Enscopic carpal tunnel surgery: A few things you can expect

Since coming to  Muskegon in August of 2015, I have performed nearly 1500 endoscopic carpal tunnel releases.  This is a very safe and effective technique, that can reduce recovery time immensely compared to the traditional open technique.

In the past, I performed many carpal tunnel releases utilizing the open technique.  I utilized a large incision with multiple sutures that required 2-3 weeks of healing.  In addition people needed additional 2-3 weeks to recover after that to go back to their work.  This was for even light duty jobs that do not require a lot of lifting. Its a lot of time off for most people, especially if they work with their hands.

 All that has changed with the endoscopic (minimally invasive) technique.

What should I expect during carpal tunnel surgery? 

The surgery itself takes only about 10 minutes.  It could be done in a hospital setting under light sedation or even local anesthesia.  If  you choose to undergo  surgery using sedation, then you will need to fast the night before and not eat anything the day of surgery, as well as getting someone to drive you to the hospital and back.  Otherwise, if you use local anesthesia you could do the surgery without fasting and drive yourself home from the hospital.  Although,  a driver is always preferred when possible.

Currently, techniques are being developed in order to be able to do the surgery in an in-office setting.  (We are very close to having that become a reality in the next 3-6 months, that will be available at a fixed price like the Oklahoma Surgery Center,  so stayed tuned in future blog posts.)

What to expect after endoscopic carpal tunnel surgery? 

What I tell patients is:  after they go home from surgery, in the evening, they can take the dressing off, wash their hands normally, and if they feel good they can even go out to dinner.  The next day they can drive, and run errands if they need to. They can lifting up to 10 lbs., which is about a gallon of milk. They can shower normally. Bathing and soaking of the hand is prohibited. They can call with any other questions they have, and they should return for suture removal in about 10-14 days.

In regards to pain, most patients do not need pain meds for more than one night, and  often ibuprofen or tylenol is more than enough.

In regards to carpal tunnel symptoms, although some residual numbness may remain for a period opf time as the nerve is healing, nighttime numbness and pain (that wakes people up from sleep and is a major reason why patients seek medical care in the first place) is gone the very first night.

In regards to a return to work, I have had a numbe of patients who hold deskjobs or lighter demand jobs go back on a Monday after Friday surgery. This is not unusual. For heavier demand jobs, it really does depend on the individual, but once again, many patients will go back after a week, with stitches still in, and perform perfectly well. This is also not unsual.

In my medical opinion, I see virtually no reason to ever perform open carpal tunnel release for carpal tunnel syndrome anymore, as long as the surgeon is a hand surgeon trained in the technique.

Should I get a Steroid Injection for Carpal Tunnel Syndrome?

This is a question that I get asked quite often and it is not always an easy one to answer because there is context and contingencies that need to be addressed before any answer can be given definitively. 

 First, a little bit about steroid injections.  Giving the steroid is a standard nonsurgical treatment for carpal tunnel syndrome, and it is usually well tolerated, even though for some people it can be somewhat painful.

Several different types of steroids can be used for the injection.  They vary in their potency as well as their chemical nature, but essentially, for practical purposes, they are all just about the same.  

I like to use one called Celestone (the generic name as betamethasone), but other surgeons like to use different steroids such as Depo-Medrol or Kenalog. 

If a person has carpal tunnel syndrome and does not necessarily want surgery and conservative measures like night splinting, physical therapy,  massage and over-the-counter medications have not helped then a person can become a candidate for a steroid injection. 

The steroid is mixed with lidocaine, a numbing agent, and then injected into the carpal tunnel in order to help reduce swelling among the tendons that might be swollen as well as the nerve itself. 

It is very important to get someone who understands the anatomy very clearly to give you a steroid injection.  The fact of the matter is that steroid injections are not 'intuitive' and 'easily done' with little or no training.  They take a particular understanding of the anatomy, as well as specific instructions which are given to the patient in order to avoid intra-neural injection. 

This means when the medicine is injected directly into the nerve rather than around the nerve. A person who has had inadvertant injection of medicine into the nerve can sustain a nerve injury which can be permanent requiring surgery and may disable them in the future.

Intra-neural injection is a very serious condition that I have seen a few times painfully only in my surgical career and I would like to see it no more; however, it does occur, especially in inexperienced hands.

Thankfully though, the more likely scenario is that somebody who is inexperienced with giving steroid injections will simply not know where to place the medication and may become a little bit 'chicken' and simply not give the medication in the correct place,  resulting in no relief of pain. 

I have patients that come to my office and say that the carpal tunnel injections did not work.  What is worse is that that the injection itself can be very painful, so the fact of the matter is they do not want another steroid injection because of the pain of the injection process itself.  This is understandable. 

Many times, I tell patients not to get a steroid injection and proceed directly to surgery because it is a definitive step in the properly selected patients and will relieve the pain in the majority (meaning 95% to 99%)  of  instances. 

But to make this decision you have to know your patient very well and know the anatomy very well and you have to understand if your conservative treatments are working or not. 

The fact of the matter is that the steroid injections are not permanent. At best they last two to three months and in fact 80% of same people who receive a steroid injection will have their symptoms return within a year and in my clinical practice that number is probably higher on the order of 90% to 95%.

In short, steroids are not a permanent solution, but they can delay the need for surgery especially if a patient wants to keep working for a little bit of time or has a personal/family issue that they would like to take care of before they undergo surgery. 

This is completely reasonable and is something that I see quite frequently because as a hand surgeon you simply do not treat the hand, you treat the person and as a doctor, you try to treat the whole person and take the big picture into account. 

I always stress in addition to all the standard conventional nonsurgical methods of treating carpal tunnel syndrome before considering surgery. 

 I stress on nutritional solutions which include proper diet, lifestyle and alternative forms of therapy such as yoga as well as specific supplementation that helps with the metabolism of nerves in general like the vitamins Coenzyme, Q10 omega 3, fatty acids, etc. 

I always try to look at the whole picture and although I am not against any of the conventional surgical methods of treating carpal tunnel syndrome, I do feel many long-term cures rest on the pillars of diet and lifestyle, that is you should always proceed with more invasive and risky procedures like carpal tunnel surgery or harsh medications or steroid injections only after you have tried the proper dietary and lifestyle interventions.  

5 supplements/foods worth taking for hand pain/joint pain

I am a big fan of trying to find natural cures as I believe the human body, under the right circumstances, has almost an infinite capacity to heal itself. It's one of my basic philosophies of how I approach medicine.

I believe that, instead of  always trying to 'cure' a sickness when it presents itself, a doctor should also attempt to find a way to unleash the power of nature to help promote the cure (where the body can heal itself).

It's at the heart of preventive medicine, and it's also at the heart of the healing arts, which I am privileged to practice on a daily basis with patients. Unfortunately, that is simply not a big part of the current medical system. For instance, screening tests often are simply test that used to identify patients who then can undergo procedures. This is one of the reasons why about 80% of breast biopsies peformed in the United States today is negative for breast cancer. But this a complex issue, and I do not want to go 'off track' here.

It is important to note that I am not abandoning conventional Western medicine by saying this. As a hand surgeon, and I do believe that things like carpal tunnel surgery, in properly selected patients, is both an effective and reliable way to treat carpal tunnel pain. It is also exceptionally safe.

But the reality is that it doesn't work for everyone, and in fact, for many patients, when they undergo carpal tunnel surgery without effectively treating things like diabetes, obesity, and thyroid conditions by trying to find cures that focus on diet & lifestyle, are basically putting the 'cart before the horse' and sabotaging their chances for an effective and long lasting cure.

So, one of the things I stress in my practice, in addition to dietary & lifestyle interventions, is supplementation.  Supplementation is controversial among many medical experts, and rightly so. There are many claims made by people who call themselves experts, which are essentially unsubstantiated.

I agree that supplementation can be a 'snake-oil' business, no doubt. However, the fact is that nutritional deficiencies do exist, and they result in medical conditions which are well recognized (and sometimes very serious) and are treated by administering a vitamin or mineral (a supplement) such as B vitamin complex, for instance.

In the realm of hand surgery, particularly when addressing hand pain and nerve pain, there are 5 supplements that I routinely recommend to patients which, in addition to other interventions and modifications, can be extremely useful in alleviating the symptoms of carpal tunnel syndrome or arthritis.

Here they are:

1. MSM and Chondroitin: These are supplements which contain sulfur, and sulfur in turn, is critical for many aspects of health, including skin health (which I write about in my other blog). Specifically, sulfur is crucial in helping create many of the joint cushioning compounds that are found within the joint and can help reduce joint pain.

2. Krill Oil: As opposed to Omega-3 only. Why? Because in addition to high levels of omega-3 fatty acids which are sorely lacking in the modern, industrial society diet, krill oil when combined with hyaluronic acid along with a natural anti-oxidant that is contained with the krill oil called astaxanthin can be very beneficial in relieving joint pain.

3. Magnesium: Both in the form of mineral salt baths and oral supplements. Magnesium is an exceptionally important mineral that is often under-appreciated in it importance in literally thousands of enzymatic reactions. Although it can be taken orally, the transdermal route via mineral salt baths can not only be effective, but also quite soothing for sore joints.

4. Turmeric: This is an ancient Indian spice that has been used for centuries in Ayurevedic medicine for all sorts of uses. In fact, I even recommend it for skin health in the form of a topical cream which I recommend for patients. Turmeric is closely related to ginger, and it's active ingredient is a compound called circumin, which is thought to have many beneficial effects in many different aspects of health, ranging from anti-bacterial and even anti-neoplastic (anti-cancer) effects to anti-inflammatory effects. Although you can take turmeric supplements, one of the best (and tastiest) ways to get more turmeric is to eat it in the form of things like curries.

5. Bone Broth: Consuming bone broth on a regular basis has many beneficial effects, one of which is joint health. Dr. Cate Shanahan writes in her book, Deep Nutrition:

"The health of your joints depends upon the health of the collagen in your ligaments, tendons, and on the ends of your bones. Collagens are a large family of biomolecules, which include the glycosaminoglycans, very special molecules that help keep our joints healthy.”

Indeed, bone broth provides great deal of these special molecules called glycosaminoglycans or GAG's for short, and it will certainly warm you up on those long and dark winter days.

3 keys to Addressing Carpal Tunnel syndrome before you ever see a Hand Surgeon

If you have (or think you have) carpal tunnel syndrome, before you actually make the commitment to visit a hand specialist for medical or surgical intervention, you might want to consider these three important points.

If you address these, it may not mean that you will cure yourself of your carpal tunnel syndrome, but it may mean that whatever treatments that are undertaken will work better because you have addressed some of the real underlying causes behind your hand pain.

1. Nutrition (Diet & Lifestyle): Above all, if you have carpal tunnel syndrome make sure that you are taking care of yourself in terms of nutritional and fitness perspective. This can mean that if you are overweight and suffering from pre-diabetes or metabolic syndrome, you should address these conditions before undergoing treatment for carpal tunnel syndrome. Carpal tunnel surgery has a much greater chance of not working for patient who has underlying health issues such as obesity related illnesses like diabetes than a person who is otherwise healthy and not suffering from these conditions. As many know, I write a lot about health and nutrition, as I think it is in many cases the best way to address obesity, diabetes, and other related diseases. In the case of carpal tunnel syndrome, your symptoms can lessen or even go away in some cases if you can lose weight and treat you diabetes. Likewise, you don't need to be 'sick' by any stretch of the imagination. If you are overworked, stressed, and not exercising, you may be 'healthy' but the reality is your healthy is declining and not improving. Take the steps necessary to improve your health, and in many cases you will find that all of the strange aches and pains, including the ones in your hands, will many times simply go away.

2. Specific Nutritional Deficiencies: Other nutritional deficiencies are equally important to consider. For instance, it is well known that B vitamin deficiency is associated with nerve dysfunction also known as neuropathy. This type of vitamin deficiency is not widespread in our society because many cereals and breads are fortified with B vitamins. That being said, there are certain conditions which can cause an otherwise healthy person not to absorb the vitamins correctly. And symptoms mimicking carpal tunnel syndrome may be also present. In this particular case, carpal tunnel surgery would provide little or no benefit compared to proper nutritional supplementation. Vitamin B12 deficiency is also becoming more and more common in our society, so it might be important to get your levels checked and perhaps even get an injection. I am one of the few hand surgeons that actually checks Vitamin B12 levels for patients I suspect have the deficiency, and give injections to help treat this condition.  Other nutritional deficiencies are equally important to consider. May people often benefit from added Coenzyme Q10 in their diet, either through supplementation or the intake of organ meats, as well as sulfur in the form of supplements like MSM, or sulfur rich foods like eggs. 

• Are there natural remedies for Carpal Tunnel syndrome? This a tricky question because it is important to note that I am suggesting that it is important to always be nutritionally optimized above all else, which is probably the most natural cure available, ie keep yourself healthy. You can not expect to take chondroitin, glucosamine, or anything else you can buy over the counter if you are not eating right, sleeping right, exercising,  sitting correctly at your workstation, wearing gloves, taking breaks, etc. Like I have said, if you have diabetes and you don’t take care of it, the best surgery will not provide the results you want or need.  Likewise, if you want the best result you can, and maybe even avoid surgery, then it is important to focus on your health and nutrition as the first, best, and only ‘natural’ remedy.

3. Treat your Diabetes!: If you are diabetic, specifically if you are suffering from type II diabetes or metabolic syndrome, it is important to discuss with your doctor how to treat these conditions first before surgical treatment of carpal tunnel syndrome is considered. High blood sugar levels affect the nerves by causing them to swell under the influence of high glucose levels in the blood. The nerves can either become damaged or pinched in places like the carpal tunnels because they are swollen, or what we call edematous.

The rates of Type II diabetes is skyrocketing in the US and around the world, and most of the type II diabetics in our society are both overweight and sedentary. In many cases, exercise along with dietary modification (which results in not only weight loss but the gaining of lean muscle mass) can go a long way in mitigating or even curing type II diabetes. This can also result in the lessening of carpal tunnel pain, and in some cases, carpal tunnel syndrome may even be cured.

Likewise, metabolic syndrome is a very similar condition which is characterized by such things as hypertension, hypercholesterolemia, poor lipid profile, obesity, and insulin resistance. I consider pre-diabetes, and so do many other doctors who treat the condition frequently. 

It can be treated effectively with an exercise regimen and dietary modification under the guidance of a skilled professional, especially one who is comfortable with the application of diets that are low in carbohydrates. 

I cannot stress enough the importance of proper nutrition and exercise in the treatment of carpal tunnel syndrome. In my view, it is an essential step which is often overlooked. Otherwise, the most fancy and expensive treatment, and the highest quality care is simply a very pretty (and expensive) band aid that does not address the critical physiology and anatomy that results in the disease process. 
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Dr. Ostric is a board certified plastic surgeon and hand specialist who practices in Chicago, IL. He has treated thousands of patients with carpal tunnel with excellent results. Call today for your evaluation. Many insurances are accepted, and Dr. Ostric offers competitive financing plans as well.