Will I Need Surgery for My Carpal Tunnel?

There are some conditions that we have been conditioned to believe need surgery.  Knee meniscus injuries, disc herniations, rotator cuff tears. Carpal tunnel is on the list as well

I recently had a new patient come into my office on a Monday.  He’s 66 and had been scheduled for shoulder replacement surgery 4 days later on Thursday, with the other shoulder to follow a few months later.  Not an easy surgery nor an easy recovery.

However, he started to develop numbness over both of his hands, with the numbness covering all 5 fingers.  He mentioned to his orthopedic surgeon that he did not think he could manage the rehab from the shoulder with his hands being this numb.  So this man has an NCV test done (a nerve conduction velocity test that can tell how well the nerves in your arms or legs are firing) that came back with a diagnosis of carpal tunnel syndrome.

I pretty sure that every NCV test report I have ever read comes back with carpal tunnel.  Even the ones done on the legs…  I think it is just a factor of how much we use overuse our hands in daily life on the computer, texting and writing.

So, with the NCV in hand, the surgeon cancels the shoulder surgery and slides a carpal tunnel surgery in place instead.  So now this patient is facing 4 surgeries in the next 6 months or so.

For those of you shaking your heads in disbelief, let me reaffirm your wonder.  No conservative care.  No rehab.  No splinting.  No injections.  Nothing.  Just straight to the knife.

For those who are not well versed in anatomy let me give you a little tidbit on what fingers the median nerve (the nerve affected by carpal tunnel) feeds.  Basically, it’s the thumb and next digit (technically, it’s the lateral 2.5 digits, but most patients can’t notice the ½ so they just note numbness over the thumb and adjacent 2 fingers).  It does NOT feed the palm—the superficial palmar branch of the median nerve branches off just before the carpal tunnel.

Now that you’ve brushed up on your anatomy, we can go back to my patient.  Remember when I said his entire hands were involved?  That is absolutely, positively not consistent with carpal tunnel syndrome and is usually more related to the shoulder (subscap trigger point referral or anterior scalene or pec minor impingements).  That’s not to say this gentleman did not have  carpal tunnel, but the picture was far more complex.

I explained all of this to the patient as well as giving my opinion that surgery was completely inappropriate without at least a trial of some type of conservative care.  We treated him that first day and left the decisions up to him.

Needless to say, he canceled his surgery, we saw him again on Wednesday and on Friday, before he was treated, he was shocked that the numbness in his hands was completely gone and was asking what we might be able to do for his shoulders.  There’s a chance I’m going to have one pissed off orthopedic surgeon on my hands.

This doesn’t mean that he was cured after 2 visits, but it certainly means we’re on the right track.  But all of this leads back to this particular article, looking at how much injections for carpal tunnel work or don’t work.

Three groups (37 patients each) of patients received 80 mg of methylprednisolone, 40 mg of methylprednisolone, or placebo injections for carpal tunnel.  All of these patients had been given a splint to help treat his or her carpal tunnel and it was unsuccessful.  Here’s the results:

1. At 10 weeks those who got the injections did better (36% @ 80 and 12% @ 40).
2. One year later, there were no differences between the groups.
3. The 1-year rates of surgery were 73%, 81%, and 92% in the 80, 40 and placebo groups.

Basically, 75% of the carpal tunnel syndrome patients in this study had surgery.  That pretty much means that injections for carpal tunnel suck at actually fixing the problem.

Lest the carpal tunnel sufferers out there begin to despair, let me throw in a few comments.

First, the is much evidence that both NSAIDs and steroids actually interfere with healing.  It may very well be that the injections themselves will prevent long term healing.

Second, the carpal tunnel is a tight tunnel, made of bone on one side and the steel-like flexor retinaculum on the other side.  Through this tunnels, 9 tendons and one tiny little soft nerve run.  When the tendons swell, the median nerve is smashed like a toddler stuck in an elevator with the entire defensive line of the Vikings.  So we put blinders on and try to control the swelling with drugs or injections, and when that fails we just go in there and make some snips, so the swelling can continue without creating a problem.

But what caused the swelling in the first place?  While it seems like the obvious question, it’s almost never asked.  In my experience, fascial / muscular problems in the forearm (both the front and back side) create a situation where the tendons are put under increased strain and begin to swell, creating the symptoms known as carpal tunnel.

ANY treatment of carpal tunnel has to address this aspect of the problem.  If not, treatment is doomed to fail from the start.  And this does NOT involve exercise; rather, it involves competent soft tissue work to the forearm and shoulder if needed.

In this study, all that the patients received was splinting, which does nothing to fix the problem but just allows the swelling to go away for a short period of time.  It was doomed to fail from the start.