WHAT IS CARPAL TUNNEL SYNDROME?
Carpal tunnel syndrome is a disorder where one of the main nerves which supplies the hand (the median nerve), which gives sensation to the thumb, index and middle fingers, becomes squashed as it passes through the wrist (in the carpal tunnel) from the forearm into the palm.
SYMPTOMS
The classical symptoms of carpal tunnel syndrome are intermittent tingling and numbness in the thumb, index and middle fingers coupled with pain, felt worst at night. Patients frequently wake in the middle of the night with the pain which leads them to shake their hand in order to alleviate it. As the symptoms gets worse, there can be weakness of the hand and dropping things as well as persistent numbness, so that the patient may be unable to feel items properly, for example when trying to pick up a needle.
DIAGNOSIS
The diagnosis is made on the basis of the history and the clinical examination, and if there is doubt, it can be confirmed by undertaking a special investigation known as ‘electromyography (EMG)’, also known as ‘nerve conduction studies’. This is an objective investigation which can detect formally whether the patient has carpal tunnel syndrome or not. It also shows the severity of the nerve compression. It is a very sensitive test, done by a neurophysiologist.
TREATMENTS
There are essentially just three treatments for carpal tunnel syndrome.
1. Wearing of night splints which help reduce the symptoms the patient feels at night.
2. Cortisone injections which can be given relatively painlessly using ultrasound guidance and which will often alleviate the symptoms for many months and can be repeated, provided the patient is not developing irreversible complications of carpal tunnel syndrome.
3. Carpal tunnel release surgery.
Who should have carpal tunnel release surgery?
Patients should have carpal tunnel release surgery if the symptoms they have, are intrusive and have not responded satisfactorily to either night splintage or cortisone injections. Secondly, they should have carpal tunnel release surgery if they are developing potentially irreversible complications, for example persistent numbness and weakness in the hand.
SURGERY (MR KURER’S TECHNIQUE)
Mr Kurer’s technique for carpal tunnel release surgery is similar to other surgeons but there are some minor modifications.
1. The surgery is almost always done under local anaesthetic only, like going to the dentist. It is not necessary to starve first. For patients who are nervous of this, they can have intravenous sedation (for that they do have to starve) but they do not formally go to sleep and can therefore go home very soon after the surgery.
2. A special local anaesthetic is used which is almost painless to administer and extremely effective.
3. No tourniquet is applied to the arm so there are no cramping feelings during the surgery.
4. Internal dissolvable stitches are used, which cannot be seen and do not need to be removed.
MR KURER’S ACCELERATED RECOVERY REGIME
Carpal tunnel syndrome often affects nursing mothers and this regime was developed so that they can manage again quickly.
At the time of surgery, a small skin plaster is applied to the wound and then some padding and a bandage. The following morning the patient removes the bandage, padding and plaster, exposing the incision but of course no stitches, as these are hidden internal dissolving stitches.
The hand is then lightly washed under the tap with soap and water and dried and a new simple plaster applied. The patient may then start to use the hand. There is no need to wear a sling or any other dressings.
Patients usually find that their hand is sore for approximately four days but they are able to use it. It is safe for them to drive once they feel that they can grip the steering wheel safely. This would not usually take more than four days. Patients are reviewed at between seven and fourteen days just to check that their wound has healed satisfactorily.
RESULTS
Those patients who have night pain will find that the night pain disappears that very first night of the surgery and they will often sleep extremely well, despite the fact that they have had the surgery that day.
The tingling sensations will take some weeks to go but have usually resolved by four weeks from the date of surgery. The sensation will slowly improve and again takes several weeks before it comes back to normal, depending on how severely it was reduced prior to the surgery. The scar will tend to remain tender for a month and it is reasonable to apply moisturising creams to the scar during that time.
HAVING BOTH HANDS OPERATED ON AT ONCE
Because patients are able to use their hand the next day, albeit limited by some pain, if both hands are affected, patients are able to have both hands done at once. It is better that they have support from family members for the first four days but after that they have very few limitations.
PATIENTS ON WARFARIN
The specialised anaesthetic used here dramatically reduces bleeding during the surgery and it is therefore possible to operate on patients who are taking Warfarin. It is not necessary to stop the Warfarin first. In this case, however, special haemostatic stitches are used rather than the internal dissolvable stitches and those haemostatic stitches are taken out at ten days. Patients are also given a prophylactic dose of antibiotics to reduce the risk of infection.
WHAT CAN GO WRONG?
The commonest problem is infection. This affects less than 1 in 20 patients and it is easily treated with oral antibiotics. Sometimes, because the carpal tunnel syndrome has been present for so long with marked weakness and numbness, and there is scarring of the nerve, there is not much improvement from the surgery but at least it stops the condition getting worse.
SELF-PAY PACKAGE
Mr Kurer offers a self-pay package including initial consultation, surgery and one follow-up at 10 days, including use of the operating theatre and all medication, bandaging and requirements for the surgery costing £995.00 (provided there is availability of the operating theatre).
