• 10 days on average (after the operation; ranging between 3 and 14 days) in non-manual professions
• 24 days on average (after the operation; ranging between 10 and 30 days) in manual profession (plumbers, butchers, workers, etc.)

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 +44 20 3286 8822 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 +44 20 3286 8822 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 Palas Athena Clinic (Hviezdoslavova 509/25, Prague 4). 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 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 Palas Athena Clinic (the exact date and time being provided immediately after the surgery).

Step 8 – 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 9 – Return to work

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

Other chapters

• Causes of carpal tunnel syndrome
• Manifestations of carpal tunnel syndrome
• Evaluation
• Conservative and semiconservative treatment of carpal tunnel syndrome
• Surgical therapy

Source: Greenberg MS: Handbook of Neurosurgery

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

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

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.

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.

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.

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.

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. The patient takes off this bandage himself in 24 hours. 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 3^rd post-op day, the second during the 7^th post-op day. The stitch is being removed from the scar at the wrist on the 7^th 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 7^th 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

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.

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%.