Carpal tunnel syndrome is a very common condition, and treatment is provided in close consultation with the guidelines and consensus of the responsible Association of the Scientific Medical Societies in Germany (AWMF) produced in 2006.

Of course, the nature and intensity of the treatment must be determined by the severity of the condition.

In the early stages of the disease – for example occasional sensory disturbances – conservative treatment is indicated in every case. A palmar wrist splint in the neutral position, worn at night, can be extremely effective.

Many patients report that they are able to remain virtually symptom-free by wearing this splint long-term, including over months or even years.

However, it is not uncommon to offer surgical treatment to patients who report persistent, agonising and characteristic symptoms of carpal tunnel syndrome and who have been treated conservatively for far too long.

There is also evidence that the local infiltration of corticoid crystal suspensions into the carpal tunnel can be effective. The effect of this measure lasts for around 8 weeks and is similar to the effectiveness of combined treatment involving a night splint and the oral administration of medications such as Diclofenac.

There is no evidence to indicate that local ultrasound therapy, yoga, carpal mobilisation, nerve exercises or magnetic field therapy are of any benefit.

Vitamin preparations also have no effect.

Idiopathic carpal tunnel syndrome can correctly be termed as an intermittent condition. The severity of the symptoms is diverse, varies, and patients often simply ignore them since numbness is, after all, not necessarily painful. We should therefore not be surprised when various treatment measures appear to be effective, however the recurrence of symptoms is predictably common.

The occurrence of chronically recurring, painful symptoms in the hand that disturb sleep and / or result in loss of the hand’s gripping sensation ultimately prompts the patient to consent to surgery in order to relieve their symptoms.

The constellation of clinical signs mentioned above, together with a clearly abnormal ENG/EMG investigation of the hand, is now considered an absolute indicator for surgery. Data irrefutably confirms that surgical treatment, where indicated, is considerably superior to conservative measures (evidence level A, 1a).

The aim of surgical treatment is to reduce the pressure on the media nerve by widening the nerve tunnel as much as possible. Over the last few decades, various surgical techniques have been used in order to achieve this result. Many surgical methods, however, have caused disruptive and in some cases devastating scarring of the palm and wrist.

The introduction of endoscopic surgery for carpal tunnel syndrome at the end of the 1980s revolutionised this surgical procedure.

In Germany, around 500,000 carpal tunnel syndrome operations are carried out each year. The special cost situation of the endoscopic approach has so far prevented its widespread use. Currently around 30 per cent of operations are carried out using various endoscopic techniques (data not finalised).

The minimally invasive surgical technique, the markedly reduced morbidity immediately post-operatively and in particular the lack of pain have improved patients’ confidence in surgical treatment.

Together with consideration of the surgical indications and patient education, the following facts are of significance.

1. The operation can also be carried out safely after radial fractures.
2. The operation is even recommended for pregnant women if there are signs of deficit, since in more than 50 per cent of cases the symptoms persist after childbirth or can recur.
3. Elderly patients benefit from the procedure – the pain caused by entrapment of the nerves can virtually always be eliminated.
4. Following surgery for breast cancer, simultaneous carpal tunnel surgery is possible even with a tourniquet with no increased risk.
5. Surgery with a tourniquet / bloodless surgery is strongly recommended.

Especially the latter point is of particular importance for operation planning and patient education, since a bloodless arm requires at least regional anaesthesia to be used. Often, the procedure is carried out as an outpatient, however it is performed under stress-free short-acting anaesthesia.

The careful pre-planning of the (primarily outpatient) operation is therefore helpful and necessary. Performing the procedure under local anaesthesia without a bloodless arm / arm under tourniquet is possible for highly experienced surgeons, (e.g. for dialysis patients), however it is only useful in exceptional cases since the surgical risk is considerably increased.

The operation can take between 5 and 20 minutes, depending on the surgeon’s experience. Stress to the patient caused by general anaesthesia is therefore commensurately short.

According to studies, open and endoscopic surgical procedures undoubtedly have the same prognosis in terms of quality of outcome. According to analyses of numerous randomised studies (1A, 1B), but also based on meta-analyses, it has been discovered that both surgical methods are equally effective if they (performed correctly) have fully widened the carpal tunnel.

The post-operative period until the operated hand can be reused in everyday activities is shorter, however, in patients treated endoscopically (evidence level A).

Minimally invasive surgery to the carpal tunnel allows elderly people, for example, to support themselves on walking sticks or walking aids considerably more quickly. If necessary, the usability of the hand for these devices can be improved even further with protective padded dressings. The hand does not need to be put in a plaster of Paris splint. The fingers can be used immediately and used for self-caring purposes.

It is unfortunately true that the limitation of usability of the hand so feared by patients often leads to essential surgery on the carpal tunnel being postponed.

It is therefore right to take away our patients’ fear of having hand “failure”, being able to eat, drink, look after themselves or dress themselves is possible almost immediately after the operation. Even operations on single-handed patients (e.g. after a stroke) is often useful in view of the very low complication rates.

The time off work, however, depends greatly on the patient’s profession. Desk workers (working in front of a computer all day) should schedule in at least 14 days of rest for the operated hand. The time taken off work for the hand is of course also determined by the extent of the pre-existing nerve damage.

In this context, it is important to realise that no physiotherapy is indicated after carpal tunnel surgery – unless there are concomitant conditions or simultaneous surgery has been carried out.

The connective tissue in the surgically divided carpal tunnel roof requires around 6-12 weeks to close fully, but this varies considerably from individual to individual. Only then can the operated hand be used fully and be suitable for playing sports. Medical gymnastics do not shorten this time in any way!

Surgical treatment of carpal tunnel syndrome promises virtually lifelong relief if the treatment was performed in good time. Around 18 per cent of patients experience similar symptoms over subsequent years, however these do not require treatment. Some professions are particularly prone to the condition, such as assembly workers.

Statistically, it can be assumed that around 5 per cent of operated-on patients will require further treatment and around 0.8 per cent of these patients will need further surgery.

BIBLIOGRAPHY

1. http://www.awmf.org/leitlinien/detail/ll/005-003.html; as of 6.10.2011
2. Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature. Muscle Nerve 2003;27:26-33
3. O’Connor D, Marshall S, Massy-Westrop N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. (Cochrane Review). The Cochrane Library, Issue 2, 2003
4. Irvine J, Chong SL, Amirjani N, Chan KM. Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle Nerve 2004;30:182-187
5. A.Neumann, A.Kube. LONG-TERM RESULTS FOLLOWING ECTR
(AGEE TECHNIQUE) WHICH IS THE RECURRENCE RATE? .
J Hand Surg Eur Vol 2008, 33: 1