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Carpal tunnel release (CTR) is a surgical treatment for carpal tunnel syndrome. This surgery creates more space for the median nerve and tendons that bend (flex) the fingers. Releasing or cutting the transverse carpal ligament (the roof of the tunnel) creates more space for the compressed nerve and tendons.
Techniques for the procedure include open release (either the “mini-palm” or the traditional longer incision technique), endoscopic (arthroscopic) release, and an experimental technique called percutaneous balloon carpal tunnelplasty. All these techniques are outpatient procedures. Involvement of other structures in the wrist, as well as surgeon preference and training, influences the choice of technique used. Recovery after surgery may be slightly quicker with the endoscopic release, but the rate of complications is higher, and the final outcome is no better.
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Source: Medical Disability Advisor
| Carpal tunnel syndrome is a condition in which function of the median nerve of the wrist is impaired, resulting in numbness and/or pain in the thumb, index finger, middle finger, and, in many people, the side of the ring finger nearest the thumb. The carpal tunnel is rigid and cannot expand to accommodate any swelling or gradual enlargement of the tendons. Swelling and subsequent nerve compression can result from normal age-related bony thickening; from acute injury like dislocation or fracture of the wrist; from diseases that enlarge the tendons in the tunnel, like rheumatoid arthritis, hypothyroidism, and diabetes; or from fluid retention (edema) in the carpal tunnel (i.e., during pregnancy). Possible ergonomic causes may include any type of activity that involves highly repetitive wrist motion, holding the wrist in awkward positions for sustained periods of time, forceful pinching or gripping, and work-task stresses. If pressure on the median nerve is unrelieved, permanent nerve damage may occur.
Carpal tunnel release relieves compression of the median nerve that supplies sensation to the thumb and first three fingers. The goal of surgery is to prevent or limit possible permanent damage to the nerve or muscles, and surgery may alleviate symptoms of pain, tingling, and decreased strength. |
Source: Medical Disability Advisor
| CTR is performed as an outpatient or in-office procedure under local or regional anesthesia. Several techniques are currently used to accomplish the release.
Endoscopic-assisted carpal tunnel release uses standard arthroscopic technique may involve exploration of the tunnel and surrounding structures.
Endoscopic carpal tunnel release uses standard arthroscopic technique with specially designed, smaller, fiber-optic instruments. This procedure allows exploration of the tunnel while cutting less tissue. The surgeon releases or cuts the roof of the carpal tunnel while looking through a camera positioned below the ligament itself (as opposed to the open- and mini-open techniques, in which the ligament is cut from above). However, the surgeon does not have the same view of other parts of the hand as during open procedures. Arthroscopic or endoscopic technique and open mini-palm have similar functional recovery.
Percutaneous balloon carpal tunnelplasty is an experimental technique in which a small balloon-tipped catheter is inserted into the tunnel through a skin incision and then inflated to stretch the ligament. |
Source: Medical Disability Advisor
| Release of pressure on the nerve can provide immediate relief from pain, but full recovery may take months, during which the nerve heals and the hand adapts to the surgical wound (cutting the ligament results in proximal palm pain, or “pillar pain,” that can last days or months). Changes in sensation may take a few weeks to improve. Regaining hand grip strength occurs gradually, and in some individuals, grip strength slowly improves for 1-2 years after surgery. However, grip strength may be permanently lessened by a small amount.
Pregnant women whose carpal tunnel pain is related to edema generally recover completely after delivery. However, many will redevelop carpal tunnel syndrome years later in middle age. |
Source: Medical Disability Advisor
| Note on research and authorship Individuals often receive therapy from an occupational therapist, a physical therapist, or a hand therapist. This can be helpful in regaining functions post surgery (Evans).
The progression of postoperative therapy is guided by wound healing principles and the tissue response to stress. Although controversy exists in the literature regarding the kind and the value of postoperative rehabilitation, therapy consistently focuses on the individual's preoperative status, surgical procedure, hand dominance, bilateral symptoms, associated conditions, and home and job requirements. Special attention must be paid during the recovery phase for signs of complex regional pain syndrome (Hayes).
Therapy addresses the anatomical regions adjacent to the surgical site and the specific needs for the postoperative care. The overall aim is to restore performance of usual and customary hand function that is both comfortable and safe. The adjacent anatomical regions are monitored for maintenance of full movement, strength patterns, and bodily posture.
For the surgical site itself, the first objective of therapy is to educate the individual on how to control pain and swelling. Thermal modalities may be used to increase muscle flexibility, to decrease pain, and to reduce edema. Individuals learn to perform scar massage to decrease the risk of forming painful adhesions (Evans; Hayes).
The second objective of therapy is to restore any lost range of motion at the wrist and hand that corresponds with the postoperative recovery plan; attention is also directed to safe body mechanics to protect the surgical site during healing while engaging in routine daily activities. Dynamic movement patterns are then progressed, and the individual is educated in safe patterns for exercise and activity related to CTS (Evans; Provinciali).
Concurrently, once the postoperative edema has resolved, a third objective is to monitor hand sensation, and provide a sensory re-education program.
The final objective of therapy is to discover if any factors in the individual's environment, either at work or home, may contribute to the CTS. If the compression can be attributed to or related to job duties or activities of daily living, education regarding the provocative positions and modifications in method or setup is provided. Such education may help abate the identified aggravating conditions, minimizing symptoms and preventing their return. The individual may benefit from an ergonomic consultation. The therapist will monitor the individual for potential complications such as severe and persistent edema, palmar pain, increased hand sensitivity, or joint stiffness (Finsen; Gerritsen). |
| FREQUENCY OF REHABILITATION VISITS | | Surgical | |
| Physical, Occupational or Hand Therapist | | Up to 5 visits within 6 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Inflammation of the tendon sheaths of the adjacent tendons (tenosynovitis) may continue to cause pain after surgery. Infection is not common but can occur. Contracture of the skin and soft tissue can complicate recovery. Damage to the nerve during surgery is a risk in any of the techniques described. Reflex sympathetic dystrophy (complex regional pain syndrome) is an uncommon complication that can result in pain and stiffness. Risks involved with any of the surgical techniques include damage to the median nerve or flexor tendons, increased inflammation, infection, skin contractures, and scarring. Some individuals may experience temporary loss of sensation in their fingers or recurrence of preoperative symptoms. |
Source: Medical Disability Advisor
| Modification of activities is the best approach for the treatment of musculoskeletal pain and carpal tunnel symptoms that are associated with activities at home and at work. Return to work depends on three conditions: capacity, risk, and tolerance. Capacity is the actual ability to perform activities, risk is the likelihood of recurrence of the condition from performing the activity, and tolerance is the individual's willingness to endure some discomfort in the healing phase.
Ergonomic evaluation of the work area is helpful to identify contributing risk factors, such as positioning keyboards too high, driving, or holding a telephone for repeated or extended periods of time. Eliminating these risk factors may allow early return to work, at least in a limited capacity. Some individuals may not be able to return to aggravating activities such as constant hammering or typing, and studies indicate that some individuals change jobs after surgery. |
Source: Medical Disability Advisor
| Evans, R. B. "The Therapist’s Management of Carpal Tunnel Syndrome." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. 660-671.Finsen, Valerie, K. Anderson, and H. Russwurm. "No Advantage from Splinting the Wrist after Open Carpal Tunnel Release: A Randomized Study of 82 Wrists." Acta Orthopaedica Scandinavia 70 3 (1999): 288-292. Gerritsen, A. A., et al. "Splinting vs Surgery in the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial." JAMA 288 10 (2002): 1245-1251. Hayes, E. P., et al. "Carpal Tunnel Syndrome." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. 643-659. Provinciali, L., et al. "Usefulness of Hand Rehabilitation after Carpal Tunnel Surgery." Muscle Nerve 23 2 (2000): 211-216. |
Source: Medical Disability Advisor
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