Pros and Cons of Endoscopic Surgery for Carpal Tunnel Syndrome

Endoscopic surgery has become the gold standard for the surgical treatment of carpal tunnel syndrome. While the actual procedure has merits, it is not the panacea of popular belief. The rush to have surgery has come under considerable scrutiny lately; thus the factors to consider for having endoscopic surgery must be weighed carefully.

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“…it should be the first therapeutic choice for treating carpal tunnel syndrome.”

British Journal of Pain,2014

Introduction

The US Bureau of Labor and Statistics and the National Institute for Occupational Safety and Health report that carpal tunnel syndrome is the second most common type of musculoskeletal surgery in the USA, with over 230,000 procedures performed annually. The surgical approach alleviate carpal tunnel syndrome has conventionally been “open release” surgery. But increasingly more surgeons are using endoscopic surgery which among other advantages is less invasive and requires less recovery time.

Yet many people and doctors alike fail to weight all of the advantages of endoscopic surgery against those of non-surgical therapies. This article will list the pros and cons of endoscopic surgery for carpal tunnel syndrome.

Considerations for Surgery

A patient is considered a candidate for endoscopic carpal tunnel surgery if one of several criteria is met.

First, every effort must be made to use non-surgical techniques to relieve the symptoms. Where most doctors and patients fail to understand is that there so many effective non-surgical treatments that are extremely effective. It’s estimated that most people undergoing endoscopic carpal tunnel surgery do so unnecessarily because the appropriate conventional non-surgical therapy was not explored first. Generally, a doctor should allow up to 12 months of non-surgical treatment to determine if surgery is needed.

A second criterion is symptom severity. If your daily activities are severely restricted by, for example, chronic numbness, loss of grip strength or loss of coordination, then surgery should be considered. Again, at least an attempt with a non-surgical intervention should be explored first if it doesn’t involve too much down-time in the daily activities.

Another criterion involves damage to the nerve. Sometimes carpal tunnel syndrome can result in damage to the median nerve (resulting in loss of function in the hand or fingers). Prolonging surgery to relieve the pressure eon the nerve could invite irreversible nerve damage.

Finally, the daily needs of the patient must be considered. Patients who do not have others to help with their care, or who use assistive devices, such as wheelchairs, crutches, etc., are likely to choose endoscopic surgery. The faster healing time allows them to care for themselves or use the assistive devices sooner.

What the Surgery Involves

Endoscopic surgery means that an endoscope is used to see inside the carpal tunnel rather than opening the tissue over the carpal tunnel completely. The surgery uses a thin, flexible tube containing a camera guided through a small incision in the wrist or through both the wrist and palm (single-portal and two-portal techniques, respectively). This gives the surgeon a view of the carpal tunnel and all of the tissues surrounding and the ability to cut tissues inside without having to make big incisions.

During surgery, the endoscope shows the surgeon the transverse carpal ligament, which is cut using a small cutting tool also passed through the endoscope. In the two-portal technique, the camera is passed through one tube and the cutting tool in the other. In the single-portal technique, all instruments pass through one tube.

The ligament is cut and pressure is relieved from the median nerve. Any incision is then closed with stitches, and the gap left where the ligament was cut will fill with scar tissues. Generally, the patient can go home the same day.

What to Expect After Surgery

The advantage of endoscopic surgery compared to open release surgery, is that there is much shorter recovery time since it avoids cutting the palm open to expose the ligament. Another advantage is that the surgical scar is smaller.

The symptoms might be alleviated immediately after surgery. However, in many patients it takes several months. In other patients, the symptoms subside only a little.

Every patient must avoid heavy use of the hand for a few weeks. Return to work depends on several factors such as whether it was your dominant hand, the type of work involved (jobs involving constant typing or using heavy equipment/tools take longer), as well as the effort one puts into rehabilitation of the hand and doing physical therapy.

With surgery on the non-dominant hand, generally patients can return to work in 2 days if the word does not involve repetitive hand work. If the surgery is on the dominant hand, and if the work is repetitive and stressful, return to work may take a month or more. All of this depends on the amount of physical therapy involved and an individual’s own speed of recovery.

Effectiveness of Endoscopic Surgery

The effectiveness of endoscopic surgery for carpal tunnel syndrome is the most often discussed matter and the source of considerable debate. This often is the most crucial aspect of deciding to have surgery versus non-surgical treatment.

For the most part patients who elect to have surgery for carpal tunnel syndrome get good results, with alleviation of symptoms after surgery. Reports of patient satisfaction range from 50% to 70%. Between 80% and 90% of patients report not having night pain after their endoscopic surgery.

The most common complication of surgery for carpal tunnel syndrome is the return of symptoms. This may occur shortly after the surgery or up to a year later. Loss of grip strength (or strength when pinching an object) is another common complication. If the muscles of the thumb had been weakened (an perhaps wasted) as a result of nerve damage, such functions may be lost permanently regardless of the surgery.

A recent medical report compared Clinically Relevant Outcomes of surgery versus non-surgical alternatives for carpal tunnel syndrome. The findings showed that surgical outcome was better than nonsurgical treatment, but the clinical relevance of that outcome was only modest at best compared to non-surgical treatments. In other words, surgery might result in better measurable parameters (such as nerve conduction velocity) but overall these parameters don’t necessarily amount to much in a patient’s life.

This is the source for the great confusion about “which is better”; surgery versus non-surgical alternatives. If the small advantages in measurable parameters don’t make much of a difference to a person’s daily activities, does it really make that procedure much “better”? The answer is “probably not”. Surgery – with its associated risks – might give patients a slightly better edge in obtaining relief that’s relevant to the patient’s life, but only modestly compared to non-surgical alternatives.

Risks and Downside of Endoscopic Surgery

Aside from specific risks of endoscopic surgery for carpal tunnel syndrome, all surgery carries with it some general risks. These include infection at the site of surgery or systemic infections, as well as risks of a reaction to general or local anesthesia. This carries with it a risk of death, although that’s rare.

Risks specific to endoscopic surgery for carpal tunnel syndrome include major problems such as nerve damage are about 1%. There also is the risk of injury to blood vessels and tendons. Scar tissue also may build up over time, creating more pain and symptoms than before the surgery. This might require a second surgery to repair. Finally, while not a risk per se, a simple unsuccessful result (meaning the surgery just didn’t work for some reason) is possible.

Even if the surgery is “successful”, and it takes you 1 month to fully recover, during that time (and for months thereafter) you must slowly start stretching and building up your strength, being careful not to re-injure yourself. That’s a lot of time, and a lot of work, that some patients cannot afford.

Finally, surgery often fails to take into account that a larger carpal tunnel syndrome dynamic leading to the symptoms in the first place. Just cutting one spot may not beneficially affect that dynamic. So with failed results, a surgeon will often say that you just need a second surgery. But it may be that your symptoms are a result of dysfunction in the neck or the front of the chest and shoulder. Thus, surgery itself can targets the wrong spot.

Alternatives to Endoscopic Surgery for Carpal Tunnel Syndrome

Endoscopic carpal tunnel surgery is often called the gold standard for treating carpal tunnel syndrome. This is not only erroneous but misleading because most doctors and patients alike fail to consider the pros and cons fairly and objectively.

There is a proven and reliable non-surgical method to reverse carpal tunnel syndrome symptoms without surgery. This is not speculation but scientific fact.

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Information provided on this website and the content of articles & videos is not to be construed as medical advice. If you suspect that you have carpal tunnel syndrome, repetitive strain injury, wrist tendonitis or any other condition addressed within this publication you should consult with a qualified health care provider for a proper diagnosis of your symptoms.