Carpal tunnel syndrome surgery

introduction

At a Carpal tunnel syndrome pass conservative therapy methods mostly not off. If the symptoms are mild, however, surgery does not have to be carried out immediately. Even older patients with low levels of suffering and high-risk pre-existing conditions do not necessarily have to undergo an operation. This also applies to a Carpal tunnel syndrome in pregnancywhere it's through special hormonal influences can only result in a temporary carpal tunnel syndrome.

The most common surgical method is that open division of Carpal ligament. But also the arthroscopic split of the carpal ligament is possible. If performed correctly, both procedures are equivalent. Certain requirements must be met for the arthroscopic method. Both surgical procedures are usually outpatient carried out.

The goal of surgery for carpal tunnel syndrome is permanent pressure relief of the median nerve, which is brought about by the splitting of the flexor-side carpal ligament (retinaculum flexorum). Although the operation is done conventionally open in most cases, there are also arthroscopic techniques that do one Splitting of the carpal ligament enable. An operation should always have a reliable diagnosis as a prerequisite. For this is the neurological evidence of carpal tunnel syndrome.

The operation is performed by orthopedists, hand surgeons or neurosurgeons. In the course of cost cutting in health care, surgery is almost the only option outpatient carried out. An inpatient stay is usually not necessary.

Indication for an operation

In most cases, it is sufficient to treat an existing carpal tunnel syndrome conservatively (i.e. not surgically but preserving the tissue of the injured organ). These include protecting the wrist region, wearing a splint at night and treating with medication to relieve pain and reduce inflammation.

Read more on the topic: Therapy of carpal tunnel syndrome using splint and therapy of carpal tunnel syndrome

However, if these therapeutic approaches do not bring about an improvement in the symptoms, i.e. relief of pain, recurring sensitivity and return of strength in the thumb muscles, surgical therapeutic measures are indicated.

Furthermore, the carpal tunnel syndrome operation is advisable as soon as there is a risk of irreversible nerve damage (i.e. the healthy state of the nerve cannot be restored). This can be the case as a result of acute compression of the nerve, triggered by an accident or an inflammation.

Carpal tunnel syndrome surgery may also be indicated if an additional disease is present, such as diabetic polyneuropathy (= damage to many nerves (polyneuropathy) that occurs as a result of diabetes mellitus.

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In order to be able to treat successfully in orthopedics, a thorough examination, diagnosis and a medical history are required.
In our very economic world in particular, there is too little time to thoroughly grasp the complex diseases of orthopedics and thus initiate targeted treatment.
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Pain related to surgery

The aim of carpal tunnel syndrome surgery should be that Relieve pain and eliminate the remaining symptoms. However, the success depends on the point in time at which a carpal tunnel syndrome operation is carried out; In patients whose discomfort and nerve damage are already well advanced, a sensitivity disorder can persist.

As with any surgical procedure, you can Swelling after surgery Provoke pain. A less typical pain arises due to a chronic neurological disease, the CRPS (Complex Reginal Pain Syndrome = complex regional pain syndrome; also Sudeck's disease called).
The causes of this disease are still unknown. It is definitely one irregular healing process after injuries, accidents or operations. Mostly hands, forearms, feet or lower legs are affected, so this disease is also affected after carpal tunnel syndrome surgery can manifest. Along with the pain, there is also one Overheating of the wrist, one reddened skin and one swelling, which in turn causes additional pain.

surgery

Outpatient surgery

The carpal tunnel syndrome operation does not necessarily have to take place in the hospital can also be carried out on an outpatient basis. One should about it however decide on a case-by-case basis. If there are no risks in the form of further illnesses or additional complications in the area of ​​the carpal tunnel and the patient is cared for at home, an outpatient carpal tunnel syndrome operation can be carried out without hesitation.

The operation itself is no different from that in the hospital. There is also the possibility of outpatient surgery Local anesthesiain which only the affected forearm and the corresponding hand region are anesthetized.

Since the anesthesia can persist after the carpal tunnel syndrome operation, it is advisable to have relatives or a taxi drive you home. You should also in the interests of other road users Don't drive a car that day.

Inpatient surgery

Besides the possibility of outpatient surgery, which is usually carried out as already described, an inpatient operation can also be carried out. Inpatient surgery is indicated for different risks. Of the "German Society for Hand Surgery" Inpatient surgery is recommended if

• the patient at home not adequately looked after can be.
• special complications are to be expected.
• a complete synovialectomy (Removal of the tendon sheaths) takes place.
• it is a Relapse surgery acts.

In general, it should be noted that a plannable intervention on the hand always only on one side should be made. Even in cases in which the other side is also affected, sufficient time should always be allowed for the first intervention. Sufficient time lag implies that the full resilience the hand operated on first should be fully restored.

Surgical procedure

Open surgical procedure

The open surgery a carpal tunnel syndrome via a "larger" (approx. 3-5 cm) incision is that more established procedures. Open surgery is always preferable, if

• anatomically rare variants of the carpal tunnel exist.
• a Tendinitis the flexor tendons is present.
• other Space claims exist.
• it is one Second intervention acts.
• the Wrist mobility is restricted.

The operation is performed in Humerus anemia. This means that the blood flow in the arm is interrupted for the duration of the operation so that visibility is not impaired during work. After all, it is important to protect not only the clearly visible median nerve, but also its small nerve branches that branch off from it. Many surgeons use one for the same reason Magnifying glasses.

The operation begins with a 3-5 cm longitudinal incision between the ball of the little finger and thumb near the wrist. Further preparation takes place on the basis of certain orientation points. The Carpal ligament is reached quickly and carefully split in layers. After complete severing, the ligament edges gape wide apart.

Then the Median nerve appraised. Depending on the extent and duration of the pressure damage, it is more or less strong narrowed and discolored. Manipulation of the median nerve should be avoided if possible. Only constricting adhesions should away become.

At a inflammatory thickening of the tendon sheaths the forearm flexor, as is more common in an underlying rheumatic disease, is the distance of the inflammatory tissue to reduce the contents of the carpal tunnel. Then the floor of the carpal tunnel is examined for space-occupying processes (bone spikes, ganglia, tumors) and, if present, these are removed. The operation ends with the skin suturing. A forearm plaster splint can also be used to support the hand.

Arthroscopic surgical procedure

The arthroscopic surgery is also known as keyhole surgery. The aim of arthroscopic surgery is to minor tissue injury a better wound healing and a less scarring to reach.

The orthopedist and the surgeon use that Arthroscope for assessment and therapy of joint diseases; the Internist with an endoscope to assess the stomach and intestines (Gastroscopy, Colonoscopy).

An arthroscope can thus be used as a special endoscope are designated. It consists of a tube (trocar sleeve), an optical system of rod lenses, a light source and usually a rinsing and suction device. In addition, the arthroscope has working channels through which surgical instruments for operative interventions can be introduced. Today the optics of the arthroscope are used Ease of work over a camera with a monitor connected. With this arthroscope, the doctor can look directly at the structures to be examined, similar to a camera. Two arthroscopic procedures are available.

In the Agee technique is about a little cut of the Wrist flexion crease operated at the Chow technique are two small incisions in the skin necessary. Free extension of the hand in the wrist is a prerequisite for both procedures. As with the open surgical method, the carpal ligament is split under sight. The advantage of the arthroscopic technique is the smaller skin incision and thus also the minor scar. However, many surgeons see some decisive disadvantages in the arthroscopic procedure, which are listed below:

• Arthroscopy carries an increased risk for Vascular and nerve injuries.
• It is no judgment of Carpal tunnel floor possible.
• It is no judgment of Tunnel content possible.
• It can be control worsewhether the retinaculum is completely split.

Duration of operative treatment

How long the operative treatment of the Carpal tunnel syndrome takes depends on many factors. On the one hand it plays method and Experience of the doctor plays an important role. On the other hand, the individual anatomical conditions of the patient are always important. In general, an uncomplicated carpal tunnel syndrome operation hardly costs more than a few minutes needed. Once the operation is complete, the patient remains in the practice for observation for some time.

So that the healing of the Operationswound guaranteed, the wrist will remain in one for the next 7 to 10 days solid association or maybe even a plaster cast. The thread is pulled about 8 to 14 days after the operation is completed. About 6 weeks after the operation, in most cases there is hardly any scar visible.

Moving the hand is possible and recommended for the first few weeks after the operation; However, more than light stress should be avoided in favor of good wound healing.

anesthesia

The carpal tunnel syndrome operation is a fairly straightforward, quick procedure and is rarely associated with complications. For this reason, surgery is usually performed in Regional anesthesia performed so that the patient is conscious throughout the procedure while a Elimination of pain only takes place in the arm.

To enable an operation with little bleeding, the arm is first evacuated by wrapping the arm using a tight bandage. To prevent new blood from flowing into the arm, a Blood pressure cuff put on and pumped up. To numb the arm itself, they become almost bloodless Veins then filled with a local anesthetic. An alternative to this is a local anesthetic procedure directly on the Nerve plexuswhich supplies the arm. This pulls through the armpit and can usually be anesthetized with the help of an ultrasound device without any problems.

A general anesthetic is very much in a carpal tunnel syndrome operation unusual and is usually used when the patient is very afraid of the procedure.

Sick leave and incapacity for work

In principle you can not a general statement about sick leave or inability to work after carpal tunnel syndrome surgery. Various aspects must be taken into account in order for the sick leave length to be reasonable. These include the Surgical method (open or endoscopic), Complications during the operation or risk factors that occurred after the operation and the Requirement of the profession on the hand. Generally speaking, the hand after carpal tunnel syndrome surgery six weeks not loaded should be. In most cases you can assume that you will be on sick leave for 3 to 4 weeks. During this period should no sport to be driven.

Due to the various aspects, it is advisable to clarify with the treating doctor in which period the individual sick leave will fail. Unpredictable complications can, of course, always prolong recovery and thus also the length of sick leave. Often, however, it is possible for the patient to have your Hand pain-free again after 3 weeks and to move with little strain.

Ability to drive

After the operation, the patient remains for some time observation in practice, around Side effects of anesthesia to exclude. Since the Effect of anesthesia can last up to a few hours depending on the type of anesthesia selected, it is not recommended to go home alone or even to drive afterwards.

In addition, it is unproblematic Healing of the surgical wound only guaranteed if the hand for the next 7-10 days spared so that for this reason, too, for the near future after the operation not advising to drive independently is. Instead, let a relative or acquaintance pick you up or call a taxi after the operation.

costs

The costs of a carpal tunnel syndrome operation depend on the type of insurance (private or statutory) and on the Surgical method (“Open” or endoscopic). Another aspect can also be the, depending on the insurance outpatient or inpatient implementation represent. The endoscopically performed carpal tunnel syndrome operation is somewhat more expensive because it involves higher material costs. This includes the knife, which can only be used once to open the carpal tunnel.

Without paying any additional fees for extra services, a carpal tunnel syndrome operation can cost between € 200 to € 2,000 go out.
The topic of costs should always be discussed in advance with the treating doctor in order to be prepared for possible additional costs.

Risks

There is no such thing as an operation without risks. Thus, in exceptional cases, the Wound healingor worsened movement of the whole hand. Since some patients have a small cutaneous nerve that runs perpendicular to the direction of the cut, an injury to the cutaneous nerve cannot be ruled out. In such cases, an almost punctiform pressure point arises in the scar, which appears “electrified”.

In very rare cases, the fine blood flow to the hand can be disturbed, causing serious movement disorders, hand swelling and pain. In this case one speaks of Sudeck's disease, the cause of which is largely unknown.

The more serious violation of the Median nerve possible. However, this complication is very rare for an experienced hand surgeon.

Danger: As a rule, the scars are barely visible after about 1 to 2 years.
However, it is important:
Scars on the hand are always more sensitive than scars on other parts of the body. The reason for this is that the hand has a very high density of sensory nerves.
It is quite normal if you feel the scar uncomfortably after 6 or 8 weeks when you use your hand every day. At this point, the scars are also red and may be a bit thicker.

Complications

All common surgical complications can also occur when splitting the carpal ligament. These include the bacterial infections, Secondary bleeding, Nerve injuries and other.
By a postoperative scarring, remaining bone spikes, again
Tendinitis or an incomplete splitting of the ligament can cause a relapse
(renewed carpal tunnel syndrome) develop.

Relapse

Unfortunately, even with a successful operation and with the correct surgical technique, there is always the possibility that the disease, including the nerve compression, will recur. This is especially the case if there is a so-called postoperative "Excessive scarring" comes. Medically speaking, one speaks of one Recurrent carpal tunnel syndrome.

In rare cases, a Reoperation necessary, especially if remnants of the carpal roof are still intact and the nerve compression persists.

Other causes for a relapse are strong growths of the tendon sheaths, e.g. at rheumatism/rheumatoid arthritis or dialysis patients, as well as the growth of a tumor in the carpal canal.

Aftercare

A distinction is made between post-treatment with plaster splint and one without plaster splint. In cases where the doctor opts for the Plaster splint decides, it will be created immediately after the operation. She usually has to for about one week and is often changed, especially in the first week. This constant change is due to the fact that wound healing as such must be under observation. After a week, a plaster splint is used for another week padded bandage created. In both cases, care must be taken to ensure that the patient can move his fingers well.

The sutures of the operation are usually removed on the 14th postoperative day.

Since the operated hand should gradually be brought closer to the everyday strain, not all activities can be performed again immediately. If the approach to everyday stress happens too quickly, pain occurs and the hand swells. As a rule, the operated hand should be moved in the first 6 weeks after the operation, but not strained.

Rule of thumb: A load begins as soon as you lift something heavier than a cup of coffee!
It has proven useful to treat the operated hand several times a day in the first few months with a fatty cream rub in. For the first 6 to 8 weeks, the hand should be in for 5 minutes three times a day lukewarm water to be bathed.

In most cases there is one Treatment by the physiotherapist unnecessary. In most cases, the above-mentioned exercises in a water bath are completely sufficient. Only if the patient is of the opinion that the mobility of his hand does not return in a reasonable time should he contact the treating doctor. Together then one can Exercise therapy be considered.

In any case, you should consider the following:
Any kind of exercise therapy - regardless of whether it was carried out independently or by the physiotherapist, is allowed never to pain to lead. If you feel pain while doing this, always remember: Pain in the context of exercise therapy does not lead to normal mobility more quickly, but rather slows down the healing process. In individual cases, the pain during exercise therapy can even cause permanent lack of movement!

A week of plaster of paris or immediate early functional exercise therapy and beyond no excessive wrist strain for 6-8 weeks. The sutures are removed after approx. 10 days. Inability to work can last for 3-8 weeks - depending on the workload and the healing process.

Carpal tunnel surgery during pregnancy

A pregnant woman encamped as a result of hormonal changes especially in the last trimester of pregnancy increased fluid a, whereby an increased fluid content in the carpal canal can be determined. If this carpal canal is already very narrow due to its individual shape, the increased fluid content creates increased pressure on the median nerve. This causes pain in one or both hands, which can also radiate into the whole arm. This pain occurs especially at night.

Basically, thank you modern anesthetic procedures (e.g. plexus anesthesia = isolated anesthesia of the arm) the risk for mother and child is justifiable and a pregnant woman is therefore also operated on for carpal tunnel syndrome.
This is especially true if the operation is carried out in the last trimester of pregnancy and the hand surgeon and gynecologist work closely together.

Any expectant mother who is a Carpal tunnel syndrome should consult the treating hand surgeon with the opinion of the Gynecologist (specialist in gynecology) ask the crucial question whether such an operation in the pregnancy should take place.

Every mother-to-be should consider that such an operation can be carried out in the event of extremely agonizing symptoms and - also in the respective situation - it can be quite useful.
On the other hand, every affected woman should know that after delivery (and possibly the breastfeeding period) by reducing the body's own water content, many carpal tunnel syndromes subside without therapy, especially if the pain first appeared during pregnancy. Several scientific causes have clearly proven this.

As soon as a young mother Weaned baby has is a surgery anytime feasible. When planning the operation, however, it must be taken into account that postoperatively large parts of the Infant care cannot be done by the mother herself. You have to expect that in the first 2-3 weeks especially that Change diaper and the to bathe of the child has to be carried out by someone else. This can be explained by the fact that the wound, even if it is sutured and additionally protected by a bandage, can be infected by bacteria from the diapers used. If bacteria get into the wound, it is very likely that an infection is triggered, which has a negative effect on healing.

forecast

Early finger exercises can be done to Bonding tendons and median nerves to avoid. However, care must be taken to ensure that the wrist is not strained too early.

An essential prognostic success factor is that timely treatment of the clinical picture, as one chronic pressure damage beyond a certain degree of damage is no longer reversible.