnel incision, Toulouse

Toulouse : Toulouse: scar 1 month after carpal tunnel surgery: it will be almost invisible at 6 months

 

This endoscopic carpal tunnel surgery can be associated with rhizarthrosis surgery in some cases.