Carpal tunnel syndrome: does it always really need surgery?
Our patient questions
This is one of the most frequent questions we hear in our consulting hours: “My hand keeps falling asleep at night and I have been diagnosed with carpal tunnel syndrome. Do I need surgery now?”
Our answer is: no, not every case of carpal tunnel syndrome has to be operated on straight away. In an early stage in particular, the symptoms can often be treated without surgery at first. What matters, however, is how severely the nerve is already compressed, how long the symptoms have been present and whether there is already any loss of sensation or strength.
Because one thing is important: carpal tunnel syndrome should not simply be ignored over a longer period. If the nerve is severely compressed for a long time, it can be damaged – and that damage may not be fully reversible even with later surgery.
What exactly is the carpal tunnel?
The carpal tunnel is located on the inside of the wrist. You can picture it as a relatively narrow tunnel through which several flexor tendons and one important nerve run: the median nerve.
Among other things, this nerve is responsible for sensation in the thumb, index finger and middle finger and in part of the ring finger. It also controls certain muscles of the thumb.
The problem: there is not much room inside the carpal tunnel. If the tissue there swells or the tunnel becomes narrower for other reasons, the pressure on the median nerve rises. That is exactly when the typical symptoms arise.
How do you notice carpal tunnel syndrome?
At the beginning the symptoms often occur at night. Many patients tell us: “I wake up because my hand has fallen asleep.”
Typical signs are tingling, numbness or an unpleasant pins-and-needles sensation, above all in the thumb, index finger and middle finger. Some people also have pain that can radiate from the wrist into the forearm or even further up.
At night, many people automatically try to shake out or move the hand. This often does bring brief relief.
Later the symptoms can also occur during the day – for example while cycling, driving, making a phone call or holding something in the hand for a longer period.
If carpal tunnel syndrome progresses further, strength can eventually decline as well. Objects suddenly fall out of the hand, bottles become harder to open, or fine motor tasks become more difficult.
How does carpal tunnel syndrome develop?
Often there is no single trigger.
In principle, carpal tunnel syndrome develops because the pressure inside the carpal tunnel increases and the median nerve is compressed. Women are affected more often than men, and the risk rises with age.
Hormonal changes can also play a role. That is why carpal tunnel syndrome occurs more frequently during pregnancy, for example. Fluid retention can make the already narrow carpal tunnel even tighter. After the pregnancy the symptoms then often disappear again.
Conditions such as diabetes, thyroid disorders or rheumatic diseases can increase the risk as well. Changes following injuries to the wrist can also play a part.
Sometimes, however, no clear cause can be identified at all.
How do we make the diagnosis?
The symptoms usually give us important clues already. In addition we examine the hand and test sensation, mobility and strength.
A measurement of the nerve conduction velocity is also important. This examines how quickly the median nerve transmits electrical impulses. If the nerve is compressed within the carpal tunnel, transmission typically becomes slower.
This examination also helps us assess how pronounced the nerve damage already is.
Not every hand that falls asleep is automatically carpal tunnel syndrome. Similar symptoms can also originate from the cervical spine or from other nerve constriction points, for example. An accurate diagnosis is therefore important.
When is treatment without surgery sufficient?
In mild carpal tunnel syndrome without persistent loss of sensation and without marked loss of strength, conservative treatment can make sense to begin with.
One of the most important measures is a special wrist splint for the night. Many people sleep with the wrist bent. This makes the carpal tunnel even tighter and increases the pressure on the nerve.
The splint keeps the wrist as straight as possible and can thereby reduce the pressure on the nerve. Particularly with night-time symptoms this often helps remarkably well.
It can also make sense to reduce certain strains temporarily. A cortisone injection into the area of the carpal tunnel can markedly improve the symptoms for a time as well.
What is important, however, is this: these measures do not permanently remove a pronounced mechanical constriction of the nerve.
Can carpal tunnel syndrome resolve on its own?
That depends on the cause.
If carpal tunnel syndrome develops during pregnancy because of fluid retention, for example, the symptoms can disappear completely after the birth.
With a permanent anatomical narrowing it is different. The nerve may calm down for a while and the symptoms may fluctuate, but the actual constriction remains.
With increasing symptoms in particular, it should therefore be checked regularly whether the function of the nerve is deteriorating.
When do we recommend surgery?
We recommend surgery above all when the symptoms persist despite conservative treatment or when clear neurological deficits are already present.
We take persistent numbness and increasing loss of strength particularly seriously. When the muscle at the ball of the thumb visibly wastes away, you should not wait much longer.
Because that is the body telling us that the nerve is already more severely damaged.
A markedly slowed nerve conduction velocity can also be a reason to recommend surgery.
The aim of the operation is not only to eliminate pain and tingling. Above all we want to prevent the median nerve from being permanently damaged.
How is the operation performed today?
Surgery for carpal tunnel syndrome is one of the most frequent procedures performed on the hand.
The carpal ligament is divided. This ligament forms, as it were, the roof of the carpal tunnel. When it is released, more space is created and the pressure on the median nerve decreases.
The procedure can be carried out openly through a small skin incision or endoscopically, that is with a small camera. Which method makes sense depends among other things on the individual findings and on the surgeon’s experience.
The decisive point is the same for both procedures: the nerve must be reliably relieved.
How long does healing take?
The fingers may be moved again immediately after the operation. That is in fact expressly encouraged.
In the first few days, however, the hand should be rested and kept elevated as far as possible. The wound needs time to heal and heavier strain should be avoided at first.
When you can return to work depends very much on your occupation. Someone who mainly works at a desk can often return earlier than someone who works physically and has to put the hand under heavy strain.
Full strength does not come back overnight either. The area of the scar and the ball of the hand in particular can remain sensitive for several weeks.
After a successful operation, the night-time tingling often improves very quickly. With numbness that has persisted for longer, by contrast, it can take weeks or months for the nerve to recover.
And this is exactly where an important point lies: if the nerve has already been severely damaged over a long period, loss of sensation or of strength can partly remain despite a technically successful operation.
In conclusion it can be said that carpal tunnel syndrome does not automatically mean surgery. With mild symptoms in particular, treatment with a night splint and an adjustment of the strain on the hand can be entirely sufficient to begin with.
If numbness persists, however, if strength declines or if examinations already show clear damage to the nerve, you should not wait too long before having surgery.
Our advice: take a hand that regularly falls asleep or goes numb seriously – especially when the symptoms no longer occur only at night. What matters is not merely how unpleasant the tingling is, but whether the nerve is already suffering from the constriction.
The sooner we recognise how pronounced the carpal tunnel syndrome is, the better we can decide together which treatment makes sense – with the aim of eliminating pain and numbness and, above all, preserving the function of your hand in the long term.
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