Carpal tunnel syndrome

We are a medical institution specializing in endoscopic carpal tunnel release via a monoportal approach. For us, this approach doesn’t represent any novelty, we have been performing these operations successfully since 2011, in more than 1600 patients. The rising number of patients undergoing this operation each year demonstrates how increasingly popular this approach became. The main advantage of an endoscopic approach consists of faster healing of the operated hand and of the possibility to resume work earlier in comparison to the classical approach. More about the carpal tunnel syndrome.

The earliest available dates

Surgeries are being performed on Fridays and Saturdays once in a month – the Saturday appointments being opened after Friday is fully booked.

Friday, 23. 7. 2021
Saturday, 24. 7. 2021
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Obtaining an appointment

If you wish to obtain an appointment, use the following phone number or e-mail address, please:

Tel.: 601 527 387
E-mai.: info@tomedica.cz
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Contact

We provide outpatient medical care and perform surgeries at the Asklepion Lasercentrum, Ltd.

Londýnská 160/39
120 00 Praha 2

The number of patients

The number of patients undergoing an endoscopic carpal tunnel release at our institution during individual years

 
Carpal tunnel syndrome
 

How to proceed?

Do you suffer from tingling (“pins-and-needles”) affecting the first to third finger, especially during the night, and/or their numbness – i.e. from symptoms of the carpal tunnel syndrome? Your treatment will proceed in the following way.

Step 1 – Electromyography (EMG)

Ask your GP or your neurologist to organize the electromyographical (EMG) examination for you.

If there is no such a possibility, call 601 527 387 and we will send you to one of the EMG laboratories we collaborate with.

The EMG conclusion is compatible with carpal tunnel syndrome (if not, your neurologist should exclude other possible causes of tingling in your fingers).

Step 2

Contact us via our web page form, write an e-mail info@tomedica.cz or dial +420 601 527 387 to inform us about your interest in an endoscopic carpal tunnel surgery.

Step 3 – Consultation

We may either provide a consultation via phone or, in case you prefer this option, we may organize your personal consultation with a physician.

Step 4 – Establishing the date of the surgery

After all your questions have been answered during the consultation, you will be offered possible date(s) of the surgery, taking place at Asklepion Clinic, Londýnská 39, Prague 2. You will not need any pre-operative assessment. However, it will be necessary to discontinue antiplatelet drugs or anticoagulants (blood thinners) if you are taking any.

Step 5 – Surgery

Step 6

Gradual return to using the operated hand for daily activities straight after the surgery.

Step 7 – The first post-operative check-up

Typically, it takes place the second to fourth post-operative day – either at your local physician (GP, surgical clinic) or at the Asklepion Clinic (the exact date and time being provided immediately after the surgery).

Step 8 – The second post-operative check-up

Between the seventh and eighth post-operative day, usually (again, it may be performed by your local physician or at the Asklepion Clinic, as arranged after the surgery).

Step 9 – Physiotherapy

We will teach you three simple exercises ensuring that the operated hand will soon return to a good functional level. Should the post-operative state of your hand demand more intensive physiotherapy, you will obtain our recommendation for your local physiotherapy center and register for rehabilitation there.

Step 10 – Return to work

Non-manual professions: 3rd to 14th post-operative day
Demanding manual professions: 14th to 30th post-operative-day

Gallery

The following pictures illustrate what carpal tunnel syndrome is about and how it may be treated surgically.

Fotografie 1

Operace karpálního tunelu

Fotografie 2

Operace karpálního tunelu

Fotografie 3

Operace karpálního tunelu

Fotografie 4

Operace karpálního tunelu

Fotografie 5

Operace karpálního tunelu

Fotografie 6

Operace karpálního tunelu

Fotografie 7

Operace karpálního tunelu

Fotografie 8

Operace karpálního tunelu

Profile

 
Robert Tomáš, M.D., Ph.D.

Robert Tomáš, M.D., Ph.D.

works as a neurosurgeon at the Neurosurgical Department of the Na Homolce Hospital in Prague. He mostly operates neuro-oncological patients, patients suffering from degenerative spinal disease and those with peripheral nerve lesions. Beside the surgical treatment of neurosurgical patients, he is also involved in intraoperative electrophysiology, improving the chances of patients to achieve favorable outcomes after complex operations of the brain and spinal cord.

 
 

Pregraduate education

  • 1991–1997 1st Medical Faculty of the Charles University, Prague
  • 1997 graduated as M.D.

Board certifications

  • 2000 1st degree board certification in general surgery
  • 2006 board certification in neurosurgery

Postgraduate education

  • 1998–2005 neurosciences, 1st Medical Faculty of the Charles University, Prague
  • 2005 graduated as Ph.D.

European Association of Neurosurgical Societies (EANS) courses

  • 2003 EANS course in Amsterdam
  • 2004 EANS course in Krakow
  • 2005 EANS course in Prague
  • 2006 EANS course in Luxembourg
  • 2006 EANS Certificate, Part I

Prizes

  • 2006 Professor Rudolf Petr Prize awarded by the Czech Neurosurgical Society for the best neurosurgical publication of an author younger than 35 years (in 2005)
  • 2007 Piťha Prize awarded by the Czech Electrophysiological Society for the best electrophysiological publication in 2006 (member of the collective of authors lead by Stejskal: Intraoperative stimulation monitoring in neurosurgery, Grada, Prague, 2006)

Selected publications

Tomáš R, Haninec P: Dorsal root entry zone (DREZ) localization using direct spinal cord stimulation can improve results of the DREZ thermocoagulation procedure for intractable pain relief. Pain, 2005, 116: 159–163

Tomáš R, Haninec P, Houšťava L: The relevance of the corticographic median nerve somatosensory evoked potentials (SEPs) phase reversal in the surgical treatment of brain tumors in central cortex. Neoplasma 2006, 53: 37–42

Haninec P, Tomáš R, Kaiser R, Čihák R. Development and clinical significance of the dorsoepitrochlearis muscle in man. Clinical Anatomy 2009, 22(4): 481–488

Haninec P, Šámal F, Tomáš R, Houšťava L, Dubový P. Direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy in the treatment of brachial plexus injury. J Neurosurg. 2007 Mar;106(3):391–9

Pachl J, Haninec P, Tencer T, Mizner P, Houšťava L, Tomáš R, Waldauf P: The effect of subarachnoid sodium nitroprusside on the prevention of vasospasm in subarachnoid haemorrhage. Acta Neurochir (Suppl) 2005, 95: 141–145

Stejskal L., Tomáš R: Monophasic positive scalp somatosensory evoked potential (SEP) wave in parietal tumors. A cerebral “killed end potential” or a volume conduction wave due to the shift of dipole layer and increased solid angles at registration sites? Čes a slov Neurol a Neurochir 2005, 68/101: 368–372

 

Carpal tunnel syndrome – description of the problem

General definition

Carpal tunnel syndrome is the most common nerve compression syndrome affecting the upper limb. The symptoms are caused by compression of the median nerve under the transversal carpal ligament where also the tendons of finger flexors are found. In the course of years, the carpal ligament becomes more bulky and stiff, starting to compress the nerve immediately underneath it. This syndrome mostly affects middle-aged people or seniors. It is 4 times more common in females than in males.


Causes of carpal tunnel syndrome

In the vast majority of patients suffering from carpal tunnel syndrome, the exact cause of this affection cannot be found. However, some patients are being exposed to certain risk factors related to their work or to other illnesses they suffer from, that are believed to predispose to the carpal tunnel syndrome.

Work-related risk factors

  • Work during which the hand and wrist are often and repeatedly being strained by wrist flexions (in carpenters, etc.)
  • Work requiring repeated and effortful instrument clinching (chopping, digging, and other components of gardening, etc.)
  • Activities during which the hand is extended for prolonged periods of time and partly flexed towards the ulnar side (e.g. typewriter of computer typing)
  • Work with vibrating devices (pneumatic drill, etc.)

Illnesses and conditions associated with higher incidence of carpal tunnel syndrome

  • rheumatoid arthritis
  • diabetes mellitus
  • obesity
  • pregnancy (temporary emergence of symptoms)
  • dialyzed patients with shunts at their forearms
  • rare causes (tuberculous tendinitis, mucopolysaccharidosis)

The symptoms of carpal tunnel syndrome may also develop acutely and be very pronounced. Most often, they appear following wrist trauma and are caused by a thrombosis (closure by a blood clot) of a persisting artery accompanying the median nerve (this artery persists in less than 10% of the population) or by a hematoma in the transversal carpal ligament.

Back

Manifestations of carpal tunnel syndrome

Most typically, patients are being awakened during the night by “pins-and-needles” or pain in their fingers, feeling as if their hand and fingers lacked adequate blood supply, as if the hand and fingers “were not theirs”. These symptoms are usually alleviated by moving the hand and fingers or by shaking them. The pain may irradiate from the wrist towards the elbow and, in some cases, as high as the shoulder.

During the day, “pins-and-needles” and pain affecting fingers are present during typical activities requiring the elevation of the upper limb (driving, holding the cell phone and having a longer call, holding the book when reading). In typical cases, these sensations involve the 1st to 3rd finger and the outer half of the 4th finger plus the outer half of the palm. Some patients also feel “pins-and-needles” in their 5th (little) finger, although the explanation of this feature remains unclear (the little finger receiving its sensory innervation through another – ulnar – nerve).

Weakness and clumsiness of the hand (especially of the handclasp) may be another symptoms. The clumsiness is rather caused by impaired sensitivity than by weakness (palsy) as such. Most often, it manifests by dropping objects, having difficulties closing buttons, putting earrings on, etc.

In 80% of patients, so called Phalen’s test is positive – wrist flexion for 30 to 60 seconds provokes painful symptoms. So called Tinel’s sign (tapping the carpal tunnel provoking pain) is positive in 60% of patients.

Which conditions may mimic carpal tunnel syndrome (differential diagnosis)

  1. Degenerative disease of the cervical spine. So called radicular pain originating in the cervical spine usually subsides at rest and is accentuated by neck movement. Some patients, however, suffer from a so called double crush syndrome, encompassing both the compression of a nerve root leaving the cervical spine (usually C6) and the carpal tunnel syndrome.
  2. Thoracic outlet syndrome – compression of a neurovascular plexus in the subclavian region. Loss of muscular mass outside the thenar represents a typical feature of this syndrome. Sensory loss affects the ulnar side of the hand and forearm.
  3. Pronator (teres) syndrome – compression of the median nerve at the level of forearm where it travels under the pronator teres muscle. In this syndrome, the pain affecting palm is the most pronounced symptom (the palmar branch of the median nerve not travelling through the carpal tunnel).
  4. Inflammation of the tendons under the carpal ligament (that of long abductor muscle – de Quervainsyndrome– or those of other flexors)

Back

Evaluation

Median nerve compression in the carpal tunnel is being diagnosed using electromyography (EMG).

Conservative and semiconservative treatment of carpal tunnel syndrome

It may be implemented in cases where symptoms have not been lasting for a long time and there are no signs of more severe sensory or motor loss.

  1. Rest – attempts not to use the affected hand more than absolutely necessary
  2. Non-steroid anti-inflammatory drugs (ibuprofen, etc.)
  3. Fixation of the wrist in a neutral position using a splint – if the symptoms of carpal tunnel syndrome are mild to moderate, this approach is effective in up to 50% of cases. Unfortunately, symptoms often reappear after the splint is removed.
  4. Application of corticosteroids into the carpal tunnel – eliminates the symptoms for at least 15 months in 33% of patients; the injection may be repeated.
Carpal tunnel syndrome

Surgical therapy

Standard open technique

Standard open surgical technique consists of a transection in the palm midline. After transecting the subcutaneous tissues and so called palmar aponeurosis (ligamentous tissue under the carpal ligament), the surgeon proceeds towards the carpal ligament itself. Next, s/he transects the individual layers of the ligament as far as the median nerve. The nerve is released then by complete transection of the ligament heading both the fingers and the wrist. The surgical wound is eventually closed by stitching the skin, typically using the adaptation suture.

Surgical therapy

Endoscopic methods

The aim of the endoscopic operation of a narrow carpal tunnel is to increase its size while traumatizing the tissues in the palm of the operated hand as little as possible. We use a monoportal system at our institution. This system makes it possible to access the carpal ligament via a single small approach in the wrist fold. Initially, it is necessary to increase the size of the carpal tunnel using dilators. Then, the working channel is placed upon the nerve and the ligament is transected from the deepest to the most superficial layers. The monoportal technique is the least invasive one, the tissues upon the carpal ligament are being preserved and the patient is left with only one scar on the wrist. At our institution, we use the MicroAire monoportal system.

Surgical therapy

Surgical treatment

What does the surgery solve immediately?

You will enjoy good sleep again. “Pins-and-needles” during the night cease to be present soon after the surgery and for many patients, the night following the surgery is the first in a long time when they are not being awakened by intense feelings of that sort. Pain projecting to the fingers of the affected hand disappears early, too.

What does the surgery solve or improve in a longer time?

In cases where sensory loss affecting the fingers of the given hand or weakness of the thumb were present, these symptoms take a longer time to subside. They are caused by damage to the nerve by a long-standing pressure and signalize that a part of the nerve fibers have “died”. The nerve released by the surgery needs some time for regeneration, and this time varies from person to person. Some people notice improvement within days, some within months (up to one year). This usually depends on how long the sensory or motor loss had been present before the surgery and on the regeneration capacity of the individual patient.

Surgical treatment
Operační léčba

What the surgery will not solve?

The surgery will not solve hand pain from other causes like arthrosis of small hand joints, rheumatic pain or finger pain related to cervical spine. The situation is similar with edemas. These complaints may accompany the carpal tunnel syndrome and may represent the reason why a part of the symptoms lasts following the surgery. Despite this fact, we recommend the operation even in such cases in order to provide at least a partial relief to the patients, and – most importantly – to avoid the irreversible damage to the nerve.

Post-surgical care

After the surgery, the hand is being covered by an elastic (compressive) bandage for several hours to avoid the development of a larger subcutaneous hematoma. This bandage is then removed by the patient during the evening following the surgery, before the patient goes to sleep, and the hand remains free ever since. It is only the small scar at the wrist that remains covered by a minor plaster.

The main principle of physiotherapy following an endoscopic surgery is not to immobilize the hand (no splints or massive bandages). On the contrary, the patients are encouraged to use the operated hand soon for common activities. Patients are typically able within 1 to 2 days to involve the hand in activities requiring fine finger movements (holding or handing something, close the button, typing…). However, holding anything (a door knob, knife, any tool) may by painful and uncomfortable for many days to weeks, this time being very variable. Some patients do not report any such problems, some are experiencing them for several weeks.

We offer two post-surgery (post-op) follow-up meeting to our patients – the first during the 3rd post-op day, the second during the 7th post-op day. The stitch is being removed from the scar at the wrist on the 7th post-op day. If the patients wish so and the healing is uncomplicated, these follow-up visits may take place close to their home (this possibility being used mainly by patients travelling from remote parts of our country).

Up to 85% of our patients do not need any physiotherapy, either out- or in-patient, after the stitch is removed. The operated hand is usually in a good shape from the 7th post-op day onwards and it can be used for most common activities and sometimes even at work. During the second post-op follow-up meeting, the surgeon instructs the patients about self-physiotherapy they can perform at home. They are advised to perform pressure massages of the palm and the scar, to extend the flexor tendons and to strengthen their clasp by compressing a small ball.

Back

Surgical technique

The endoscopic monoportal carpal tunnel release surgery is being performed under local anesthesia combined with median nerve blockage (i.e. without putting the patient to sleep) at our institution. This fact has several consequences for the patient. We do not require any pre-surgical examinations. At the day of the surgery, the patient enjoys his or her usual routines, i.e. can eat and drink as s/he wishes. If s/he is on regular medication, s/he takes it as usual except for drugs affecting blood clotting (Anopyrin, Godasal, Trombex,etc.). These medications have to be discontinued before the surgery (usually for one week) so that blood clotting is not affected during the operation; if necessary, they can be replaced by substitutes such as Fraxiparine that do not interfere with the surgery while still protecting the patient from thromboembolic complications.

The surgery itself

The carpal ligament is being released from a single approach (1 cm) in the wrist fold. First, the carpal tunnel has to be widened using dilators. The working channel is placed upon the nerve then and the ligament is being transected from the deepest to the most superficial layers. The monoportal technique is the least invasive one, the tissues upon the carpal ligament being preserved and the patient being left with only one scar on his or her wrist. We use the MicroAire monoportal system at our institution. Bloodless surgical field is required for proper performance of the surgery – to achieve this, the patient’s forearm is being compressed by a cuff (similar to that used to measure blood pressure) during the procedure. The time required for the surgery represents a major advantage of the endoscopic approach – at present, our surgeries do not last more than 4 to 5 minutes.

Surgical technique
 
 

Possible complications of the surgical treatment of carpal tunnel syndrome

  1. Damage to the palm branch of the median nerve – manifesting as pain affecting thenar and the base of the thumb
  2. Contusion of the median nerve
  3. Damage to the motor branch of median nerve (so called ramus recurrens)
  4. Hypertrophic scar
  5. Persisting symptoms of carpal tunnel syndrome following the surgery – maybe caused by erroneous diagnosis or by insufficient transection of the carpal ligament. If the latter is true, this fact being confirmed during another operation, the “second look” operation is successful in about 75% of cases
  6. Stiffening of the small hand and finger joints – in cases of unnecessarily long immobilization
  7. Wound infection – leading to scar hypersensitivity; the scar may disintegrate in extreme cases
  8. Hematoma – also leading to scar hypersensitivity

The risk of complications

The risk of complications decreases with the accumulating experience of the surgical team and number of successfully operated patients. Given the number of patients we have treated (more than 1600) and our expertise, the endoscopic surgery has become a safe technique and the incidence of complications in our series is much less than 1%.

References

Marta Kubišová

I had been ignoring tingling in my left hand while driving a car for a long time. It was only after pain and weakness of my right hand, in which I hold the microphone while singing, had appeared that I started to collect information about carpal tunnel syndrome. Despite my fear of the operation, I committed myself to the hands of Robert Tomáš, M.D., Ph.D.In a very short time, I underwent the endoscopic operation of my right hand – painlessly, to my surprise! I took it for granted that my left hand would also require the same operation but dr. Tomáš told me: “Let’s wait – sometimes the less affected hand recovers spontaneously after the more affected hand has been operated…” and he was right. Since then, I feel no pain at all. And it has been a long time, really. Thus, I would gladly recommend the endoscopic operation to anyone!

Miloslav Zapletal

Miloslav Zapletal

The problems with fingers of my right hand had been gradually worsening. A minor complication had evolved into a serious problem for me. Finally, the operation was inevitable. I had expected demanding and prolonged rehabilitation and the reality proved to be a cheering surprise. The medical team lead by Robert Tomáš, M.D., Ph.D. was really professional. Thanks to them, I was able to perform common activities within a few days and I fully recovered in three weeks. I can warmly recommend this doctor to you.

Darina Darja Majková

Even my 82-years-old mum has underwent the endoscopic carpal tunnel operation performed by doctor Tomáš last summer and autumn. She had been offered the classical operation by physicians in Moravia but she was trying to postpone it as much as possible since she has to use crutches. She had concerns with respect to the length of convalescence. At the same time, she knew that the operation was inevitable – the sensations in her hands had been waking her during the night. As soon as we learned about the possibility to have the carpal tunnels operated endoscopically, we didn’t hesitate and made an appointment for her. One hand first, the second within two months. It was a good choice. The operation was painless, my mum recovered quickly. She is happy now, sleeps as a baby, no pain or tingling interferes with her sleep as it had before the procedure. Doctor Tomáš has “golden hands”, as we say in Czech, and is very kind, too. He is able to convince anyone that there is no need to fear the operation. We recommend him to anyone from the bottom of our hearts and are so grateful to him!

Iva Ježková

I had been facing problems with carpal tunnel syndrome for 20 years and it was not before coming across the references on endoscopic operations performed by doctor Tomáš that I decided for the surgeries, having both hands operated within a year. The pain and tingling disappeared instantly, the post-operative discomfort could be managed by one single dose of paracetamol. I still have a minor swelling of one of my hands but became capable of performing minor chores after a week and doing almost anything within a month. The operation only took an hour, including all the pre-op and post-op procedures. Very amiable approach and atmosphere.

Eva Hrušková

In September 2020, I underwent the carpal tunnel operation of my left hand, followed by the operation of my right hand in December of the same year. I would gladly recommend the same to anyone who doesn’t wish to miss his or her time at work. The operation took place on Friday and I was back at work the next Tuesday. No more is needed after such an operation than being somewhat careful with oneself. Robert Tomáš, M.D., Ph.D. and his nurses are highly professional, no doubt. Thank you so much for the relief!

I am fully satisfied – both hands operated within two months and no problems at all. Doctor Tomáš is a great professional.

Johana Mahrlová

Doctor Tomáš has performed the carpal tunnel operation on both of my hands and no words can say how satisfied I am. The attitude, operation, post-operative care, technique… simply perfect. Recommended to all!

Surgery dates and payment

Our surgeries take place on Fridays and Saturdays once in a month – the Saturday term always being opened after the Friday capacity is fully filled (during summer holidays, minor changes may be expected).

Price list
Consultation 0 CZK
Outpatient follow-up visits 0 CZK
Endoscopic surgery using the monoportal system (MicroAire) 10 000 CZK
Surgery dates currently available
8. 1., 9. 1. 2021
12. 2., 13. 2. 2021
12. 3., 13. 3. 2021
16. 4., 17. 4. 2021
14. 5., 15. 5. 2021
11. 6., 12. 6. 2021

 

Please be informed that the payment may currently be made in cash at the Asklepion reception before the surgery or by a bank transfer (the patient will receive the bank account number along with the informed consent form). The payment MAY NOT be made using a payment card.

Contact

Robert Tomáš, M.D., Ph.D.
Private medical institution
We provide outpatient medical care and perform surgeries at the Asklepion Lasercentrum, Ltd.

Address

Asklepion Lasercentrum,Ltd.
Londýnská 160/39
120 00 Prague 2

Phone

+420 601 527 387
+420 731 680 734

 

Consultations regarding endoscopic carpal tunnel release surgeries may be fixed using the above phone number or leaving a message at our web pages (we will contact you later). There is no need to have a recommendation from your GP or any medical specialist.

We only require that you have an electromyography (EMG) report confirming that you suffer from a carpal tunnel syndrome. The consultation itself can take place after you visit us in person or via phone (in this case, the assistant will instruct you how to send the EMG report via e-mail).

Please be informed that all medical care provided at our private institution, including consultations, is being paid by the patient (see Payments).