Carpal Tunnel Syndrome

Do I Really Need Carpal Tunnel Surgery?

I have been asked this very question many times, by many patients, and my answer is almost always “No! Carpal tunnel surgery is not always necessary.” But I always inform them of the procedures involved in both kinds of surgeries as well as the possible outcomes, allowing them to make their own decision. But before we discuss the surgeries themselves, it is import to know what is happening within the body with carpal tunnel syndrome.

Carpal tunnel syndrome is known an entrapment or strangulation of the median nerve as it passes through a narrow tunnel at the wrist known as the carpal tunnel. Bones of the wrist on three sides and a strip of “Saran wrap” on the roof, called the transverse carpal ligament, form this tunnel. The nerve entrapment can be caused by a number of things, such as: a bony projection, inflammation, or water retention (like in pregnancy). Normally it is caused from inflammation and a buildup of scar tissue from overuse of the flexor tendons, which also accompany the median nerve through the tunnel. This is why it is commonly known as an “Overuse injury” or a “Cumulative Trauma Disorder.”

Carpal tunnel surgery is the most common surgical procedure performed in the U.S. It is usually recommend if a patient is experiencing any signs of nerve damage, which can be seen by progressive weakening of the muscles of the hands or using a nerve conduction velocity test (NCV). There are basically two different approaches to a carpal tunnel surgery; however both have the same objective, to increase the amount of space within the carpal tunnel. After the descriptions, I will discuss the benefits and faults of each approach.

Open carpal tunnel surgery

This type of surgery requires a local anesthetic, which is directed in the region of the carpal tunnel. Once the patient is prepped and ready, the doctor makes a 2-inch incision into the base of the palm, down to the layer of the transverse carpal ligament. Once the ligament is visible, it is then cut in half and left to scar over. The hand is then stitched up and left to heal. This procedure is also known as open carpal tunnel release surgery, because the transverse carpal ligament is being released.

Endoscopic carpal tunnel surgery

This type of surgery allows for a faster recovery, mainly by limiting the amount of invasiveness. The doctor makes two half-inch incisions in the wrist and palm to go in and cut the transverse carpal ligament, just as in open carpal tunnel surgery. Again a local anesthetic is used and the patient will be allowed to go home the same day.

The cons of a carpal tunnel surgery

The major problem with any type of carpal tunnel release surgery is the cutting of the transverse carpal ligament. Cutting the structure does provide for more space for the nerve and the tendons; however, it is also a site of attachment of some intrinsic muscles of the hand, such as the muscles you use when touch your thumb and pinky finger together. For this reason, in some cases, patients will not regain full function of the hand.

The second problem with a carpal tunnel release surgery is, which has been minimized in the endoscopic procedure, is an increase in scar tissue in the carpal tunnel itself, following the surgery. In the opinion of many alternative healthcare providers, a build-up of scar tissue within the tunnel and around the median nerve is the primary cause of the condition in the first place. Why would a build-up of more scar tissue post-op be beneficial?

The third problem with having a carpal tunnel surgery is that many times the surgery is being performed at the wrong location. It is true the median nerve can be entrapped at the carpal tunnel; however, it is just as possible for the nerve to be trapped at any of the other 6 common median nerve entrapment sites, which causes the same kind of clinical presentation! So why would a surgery at your wrist help if the primary cause is actually at the forearm? It wouldn’t!

The fourth reason why carpal tunnel surgeries should be considered a last resort is the amount of recovery time from the date of the surgery. If the surgery was performed on your dominant hand (in fact it is usually done on both hands), it can take up to 3 months to return to full work duties. Keep in mind this is just to recover from the surgery, this is not saying the surgery was successful in getting rid of the pain your hands. This period of time can have a monumental impact on the patient’s financial situation, as well as any employer’s who hired the patient or even paid for the surgery with worker’s compensation.

Alternative Treatment for Carpal Tunnel Syndrome

There are many different types of alternative therapy, non-surgical treatments that have been used for carpal tunnel syndrome in the past. Here is a small list of these treatments: nonsteroidal anti-inflammatory drugs, stretching and strengthening by a physical therapist, wrist splints, acupuncture, chiropractic adjustments and yoga. Something on this list is usually the first option when people present with carpal tunnel symptoms, but they have only been proven to have limited success.

ART Therapy

Active Release Techniques (ART) is a relatively cheap, effective alternative to surgery and it is considered the “Gold Standard” of soft tissue techniques. ART is the only soft tissue technique which takes into account each individual muscle’s orientation and action, making treatment specific to the exact site of the median nerve entrapment, which is not always at the carpal tunnel. ART breaks up scar tissue, formed from chronic inflammation, from between nerves and surrounding soft tissues, freeing up the nerve. The formation of scar tissue is the normal way the body repairs itself, however if an injury is not treated early on, chronic conditions occur.

Active Release providers are soft tissue specialists and are trained to feel abnormal texture and tension within small and large muscles. Because nerve and some muscles are so small, it takes special training and experience in Active Release Techniques to accurately detect and treat these areas of a nerve entrapment. Don’t be fooled by people who claim they perform myofacial release or deep tissue work. It is not the same. Active Release Techniques® is so precise that it specially addresses over 350 soft tissue structures in the body, based upon their biomechanical actions and orientation in the body.

Overall recommendation for treatment of carpal tunnel syndrome

I feel the first and most effective treatment should be by the use of Active Release Techniques. Generally I have found many patients notice a significant difference within 3- 4 visits of about 15 to 30 minutes each. This treatment may not be for everyone, due to its aggressive nature, it should only be considered for those who are dedicated to getting better. Many times full resolution can be seen in about 8 treatments. However, if a patient does not respond as expected to ART, I would consider a surgical consultation, especially if they are having signs of nerve damage. In this case, I would say the endoscopic version of the carpal tunnel surgery is the way to go, because there is less scar tissue after the procedure is complete; however this surgery, just like all other surgeries should only be considered as a last resort.

If you or someone you know is suffering from carpal tunnel syndrome, contact Temecula Chiropractor Dr. Horst today!