Guide to Open Carpal Tunnel Surgery

From Dr. Z - Carpal tunnel syndrome specialist

About Open Carpal Tunnel Release Surgery

Below are the 5  Phases of open carpal tunnel surgery. You will go through all of them when you have this operation. If everything goes well, the surgery will relieve the severe hand or finger pain, numbness, tingling or weakness you have. And while this surgery is not a guarantee of relief, most surgeons recommend it for carpal tunnel symptoms when all other nonsurgical alternatives failed. 


Reason you have open carpal tunnel surgery

The American Academy of Orthopedic Surgeons sets the patient qualification guidelines for this type of hand surgery. They say that doctors should perform open carpal tunnel surgery only when the patient meets 3 criteria. They are:

 

  1. Symptoms are at least 6 months old.
  2. The patient's symptoms interfere significantly with their daily life.
  3. The patient already tried ALL nonsurgical alternatives without success.

 

carpal tunnel

The aim of open carpal tunnel surgery is to relieve pressure on your median nerve. This is one of the main nerves of the hand that carries sensations (like touch, pressure, pain, etc.).


The nerve is located deep inside your wrist joint. It lies very close to the flexor tendons which flex (curl) your fingers. These structures are adjacent to each other in a confined space called the carpal tunnel (hence the name of the disorder).


When you have carpal tunnel syndrome, the nerve is under great pressure. That's because swollen tendons push on it and compress it. It's that nerve compression which causes all of the symptoms like pain, numbness, tingling, weakness, etc.


The tendons are swollen due to inflammation.  And the inflammation is a result of adhesions around the tendons. These adhesions stiffen the tendons, making them less supple. 

Open carpal tunnel surgery relieves pressure by cutting the transverse carpal ligament. The ligament is like a roof over the carpal tunnel space. Actually the ligament is a tough band of tissue which holds the wrist bones tightly together. (Imagine the wooden part of an archery bow which represents the bones, and the string represents the ligament.)


Cutting the ligament allows the wrist bones to snap apart. (Like cutting the string on the bow.) As a result, the carpal tunnel space opens up and the nerve decompresses. That, then relieves the symptoms of carpal tunnel syndrome.

bearded man deeply thinking

The exact procedure for open carpal tunnel surgery

Generally, when you have open carpal tunnel surgery, you do not need to stay overnight in the hospital. Also, doctors prefer to use a regional anesthesia (or nerve block). However, many still prefer using general anesthesia. Either way, you can go home on the same day unless complications arise.

Just before the operation

Ready for the surgery!

In the preoperative area, you will remove you clothes and wear a gown. You will lie on a table and a nurse inserts an IV into your arm vein. This is for two reasons:

  • First, to provide a route for general anesthesia. However, this is irrelevant if the open carpal tunnel surgery is done under regional anesthesia.
  • Second, as a precaution in case other intravenous medicines are needed during the operation.

In addition, you will have EKG electrodes placed on your chest. Finally, the doctor may order a pill to swallow that makes you calm and reduces anxiety. When you’re prepared, the orderly wheels you into the operating room. 

In the operating room

general anesthesia

What happens next depends on your having general or regional anesthesia. With general anesthesia, the doctor injects the anesthetic into your IV line. You might also be asked to breathe anesthetic through a face mask. Then you drift off to sleep. 


In contrast, with regional anesthesia you can see everything going on the entire time. 


The surgeon will then tie down your arm out to the side. The doctor will apply tight compression on your upper arm using a tourniquet. The tourniquet is a cuff that limits blood flow to your hand during the operation. That means you won’t bleed too much.


Next, the doctor sterilizes your hand and arm with a solution. The surgeon uses a pen to draw a line marking where to make the incision. If you have regional anesthesia, the surgeon makes several injections of a local anesthetic into your wrist and palm. Also, your hand may twitch involuntarily as the needles are move around inside your hand. But you won't be aware of this under general anesthesia. Finally, your hand goes completely numb.

Exposing the ligament

open carpal tunnel release surgery

The surgeon makes a 2-3 inch long incision starting at the wrist and moving toward of your palm. Then the doctor pushes aside the connective tissue and fat pad under your skin. This lets the surgeon see the transverse carpal ligament straddling your carpal tunnel. It also permits a clear view of the median nerve. 


Indeed, this is crucial because the doctor must take care to avoid cutting or nicking the nerve located directly below. Being able to directly see the nerve is the big benefit of the open technique compared to the endoscopic technique.

Cutting the ligament

carpal ligament

Usually, if there isn’t too much bleeding, the doctor cuts or "divides" the transverse carpal ligament. As a result, its loose ends retract inward as little. Subsequently, the carpal bones snap apart. 


In the process of cutting the ligament, fluid sometimes squirts out due to excess fluid pressure deep inside. The gap where the ligament had been will eventually fill with scar tissue under the skin.

Completing the operation

woman with hand surgery

Finally, the doctor closes the tissue and fat previously pushed aside with absorbable sutures. Then the doctor closes your skin with individual stitches. These are usually non-absorbable stitches. Sometimes, the doctor will use stainless steel staples instead of stitches. 


You must return 10-14 days later so the the doctor can remove these stitches or staples.


The doctor applies antibiotic ointment and gauze pads to the area. Tape holds the pads over the stitches. Then the doctor wraps your hand and forearm in a sterile bandage. 

After open carpal tunnel surgery

After surgery an orderly will wheel you to the recovery room. Your immediate carpal tunnel recovery can take a couple of hours. With general anesthesia, you wake up within 15 minutes.


The pain medicines will be in full effect, so your hand may only feel sore. If you had only a regional anesthesia, it may take several hours before the feeling comes back into your hand. It will be uncomfortable, but you will have medicines to manage the pain.


Take special care not to bump or knock against the wound area. It’s important to keep your hand elevated above your heart level to prevent swelling and pain. You also must move your fingers a little to help prevent stiffness.


Within a couple hours, the doctor clears you for discharge. You’ll need somebody to drive you home. Your doctor will give you instructions for aftercare at home.

carpal tunnel scar

Conclusion

The aim of open carpal tunnel surgery is to expose the transverse carpal ligament. This tissue holds your wrist bones together. The doctor cuts the ligament, letting the wrist bones snap apart. In doing so, it relieves pressure on your median nerve. As a result, and if all goes well, it relieves the pain, numbness and tingling of carpal tunnel syndrome.