I am a retired orthopedic surgeon. Been out of practice for 20 years now but my granddaughter is following in my footsteps. She is in a residency at Mass General and plans to be a hand surgeon. In my day, we did a lot of carpal tunnel surgeries. She says it's different now in this arena. Thought I might brush up a bit on current events without letting her know. So what can you tell me about current clinical practice for carpal tunnel?
As your granddaughter indicated, the treatment of carpal tunnel syndrome has changed quite a bit from 25 years ago. This information comes from a new study done by the American Society for the Surgery of the Hand (ASSH). They sent email questionnaires to all of their members (a total of 1,463) and compared the answers to the same questions sent out 25 years ago. The goal of the study was to see how clinical practice has changed in the last 25 years. That is a little bit longer than the time you've been away from practice but should still give you the general idea of what's going on. One of the major changes in the way CTS is managed today is the increased use of conservative (nonoperative) care over a longer period of time. Surgery is still a treatment choice, but it takes a back seat to activity modification, antiinflammatory medications, hand therapy with a physical or occupational therapist, splinting, and possibly steroid injections. If after a lengthy period of time (at least three months), there has been no (or minimal) change in symptoms, then surgery to release pressure on the median nerve may be advised. Surgery today is more likely to be done without an open incision using an endoscope. Choice of anesthesia has shifted from regional blocks to local anesthesia with sedation. Today's surgeon is less likely to use sutures deep within the carpal tunnel and less likely to inject corticosteroids into the tunnel during surgery. Only about one-third of the surgeons prescribe antibiotics before surgery to prevent infection. Current clinical practice guidelines recommend electrodiagnostic tests before doing carpal tunnel surgery. This test confirms that the median nerve is compromised and that the problem is indeed coming from pressure (or compression) on the nerve in the carpal tunnel. As you know, this is important because carpal tunnel symptoms can develop with pressure on the nerve anywhere from the neck down to the wrist. Releasing soft tissue structures in the wrist will not alleviate the symptoms if the problem is really coming from above (e.g., the neck or elbow). After surgery, fewer surgeons apply a splint to the patient's arm. In fact, half as many practice this approach compared with 25 years ago. The surgeons surveyed this time indicated that their expected outcomes are for patients to experience pain relief fully with gradual return of normal sensation, movement, and strength. One of the biggest changes observed from 25 years ago to the present time is a narrower gap in treatment practices and opinions on the management of this problem. This finding may be as a result of The American Academy of Orthopaedic Surgeons' published guidelines on the treatment of carpal tunnel syndrome. These guidelines reflect current research evidence and may have influenced many of today's practicing hand surgeons who are treating carpal tunnel syndrome.