Carpal tunnel syndrome: How is it treated?

In this detailed article, highly-respected consultant hand, wrist and elbow surgeon Mr Alistair Phillips shares his expert insight on carpal tunnel syndrome and how it can affect function and sensation in the hand. The revered specialist also sheds light on the most commonly used approaches to treatment, as well as what carpal tunnel surgery entails.

What is carpal tunnel syndrome?

Carpal tunnel syndrome is a problem with the nerve that travels into the hand. It’s called the median nerve and it supplies the thumb, index finger, middle finger and usually half of the ring finger with sensation. It also supplies the muscles at the base of the thumb with motor power. It travels through the carpal tunnel which is bounded by four sides, with bone on three of the sides and a ligament on the top.

Unfortunately, the median nerve is the only compressible thing inside the carpal tunnel. This means that if there’s anything inside the carpal tunnel that takes up more space than it should, although the other nine tendons within it keep working, the median nerve gets compressed and stops working properly.

The patient feels this as pain as the compression acts like a tourniquet on the nerve. They may also experience a loss of sensation because the sensory part of the nerve isn’t working very well. If the problems remains for long enough, patients can also suffer from weakness in the thumb when gripping things which can be quite serious.

Is urgent treatment required for carpal tunnel syndrome?

Carpal tunnel syndrome doesn’t have to be treated immediately and may go away of its own accord. However, you should certainly seek advice if the problem is more prolonged.

You should definitely see a doctor urgently if you experience weakness in your thumb.

Is carpal tunnel syndrome serious?

Carpal tunnel syndrome is serious, or at least it can be serious in some cases. However, the vast majority of patients with carpal tunnel syndrome can be treated without surgery and in fact, treatment may not be required at all if the problem is just temporary. If necessary, the condition can also be treated with splints or steroid injections.

Most of the time conservative treatment and general advice is all that’s needed and the problem should go away of its own accord. Very occasionally, and right at the end of the road, surgery may be indicated. Carpal tunnel surgery is extremely successful. Nonetheless, as a surgeon, I don’t want to expose patients to the risks associated with an operation, however unlikely, unless absolutely necessary.

What can happen if carpal tunnel syndrome is left untreated?

Consider what would happen if you left a tourniquet on your arm. Eventually, it would stop working entirely, but first you would notice is that the muscles and the nerves would stop functioning and you would lose sensation. This is exactly the same as having a tourniquet on the nerve inside the carpal tunnel. Patients notice that the fingers have less sensation, they become a bit clumsier, and eventually, if the motor nerve stops working, they will experience weakness of the thumb.

When is surgery required to treat carpal tunnel syndrome?

Surgery is required when all non-operative treatments, as I’ve mentioned above, have been exhausted. It may also be indicated if things are progressing rapidly, particularly with weakness of the thumb as the nerve is unable to regenerate your motor power once lost. Therefore, although sensory problems will get better very quickly, weakness maybe impossible to resolve. For this reason, surgery would be very strongly indicated if you have weakness of the thumb.

How is carpal tunnel surgery performed?

Carpal tunnel surgery is the most common operation that I do. It is performed with a small incision (around an inch) in the base of the palm between the base of the thumb and that of the little finger. We go down through the skin and the layers underneath and expose the nerve by cutting the ligament that forms part of the canal. We don’t need to repair the nerve because it does so itself and so we simply close the skin.

There are lots of different ways of closing the skin and stitches can be on the outside or the inside and may be absorbable or non-absorbable. Personally, I don’t like to inconvenience my patients and therefore I use absorbable stitches on the inside.

Another important area is being able to stay clean after the surgery and so I close my incisions in such a way that allows patients to wash their wounds the next day in the shower. After this, they then simply manage the wound themselves with a simple sticky plaster every day. This means patients don’t have to come back to see me or visit their GP or practice nurse. Obviously if there are any problems or you have any questions, I’m always there for support but I don’t want to inconvenience patients by making them come in needlessly.

There are other ways of doing carpal tunnel decompression and the evidence in the literature would suggest that patients who do a lot of manual work, such as builders, could benefit from a minimally invasive approach called endoscopic carpal tunnel. This has to be performed in main theatres and is much more expensive because we have to use special equipment. In this procedure, a smaller incision is used, about three or four millimetres wide and the evidence would suggest that it may help manual workers to get back to work more quickly.

I’m also currently exploring another method using ultrasound used by many of my colleagues in Europe. I’ve also recently been in touch with an American colleague at the Mayo Clinic who uses lots of needles and specialist equipment to perform an incision-less technique using ultrasound guidance, which may be available here in the future.

If you require surgery for carpal tunnel syndrome and wish to schedule an appointment with Mr Phillips, you can do so by visiting his Top Doctors profile.