Surgeries for nerve compression (nerve constriction) of the hand and arm represent surgical therapeutic procedures that are instrumental in the treatment of carpal tunnel syndrome. Carpal tunnel syndrome (CTS, synonyms: carpal tunnel syndrome (CTS); median compression syndrome; as a symptom brachialgia paraesthetica nocturna) describes the nerve compression of the hand most frequently leading to clinical symptoms. The underlying problem of carpal tunnel syndrome is constriction of the median nerve in the region of the carpus. The first symptom is pain or paresthesia at night, which can radiate from the hand into the entire arm. Later, these complaints also increasingly occur during the day. In the advanced stage, there may be muscle atrophy in the area of the ball of the thumb and weakness when grasping. Furthermore, there is a reduction in the sense of touch. Due to the resulting pain and, in later stages, loss of function of the muscles innervated by the median nerve, prompt therapy is imperative.
Indications (areas of application)
Median nerve
- Proximal median nerve lesion – a lesion (damage) of the median nerve caused by both chronic compression and trauma, represent the most common nerve damage outside the central nervous system. The localization of the damage is of decisive importance for the selection of the surgical procedure and for the symptomatology. On this basis, surgery distinguishes between proximal lesions (damage in the elbow region) and distal lesions (damage in the carpal region and forearm). The picture of a proximal lesion is characterized by the swear hand symptoms. The Schwurhand occurs when trying to close the fist, because important muscle groups can no longer be innervated (supplied) by the median nerve.
- Distal median nerve lesion (carpal tunnel syndrome) – the median nerve is particularly at risk of compression when passing through the carpal tunnel. Causes of compression of the nerve can be fractures of the carpal bones, inflammatory processes in the connective tissue or metabolic changes as a result of, for example, pregnancy or diabetes mellitus.
Radial nerve
- Proximal radial nerve lesion – compression symptoms can be provoked by exerting permanent pressure on the axilla (axilla). The clinical picture of this lesion is a so called drop hand with insensations.
- Median radial nerve lesion – when compression or damage occurs in the radialis tunnel, a drop hand with sensory disturbances (insensitivity) is provoked.
- Distal radial nerve lesion – damage near the carpus does not lead to the formation of a drop hand or sensory disturbances.
Ulnar nerve
- Proximal ulnar nerve lesion – when damage occurs in the elbow area due to, for example, trauma or chronic compression, this results in the image of the claw hand with sensory disturbances.
- Middle ulnar nerve lesion – in the area of the wrist damage can lead to the claw hand with sensory disturbances.
- Distal ulnar nerve lesion – in the palm area, the nerve can also be damaged, so that a claw hand can be diagnosed without sensory innervation problems.
Contraindications
- Severe general disease – if there is too high a risk of surgery, surgery should either be replaced by a less invasive procedure or a conservative treatment option should be considered.
- Metabolic disease – the risk of surgery for metabolic disease must be assessed by the treating physician.
Before surgery
- Discontinuation of anticoagulants (anticoagulants) – in consultation with the attending physician, medications such as Marcumar or acetylsalicylic acid (ASA) must usually be temporarily discontinued to minimize the risk of bleeding during surgery. The re-taking of the drugs may only take place under medical instruction.
- Anesthesia – usually the procedure is performed under general anesthesia for an open surgical procedure, so the patient must be fasting. For endoscopic procedures, general anesthesia may not be indicated (indicated).
The operation procedures
Open surgical technique for carpal tunnel correction.
- After the tourniquet is applied, a short skin incision is made so that permanent visible scars can be prevented.
- The basic principle of the procedure is the complete transection of the retinaculum flexorum, which is a tendon structure that anatomically delimits the carpal tunnel. Thus, the affected carpal tunnel can be widened. The resulting decompression relieves the nerve, allowing it to regenerate. A direct surgical correction on the median nerve is very rarely necessary.
- The open surgical technique is very precise, so that permanent postoperative clinical symptoms rarely occur.
Endoscopic surgical technique for carpal tunnel correction.
- Unlike the open surgical technique, this procedure does not require a long skin incision (skin cut). Thus, the risk is minimized that a visible scar remains.
- Furthermore, with the help of this procedure, the inability to work can be significantly shortened, since the muscle strength in the hand muscles can be regenerated more quickly.
- However, it must be considered problematic that the retinaculum is only incompletely cut, if necessary, because the visual overview is reduced compared to the open technique.
After surgery
- Wound care – application of a light compression bandage is indicated. Short-term immobilization of the wrist may be useful in carpal tunnel surgery to achieve an improved healing process.
Possible complications
- Bleeding and hematoma – secondary bleeding may occur as a result of surgery. There is also a risk of vascular injury.
- Nerve lesions – as a result of the localization of the surgical site, nerve damage is possible. This can result in insensations, which, however, usually occur only temporarily (limited in time).
- Infections – in rare cases, the wound area may become inflamed. Nevertheless, the probability of a wound infection is low.
