Carpal Tunnel Syndrome

Carpal Tunnel Syndrome | Denver, Colorado

Carpal tunnel syndrome (CTS) is one of the more common conditions I see in my hand surgery practice in the Denver metropolitan area.

CTS is a condition of the hand and wrist. It occurs when the median nerve is compressed as it travels from the forearm into the hand (see Figure 1). Carpal tunnel syndrome typically involves symptoms in the thumb, index finger, middle finger, and ring finger. It is often felt as numbness, tingling, pain, or burning in these fingers. These symptoms are typically felt worse at night. In severe cases, CTS can also result in irreversible weakness of the hand.

Carpal Tunnel Diagnosis & Treatment

Currently, carpal tunnel syndrome is diagnosed by a combination of examination by your doctor and special nerve testing known as electromyography (EMG). This test is performed by a neurologist. In mild to moderate forms of carpal tunnel syndrome, wearing a wrist brace at night can significantly improve your symptoms or even resolve them altogether. Many doctors will start with this as the initial step to treatment. Patients who don’t improve after consistent brace wear may wish to consider carpal tunnel steroid injection or carpal tunnel release surgery.

Fortunately, there is a newer diagnostic tool that is becoming more mainstream. This diagnostic method uses a standard ultrasound imaging device to visualize the median nerve as it passes through the carpal tunnel. I then measure the cross-sectional area of the nerve. A larger nerve indicates a nerve full of fluid that is suffering from carpal tunnel syndrome. Recently, this test has been shown to be as accurate as traditional EMG. The best part? It can be done in our office without the need for a referral elsewhere. And it doesn’t hurt!

Carpal Tunnel Release Surgery

Carpal tunnel syndrome, which results in hand numbness, often worse at night while sleeping. — **Figure 1** - In carpal tunnel syndrome, the median nerve is compressed under the transverse carpal ligament as it travels through the carpal tunnel.

Carpal tunnel release surgery is a relatively minor procedure with a high rate of success. In this surgery, I make a 2-cm incision at the base of your palm to reveal the ligament that compresses the median nerve. After dividing that ligament, your nerve will no longer be compressed. This surgery typically requires 3 to 4 stitches and 2 to 3 weeks to allow for the wound to heal.

Additional Information

While this is an overview of carpal tunnel syndrome, if you’d like more information on this topic, please continue reading through my patients’ frequently asked questions below, or see my ‘deep dive’ section to the right of the FAQs where I have links to the longer-form articles I have written about various topics related to carpal tunnel syndrome and its treatment.

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The Basics

Carpal tunnel syndrome is a collection of symptoms that result from compression of the median nerve in the carpal tunnel. The carpal tunnel is an anatomic space near the wrist joint through which the median nerve passes as it travels from the forearm to the hand (see Figure 1).
Carpal tunnel syndrome results when there is any compression on the median nerve inside the carpal tunnel. The median nerve passes through the carpal tunnel with nine flexor tendons, the tendons that bend your fingers (see Figure 1).
Causes of median nerve compression in this space include progressive thickening of the roof of the tunnel (the transverse carpal ligament), cysts or masses within the carpal tunnel, irritation from the adjacent flexor tendons, trauma to the wrist, or excess fluid in the tunnel associated with conditions like pregnancy.
Carpal tunnel syndrome is very common. In fact, 3% of the population is expected to develop it at some point in their lifetime.
Risk factors that make one more likely to develop carpal tunnel syndrome are those who work with vibrating machinery or equipment, perform highly repetitive hand/wrist tasks, or engage in excessive computer use.
Additionally, those with diabetes, rheumatoid arthritis, and increasing age are also at risk of developing carpal tunnel syndrome.

Carpal Tunnel Symptoms & Diagnosis

Classic carpal tunnel symptoms are numbness and tingling in the thumb, index finger, middle finger, and half of the ring finger. These symptoms can also include pain or burning, and they are usually worse at night.
In severe cases, patients can permanently lose the muscle mass at the base of the thumb pad and suffer from irreversible weakness of the thumb with pinch.
This is an area of active research. Currently, the standard diagnosis of carpal tunnel syndrome is with nerve tests known as electromyography or nerve conduction studies (EMG/NCS). This is a test performed by a neurologist.
As a side note, some are now advocating a way of diagnosing carpal tunnel purely through clinical questioning and tests (the CTS-6 score) or with in-office ultrasound. Lots more to come on this topic as the field evolves.
If you’re interested in how we use the CTS-6 score, you can find more information in my article “Carpal Tunnel Syndrome: How To Diagnose Yourself in 6 Easy Steps.”
While most patients would not describe the test as frankly painful, it can be uncomfortable to some. The test involves transmission of a small electrical current through the arm to measure the speed at which electricity is conducted down the median nerve through the carpal tunnel.
Because this test is conducted by a neurologist, it will require a referral. This is a referral we can send to a local facility. That office will contact you to arrange a time and location for your test.

Carpal Tunnel Treatment

If you’re interested, I go into this in more detail in my deep dive “Carpal Tunnel Syndrome: What Are The Treatment Options?”
If you think you have CTS, the first thing to do is sleep in a wrist brace. Use this wrist brace only at night but every night for a minimum of 4 weeks. Preferably 6 weeks. Consistency is key.
What does this do? This keeps your wrist straight and thus prevents the walls and floor of the carpal tunnel (your wrist bones) from collapsing every night when you curl up for sleep. Which prevents 6-8 hours of a pinched nerve. If you can prevent this for 4-6 weeks, your nerve will have time to heal…and if that was the primary cause of your CTS, then you are cured!
Important note: please don’t wear the brace all day too or you’ll come back to me with stiff, painful wrists. A new problem we now have to treat.
While some patients ultimately benefit from exercises known as nerve glides, the overall benefit has been found to be small and unreliable. Because of this, therapy is not a routinely recognized method of treating carpal tunnel syndrome.
Steroid injections are certainly an option for carpal tunnel syndrome. Because carpal tunnel syndrome is not an inflammatory condition, steroid injections (an anti-inflammatory treatment) will often provide only temporary relief of carpal tunnel symptoms.
That being said, temporary relief can be very important depending on your current life situation. Whether symptoms have just become too painful or it’s not the right time for surgery, injections can provide a helpful middle ground in the treatment of carpal tunnel syndrome.

Carpal Tunnel Surgery

The surgery for carpal tunnel syndrome is called a carpal tunnel release. In this procedure, the transverse carpal ligament is divided. This ligament forms the roof of the carpal tunnel and plays a significant role in compressing the nerve. Once it is divided, the pressure is released from the median nerve.
To me, this is the cornerstone of understanding carpal tunnel release surgery. The only thing we can do as surgeons is release the transverse carpal ligament. This takes the pressure off the nerve and allows the restoration of blood flow and nutrients.
Once this happens, the nerve begins a biological healing process. This, unfortunately, is a process you and I have no control over. Your nerve is going to try its hardest to heal itself, but the degree to which this occurs is out of our control.
Nerves that have been compressed more severely or for a longer duration have the hardest time recovering. Here’s a summary of what I typically see:
1. The vast majority of patients have a resolution of their painful nerve symptoms (burning, tingling, pain).
2. Many have full restoration of their sensation. However, some patients suffering from ulnar nerve compression show little improvement following carpal tunnel release surgery.
3. Very few patients have any improvement of weakness or muscle loss from prolonged nerve compression. This is typically irreversible.
If you’ve seen me for carpal tunnel syndrome, then you know I stress this a lot:
Carpal tunnel release surgery is performed so that your symptoms won’t continue to worsen; improvement following release is common, but by no means guaranteed.
I find it helpful to understand the biology when developing expectations around carpal tunnel release surgery.
In general, there are two current techniques for carpal tunnel release surgery.
Open: This is the traditional carpal tunnel release surgery. In my practice, I make a 1.5-2 cm incision at the base of the palm to access and divide the transverse carpal ligament.
Endoscopic: This is an alternate form of carpal tunnel release surgery. It involves one or two 0.5 cm incisions in the wrist, followed by the use of cameras and a retractable knife to divide the transverse carpal ligament.
I do not perform endoscopic carpal tunnel release surgery. I believe a 1.5-2 cm incision to directly visualize the ligament and nerve is paramount to safely performing this procedure.
Carpal tunnel release surgery is a day surgery typically performed in an outpatient surgery center. In most cases, anesthesia options are up to you.
Some patients elect to have numbing medicine injected into their wrist (like the dentist) and remain wide awake for the 15-minute procedure.
Most patients will choose a ‘twilight’ sedation (similar to a wisdom tooth extraction or colonoscopy procedure) during which they feel asleep but are breathing on their own without the need for a breathing tube.
Following carpal tunnel release surgery, you will have 2-3 sutures in the palm. All my patients have a visit with a Certified Hand Therapist within 10-14 days of surgery. Often, sutures are ready for removal at that time and they are removed by the therapist. Any concerns are communicated directly to me by my team.
I will then meet with you approximately 3 weeks after surgery to evaluate your healing process. Many patients are healed and appropriate for release from care at that time.
Restrictions are fairly simple after carpal tunnel release surgery. The surgical dressing must stay on and dry for the first 5 days after the procedure. Finger movement and light to moderate use of the hand is allowed and encouraged. But you must take care not to do anything vigorous enough to tear the stitches or disrupt wound healing.
Fortunately, the risks of carpal tunnel surgery are low. Any surgery has risks associated with anesthesia, pain, bleeding, and infection. Additionally, there is a very small risk of nerve injury. Some patients do not improve (see more above) or have a recurrence of their carpal tunnel syndrome in the future.
Ultimately, your decision for surgical treatment of carpal tunnel syndrome is just that - your decision.
If your carpal tunnel syndrome is mild to moderate in severity, it can be a reasonable decision to avoid or delay surgery. If you make this decision, you must understand that many cases of carpal tunnel syndrome slowly worsen over time. And they can worsen to the point of permanent muscle loss in the hand. So if you decide no surgery for now, be sure to follow up with your hand surgeon every 6 months to ensure your symptoms aren’t progressing beyond a point of no return.
In the case of severe carpal tunnel syndrome, the standard recommendation will be for surgical release as soon as possible. Severe carpal tunnel syndrome means the muscles in your hand are no longer receiving adequate signals from the median nerve. These muscles will eventually shrink (atrophy) and eventually disappear. This is an irreversible condition that can result in a dysfunctional hand.