Surgery for CARPAL TUNNEL SYNDROME

Continuing from the previous post, lets talk a bit about SURGERY for CARPAL TUNNEL SYNDROME.

Surgery entails cutting or transecting the transverse carpal ligaments that overlies the median nerve and can be done as an outpatient basis or a day care procedure in the OT.

The surgery itself can be accomplished in two ways:

The traditional approach is by open carpal tunnel surgery, whereby a longitudinal skin incision is made in the wrist and the carpal ligament cut to relieve the pressure on the median nerve. Incisions generally have become smaller over the years, and the so-called "mini" 2cm skin incision have become the standard length now.


Surgery takes about 20 minutes and can be done under  local anaesthesia although my preference is to do it under general anaesthesia, unless there are contraindications.

Torniquet applied to prevent bleeding

Local anaesthesia injected

Checking for the landmarks

Incision over the wrist

Incision deepened

The carpal ligament is cut

The underlying median nerve could be seen

Wound washed and closed 

Post operatively, the patient will feel relief from the night pain, as early as the day after surgery. Numbness of the fingers will take a bit more time to disappear, as is wasting of the hand muscles which will be the last to recover.

Sutures are usually taken off at two weeks and patients are advised not to lift heavy objects or to grip tightly for the next 4-6 weeks. There might be some weakness of the hand grip but this will also recover over time.

Another, more minimally invasive method would be through the endoscopic method. A small incision is made at the wrist and a small camera, together with a knife, introduced into the wound to see the carpal tunnel. The ligament is then cut below the skin by the knife. Proponents of this technique claim shorter recovery time and less post operative pain. The downside is the complexity of the procedure as it necessitates more (expensive) equipment and has a steeper learning curve on the part of the surgeon.

- the BOMOH TULANG -

Numbness in your hand - CARPAL TUNNEL SYNDROME?

Do you have numbness in your hands? Worse in the early hours of the morning, painful too? pain wakes you up at night? Or, do you notice that sometimes your hands get all clumsy and you start dropping things, like a coffee cup for instance?

Well, you have come to the right place. Today let's talk  a bit about CARPAL TUNNEL SYNDROME, a condition that affects between 1 to 10% of the population.

Lets start with the textbook description:

CARPAL TUNNEL SYNDROME (CTS) , by definition, is a syndrome characterized by pain, tingling, and numb sensations in your hand, typically involving the lateral (radial) 3 ½ digits (ie the thumb, index and middle fingers) caused by compression of the median nerve at the wrist, by whatever reasons. 

 

Shaking the hands to make it better

Patients usually complain of numbness and tingling at night that wakes them up;  they often find that they have to shake their hands to make it better. They can also experience numbness  when driving, reading the newspaper or a book, when typing on a keyboard, or any activity that requires the hands to be kept flexed for a period of time. Sometimes they can also have referred pain radiating to the forearm and arm, in which case the condition could be misdiagnosed by other health care professionals.




Where is the CARPAL TUNNEL?


The carpal tunnel is located at the wrist; the concave bottom part is created by the bony structures of your small bones of the wrist (the carpal bones), and tunnel completed on the top by a non-yielding structure called the transverse carpal ligament. Traversing the crowded tunnel are the tendons that go to your fingers and the median nerve, which supplies sensation to the thumb, index finger, middle finger, and the radial side (thumb side) of the ring finger

What causes CARPAL TUNNEL SYNDROME?

 Carpal tunnel syndrome is due to median nerve compression within the carpal tunnel, as increased pressure causes decreased blood flow to the nerve.  This increased pressure comes from swelling (edema) of the tissues surrounding the tendons called the synovium. This swelling may be due to injury to the synovium from overuse, trauma, or other causes such as metabolic disturbances (endocrine disorders, pregnancy, menopause). Increased pressure in the tunnel could also be due to anything that decreases the volume available in the tunnel, such as a lipoma or neuroma.

Having said that, do keep in mind that most of the time no cause could be found.


How does the doctor know I have CARPAL TUNNEL SYNDROME?

Well, as per the usual way, through questioning and thorough clinical examination.
A variety of special tests involving the wrist could be performed ie the Tinel's test and Phalen's test.

Additional tests such as X rays, MRI and nerve conduction tests could be called upon to make the diagnosis or rule out other conditions

What happens next

Usually once a firm diagnosis is made, the doctor could start the patient on a trial of conservative measures, typically lasting a month or two, and best results are obtained with early onset of symptoms. These might include:

• Activity modification
• Splinting - to rest the joint, and keep it in a neutral position
• Addressing the primary cause of CTS - treating hypothroidism for example
• Oral medications - NSAIDS and oral steroids
• injections into the carpal tunnel

 
Well, I have I tried all that, and it still doesnt seem to work..

Failed conservative treatment indicates that the patient is a candidate for the next step: SURGERY.
Surgery is also indicated for worsening symptoms and evidence of atrophy of the small muscles of the hand.
There are various techniques in doing surgery on the carpal tunnel , which i will discuss in the next entry.

Till then,

-The BomohTulang -

NB: there a literally tons of info on the net about CTS, so I have compiled some links which i think could be useful:

The  American Academy of Orthopedic Surgeons (AAOS) has an article about CTS here

Additionally, you can download the American Society for Surgery of the Hand (ASSH) brochure on CTS here (PDF file)

Closer to home, the Arthritis Foundation Malaysia (AFM) has an article on CTS here

Happy CNY!!

So we are about to celebrate the dawn of another year (reader: err I thought we already did, about a month ago?)
February 3 this year marks another year on the Chinese calendar, and this year we usher in the year of the rabbit, with 2011 being the year of the metal rabbit. If you are a believer of Feng Shui, head on here to see what the future holds for you. Otherwise, I would like to wish all our Chinese readers a happy and prosperous year ahead!

Speaking of prosperity, we had Yee Sang for lunch the other day - down the road at Kota Kemuning.
This dish is traditionally available during the new year and is symbolic of good luck, prosperity, health and all things auspicious.

The ingredients - err can you see the salmon?

You toss em and mix them up real good.

Apa lagi.. makan time!

Yes you (together with your friends / family members) need to mix the ingredients together and toss them up real high - the significance of the tossing is to wish for abundant luck and happiness for all.

Yee Sang Wiki can be found here
Someone was busy researching the origins of Yee Sang

Happy CNY to all!

-the Bomoh Tulang -