Surgery for carpal tunnel syndrome
- Alice A Hunter, MD
Alice A Hunter, MD
- Staff Orthopedist
- Lahey Hospital and Medical Center
- Barry P Simmons, MD
Barry P Simmons, MD
- Associate Professor of Orthopaedic Surgery
- Harvard Medical School
- Section Editors
- Charles E Butler, MD, FACS
Charles E Butler, MD, FACS
- Section Editor — Plastic and Reconstructive Surgery
- The University of Texas, MD Anderson Cancer Center
- Jeremy M Shefner, MD, PhD
Jeremy M Shefner, MD, PhD
- Section Editor — Neuromuscular Disease
- Professor and Chair of Neurology, Barrow Neurological Institute
- Professor of Neurology, University of Arizona, Phoenix
- Clinical Professor of Neurology, Creighton University
Carpal tunnel syndrome (CTS) is a common nerve entrapment disorder manifested by pain, paresthesias, and ultimately muscle wasting of the hand. Appropriate treatment can interrupt the progression of this disorder and avoid the development of permanent disability. Conservative therapy may be sufficient, although many patients require surgery. Surgical treatment may involve open or endoscopic technique. The goal of either approach is to decrease pressure upon the median nerve at the wrist by dividing the transverse carpal ligament and antebrachial fascia.
This topic review will discuss the surgical treatment of CTS. The clinical manifestations, diagnosis, and conservative therapy of this disorder are reviewed elsewhere. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome: Treatment and prognosis".)
Indications for surgery include persistent numbness and pain, motor dysfunction with diminished grip or pinch grasping, or thenar eminence flattening.
Prior to contemplating surgical carpal tunnel release, one must be sure of the correct diagnosis. Although median nerve entrapment at the wrist is the most common and most well-studied manifestation of CTS, it is often confused with other disorders, such as cervical radiculopathy, thoracic outlet syndrome and pronator syndrome.
The symptoms of carpal tunnel syndrome include numbness and tingling in the hand, especially if confined to the median nerve distribution. The symptoms are often worse at night but can also be present in the daytime in the worker with a provocative job. Symptoms are often worse with driving or holding a book, newspaper, or telephone .
- Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am 1993; 75:1585.
- Jablecki CK, Andary MT, So YT, et al. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. AAEM Quality Assurance Committee. Muscle Nerve 1993; 16:1392.
- Concannon MJ, Gainor B, Petroski GF, Puckett CL. The predictive value of electrodiagnostic studies in carpal tunnel syndrome. Plast Reconstr Surg 1997; 100:1452.
- Kaplan, EB. Surface anatomy of the hand and wrist. In: Functional and surgical anatomy of the hand, Spinner, E. (Ed). Lippincott, Philadelphia 1953. p. 227.
- Panchal, AP, Trzeciak, MA. The Clinical Application of Kaplan's Cardinal Line as a Surface Marker for the Superficial Palmar Arch. Hand 2009; [Epub ahead of print].
- Zhang X, Li Y, Wen S, et al. Carpal tunnel release with subneural reconstruction of the transverse carpal ligament compared with isolated open and endoscopic release. Bone Joint J 2015; 97-B:221.
- Curtis RM, Eversmann WW Jr. Internal neurolysis as an adjunct to the treatment of the carpal-tunnel syndrome. J Bone Joint Surg Am 1973; 55:733.
- Rhoades CE, Mowery CA, Gelberman RH. Results of internal neurolysis of the median nerve for severe carpal-tunnel syndrome. J Bone Joint Surg Am 1985; 67:253.
- Lowry WE Jr, Follender AB. Interfascicular neurolysis in the severe carpal tunnel syndrome. A prospective, randomized, double-blind, controlled study. Clin Orthop Relat Res 1988; 227:251.
- Chapell R, Coates V, Turkelson C. Poor outcome for neural surgery (epineurotomy or neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone: a meta-analysis of global outcomes. Plast Reconstr Surg 2003; 112:983.
- Lee WP, Plancher KD, Strickland JW. Carpal tunnel release with a small palmar incision. Hand Clin 1996; 12:271.
- Katz JN, Keller RB, Fossel AH, et al. Predictors of return to work following carpal tunnel release. Am J Ind Med 1997; 31:85.
- Biyani A, Downes EM. An open twin incision technique of carpal tunnel decompression with reduced incidence of scar tenderness. J Hand Surg Br 1993; 18:331.
- Chow JC, Hantes ME. Endoscopic carpal tunnel release: thirteen years' experience with the Chow technique. J Hand Surg Am 2002; 27:1011.
- Sabesan VJ, Pedrotty D, Urbaniak JR, Aldridge JM 3rd. An evidence-based review of a single surgeon's experience with endoscopic carpal tunnel release. J Surg Orthop Adv 2012; 21:117.
- Van Heest A, Waters P, Simmons B, Schwartz JT. A cadaveric study of the single-portal endoscopic carpal tunnel release. J Hand Surg Am 1995; 20:363.
- Finsen V, Andersen K, Russwurm H. No advantage from splinting the wrist after open carpal tunnel release. A randomized study of 82 wrists. Acta Orthop Scand 1999; 70:288.
- Henry SL, Hubbard BA, Concannon MJ. Splinting after carpal tunnel release: current practice, scientific evidence, and trends. Plast Reconstr Surg 2008; 122:1095.
- MacDonald RI, Lichtman DM, Hanlon JJ, Wilson JN. Complications of surgical release for carpal tunnel syndrome. J Hand Surg Am 1978; 3:70.
- Bland JD. Treatment of carpal tunnel syndrome. Muscle Nerve 2007; 36:167.
- Assmus H. [Correction and reintervention in carpal tunnel syndrome. Report of 185 reoperations]. Nervenarzt 1996; 67:998.
- Brown RA, Gelberman RH, Seiler JG 3rd, et al. Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods. J Bone Joint Surg Am 1993; 75:1265.
- Agee JM, Peimer CA, Pyrek JD, Walsh WE. Endoscopic carpal tunnel release: a prospective study of complications and surgical experience. J Hand Surg Am 1995; 20:165.
- Murphy RX Jr, Jennings JF, Wukich DK. Major neurovascular complications of endoscopic carpal tunnel release. J Hand Surg Am 1994; 19:114.
- Nath RK, Mackinnon SE, Weeks PM. Ulnar nerve transection as a complication of two-portal endoscopic carpal tunnel release: a case report. J Hand Surg Am 1993; 18:896.
- Lee DH, Masear VR, Meyer RD, et al. Endoscopic carpal tunnel release: a cadaveric study. J Hand Surg Am 1992; 17:1003.
- Rowland EB, Kleinert JM. Endoscopic carpal-tunnel release in cadavera. An investigation of the results of twelve surgeons with this training model. J Bone Joint Surg Am 1994; 76:266.
- Chow JC. Endoscopic release of the carpal ligament for carpal tunnel syndrome: 22-month clinical result. Arthroscopy 1990; 6:288.
- Ghaly RF, Saban KL, Haley DA, Ross RE. Endoscopic carpal tunnel release surgery: report of patient satisfaction. Neurol Res 2000; 22:551.
- Louie DL, Earp BE, Collins JE, et al. Outcomes of open carpal tunnel release at a minimum of ten years. J Bone Joint Surg Am 2013; 95:1067.
- Katz JN, Fossel KK, Simmons BP, et al. Symptoms, functional status, and neuromuscular impairment following carpal tunnel release. J Hand Surg Am 1995; 20:549.
- Netscher D, Steadman AK, Thornby J, Cohen V. Temporal changes in grip and pinch strength after open carpal tunnel release and the effect of ligament reconstruction. J Hand Surg Am 1998; 23:48.
- Katz JN, Keller RB, Simmons BP, et al. Maine Carpal Tunnel Study: outcomes of operative and nonoperative therapy for carpal tunnel syndrome in a community-based cohort. J Hand Surg Am 1998; 23:697.
- Vasiliadis HS, Georgoulas P, Shrier I, et al. Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev 2014; :CD008265.
- Zuo D, Zhou Z, Wang H, et al. Endoscopic versus open carpal tunnel release for idiopathic carpal tunnel syndrome: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2015; 10:12.
- Saw NL, Jones S, Shepstone L, et al. Early outcome and cost-effectiveness of endoscopic versus open carpal tunnel release: a randomized prospective trial. J Hand Surg Br 2003; 28:444.
- Agee JM, McCarroll HR Jr, Tortosa RD, et al. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg Am 1992; 17:987.
- Jacobsen MB, Rahme H. A prospective, randomized study with an independent observer comparing open carpal tunnel release with endoscopic carpal tunnel release. J Hand Surg Br 1996; 21:202.
- Macdermid JC, Richards RS, Roth JH, et al. Endoscopic versus open carpal tunnel release: a randomized trial. J Hand Surg Am 2003; 28:475.
- Atroshi I, Larsson GU, Ornstein E, et al. Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial. BMJ 2006; 332:1473.
- Brown RK, Peimer CA. Changes in digital flexor tendon mechanics after endoscopic and open carpal tunnel releases in cadaver wrists. J Hand Surg Am 2000; 25:112.
- Atroshi I, Hofer M, Larsson GU, Ranstam J. Extended Follow-up of a Randomized Clinical Trial of Open vs Endoscopic Release Surgery for Carpal Tunnel Syndrome. JAMA 2015; 314:1399.
- ANATOMY OF THE CARPAL TUNNEL
- Median nerve
- SURGICAL TECHNIQUES
- Open technique
- - Standard incision
- - Small palmar incision
- Endoscopic technique
- - One-portal approach
- - Two-portal approach
- POSTOPERATIVE CARE
- Open versus endoscopic complications
- Open versus endoscopic techniques
- SUMMARY AND RECOMMENDATIONS