Carpal tunnel syndrome · Diagnosis & Treatment

Nerve involved: Median nerve at the wrist
Symptoms: Numbness — thumb, index, middle, half ring finger
First-line: Night splinting
Diagnostic test: Nerve conduction studies
Surgical option: Endoscopic or open carpal tunnel release

What carpal tunnel syndrome is.

The median nerve runs from the upper arm into the hand through a narrow channel at the wrist called the carpal tunnel. The roof of the tunnel is a thick band of fibrous tissue — the transverse carpal ligament. Within the tunnel, the nerve shares a tight space with the nine flexor tendons of the fingers and thumb. Anything that reduces the space (or increases the contents) compresses the nerve.

Carpal tunnel syndrome is the constellation of symptoms produced by this compression: numbness, tingling, weakness and (in advanced cases) muscle wasting in the median nerve distribution.

Symptoms.

The classical presentation:

Numbness and tingling in the thumb, index, middle and half of the ring finger.
Worse at night, waking the patient from sleep.
Worse on activities with sustained wrist position — phone, steering wheel, book.
Relief by shaking the hand out — the "flick sign", almost diagnostic.
In advanced cases: weakness of pinch and grip; wasting of the thenar (thumb base) muscles.

How the diagnosis is made.

Clinical examination identifies Tinel's sign at the carpal tunnel, Phalen's test (1 minute of sustained wrist flexion reproduces symptoms), and Durkan's compression test. Nerve conduction studies are the gold standard — they confirm the diagnosis, localise the compression to the wrist, and grade the severity.

Non-operative treatment.

Night wrist splinting — keeping the wrist neutral during sleep. The single most useful conservative measure.
Activity modification — reducing sustained wrist flexion or extension; ergonomic adjustment of the desk.
Image-guided corticosteroid injection — into the carpal tunnel by a musculoskeletal radiologist. Useful diagnostically and therapeutically; provides short-to-medium term relief.

Surgery.

Surgical decompression — carpal tunnel release — is recommended when night-time symptoms are persistent, when nerve conduction studies show moderate or severe compression, or when motor weakness develops. The operation can be performed open (a 2–3 cm palm incision) or endoscopically (one or two 1 cm portals at the wrist crease). Dr Coory routinely offers endoscopic carpal tunnel release in suitable patients — the technique has the same long-term result as open release but with less scar tenderness and faster return to grip strength.

Risks and complications.

Carpal tunnel release is a common and well-established operation, but like any surgical procedure it carries a defined risk profile. Dr Coory will discuss the relevant risks for your specific case at consultation. The most important to be aware of are:

Nerve injury — the median nerve and its palmar cutaneous branch are in close proximity. Injury is rare but can cause persistent numbness or pain.
Incomplete release — if the transverse carpal ligament is not fully divided, symptoms may persist and revision surgery may be required.
Conversion to open — in endoscopic release, the surgeon may need to convert to an open incision if safe visualisation is not achieved. This is a safety decision, not a complication.
Recurrence — uncommon, but symptoms can return if scar tissue reforms around the nerve.
Pillar pain — tenderness at the base of the palm where the ligament was divided. Usually temporary, resolving over weeks to months.
Infection and wound complications — uncommon with standard surgical technique and wound care.

Frequently asked questions.

Will night splinting fix it?

Night splinting reliably reduces or eliminates night-time symptoms in mild cases, and is the appropriate first-line treatment. It does not change the underlying compression. If symptoms persist or motor weakness develops, surgical release is recommended.

How long does endoscopic carpal tunnel release take to recover from?

Most patients are using the hand within days, with grip strength returning over 2–6 weeks. Numbness improves gradually over 3–6 months as the nerve recovers.

Open or endoscopic release — which is better?

Long-term outcomes are equivalent. Endoscopic release has less scar tenderness and faster return to grip strength. Open release is preferred in revision surgery or when other procedures are being performed at the same time.

Will my numbness fully come back?

Mild to moderate cases usually recover fully. Severe long-standing cases with thenar wasting often have residual numbness — which is why earlier surgery produces better results.

Will I need it in the other hand too?

Carpal tunnel is often bilateral, with the dominant hand affected first. Many patients require release on the non-dominant side too, typically 3–6 months later.

References.

Atroshi I, et al. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–158.
Padua L, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273–1284.
Vasiliadis HS, et al. Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev. 2014;1:CD008265.

Carpal tunnel syndrome.