Treatments

I will offer surgery to patients who have developed continuous numbness, or in whom there is weakness of the muscles at the base of the thumb. Patients with less severe symptoms can consider use of a night-time wrist splint (available on-line) to reduce night time symptoms and a steroid injection (which is well known to give at least temporary relief of symptoms, and can be administered in clinic.)

Investigations

I would recommend that patients consider having nerve conduction studies before surgery. This investigation can be done as an out-patient, it gives objective information to confirm the level of damage to the electrical activity of the nerves to the hand, and can help estimate the likely speed and extent of recovery after surgery.

Nerve conduction studies are funded by most insurance companies and can be carried out at the Spire Lea Hospital (01223 266900) either before or after our consultation

Conditions contributing to carpal tunnel syndrome

Carpal tunnel syndrome can be exacerbated by prolonged wrist flexion, diabetes, wrist-arthritis, old fractures of the wrist, thyroid disease, pregnancy, and obesity. Where possible, I will advise correction or optimization of any exacerbating factors.

Cycling and carpal tunnel syndrome

There are some simple changes things that might help: check the tilt of the saddle and the height of your handle-bars: the lower the handle-bars, the more weight is transferred to the hands and the greater the likelihood of carpal tunnel syndrome.

Look at your hand and wrist position: angle your handle-bars downward to minimize wrist extension and to put the wrist in a more neutral position (whilst still allowing confident use of the brakes.) Strengthen your core trunk muscles to reduce tension on your forearms, change your grip every twenty minutes.

Rowing and carpal tunnel syndrome

In the majority of rowers I believe the problem is caused by an extended posture to the wrist, or ulnar deviation of the wrist, at the finish of the stroke. Good technique places the wrist in neutral during the power phase of the stroke, with the oar handle held loosely during the recovery phase. Better positioning of the trunk, good coordination of the leg drive toward the finish, and attention to the elbow position (if the elbow is away from the body at the finish the wrist is ulnar deviated) can help.

Carpal tunnel release surgery

The objective for carpal tunnel release surgery is to safely divide the carpal ligament and prevent further damage to the median nerve. This should help preserve existing hand function and potentially allow symptoms to improve.

Surgery is performed under local anaesthetic as a day case procedure.

I use an open, or an endoscopic approach.

The operation takes about thirty minutes:  patients should expect to be at hospital between one and two hours. Patients cannot drive home after surgery.

The skin incision is at the base of the palm and is usually less than 2 cm in length.

The skin wounds are closed using a nylon suture.

How effective is surgery?

Carpal tunnel release surgery is very effective at preventing further damage to the median nerve as a result of carpal tunnel syndrome. Carpal tunnel release surgery is effective at reducing symptoms in moderate and early severe carpal tunnel syndrome. Surgery is less effective in the presence of generalized disease such as diabetes, or in when prolonged carpal tunnel syndrome has caused irreversible damage to the median nerve.

Aftercare

Patients go home the same afternoon or morning, wearing a padded bandage with the thumb and fingers un-bandaged.

I recommend that patients remove the outer bandage at 3 days. Patients should then keep their hand clean and dry for a further 9 days before having their sutures removed by the practice nurse at 12 days. (The hospital will give patients a letter for the practice-nurse, patients can also have their sutures removed at the Spire Lea Hospital by one of their nurses if more convenient). The hand can now get wet, the patient can usually return to normal bathing, swimming and sports that avoid direct contact with the base of the hand.

I would recommend that patient then place a small piece of Micropore™ tape across the wound each day for two further weeks. At the end of this period moisturizer can be applied firmly to the scar twice daily for about one month.

Return to driving

The DVLA is quite specific in their guidance to drivers and medical practioners:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/312882/aagv1.pdf

“It is the responsibility of the driver to ensure that he/she is in control of the vehicle at all times and to be able to demonstrate that is so, if stopped by the police. Drivers should check their insurance policy before returning to drive after surgery.”

I would recommend that patients wait at least seven days before considering driving. I would recommend that patients sit in the driving seat and check that they feel confident and comfortable before driving. Patients should be able to hold and manipulate the steering wheel and gear stick without any significant impairment. If in doubt: don’t drive.

Return to work

When a patient will return to work depends upon the patient’s job, his or her demands in that job, whether he or she can control his or her duties, and how motivated he or she is to return to work. I can give anecdotal guidance.

Office / managerial workers, who return to work the next day report that they struggled. I would suggest at least a five day gap after surgery before entering the office. Manual workers who return to work at three weeks also reported that they struggled. The strength and stamina in the hand will be reduced for at least six weeks. I would suggest between four and six weeks before returning to manual work.