Carpal Tunnel Surgery (Release) Cost and Guide

What is carpal tunnel syndrome?

Carpal Tunnel Syndrome (CTS) is caused by pressure within the small passage of the wrist and palm called the carpal tunnel. This pressure compresses (squashes) one of the nerves of the hand, leading to pain, numbness and weakness in the hand and occasionally in the arm.

Several nerves pass through the wrist and into the hand, but only a nerve called the median nerve passes through the carpal tunnel. As the median nerve only functions in certain parts of the hand, only these areas are affected in CTS (part of the palm nearest the thumb, the thumb, the index, the middle finger, and part of the ring finger).

Symptoms

Symptoms start gradually and, without treatment, can get progressively worse. This progression can take months to years, with symptoms coming and going. Patients often get used to the pain and have their own ways of coping with symptoms, like shaking their hand to relieve the pain, for example. This means it is common for patients not to seek treatment until the symptoms have become unbearable, which can be years after the first symptoms were noticed.

The symptoms of CTS are usually confined to the hand. In some cases, people may suffer those symptoms throughout the arm, to the elbow and, in rare cases, up to the shoulder. Most patients complain of symptoms more at night, which is thought to be caused by bending the hands when sleeping.

Mild to moderate CTS symptoms in the hand:

• Pins and needles (paresthesia)
• Numbness
• Feeling swollen and sensitivity to temperature changes
• Aching and pain (bending the hand can cause sharp pain)
• Mild weakness (often when gripping with the thumb)
• Dry skin on fingers

Moderate to severe CTS symptoms:

• All symptoms above but usually worse
• Increased weakness (dropping heavy objects or difficult to hold)
• Loss of sensation in parts of the hand
• Muscle wastage at the base of the thumb

A more detailed look at CTS

There are several important structures that are important when looking at CTS.

Carpal bones - Small wrist bones form the bottom of the carpal tunnel

Flextor tendons - Fibrous bands of tissue that connect the muscles and bones together to provide stability and move the fingers and thumb. They run through the carpal tunnel.

Transverse carpal ligament - Also known as the flexor retinaculum, this dense fibrous band forms the roof of the carpal tunnel and provides stability to the tendons and bones in the wrist and hand.

Median nerve - The nerve runs from the upper arm, through the carpal tunnel, and into the hand. There, the nerve branches out and is responsible for sense (including pain and touch) and controls movement for parts of the hand. It covers the palm side from the thumb to half of the ring finger and the back side of the index, middle, and half of the ring fingers.

The symptoms of CTS are caused by the compression of the median nerve inside the carpal tunnel. Inflammation of the nearby tendons and tissues causes fluid to build up in the narrow space and increases pressure inside the small tunnel. Long-term compression of the median nerve causes neuropathy (damage, disease or dysfunction of nerves), leading to sensory disruption and muscle weakness.

Why are only parts of the hand affected?

Sense and movement of the hand are made up of a system of nerves that cover different areas.

As shown in green above, the median nerve covers the palm side of the thumb, most of the palm, and the top of the index, middle, and half of the ring fingers. The ulnar and radial nerve cover the other areas and do not run through the carpal tunnel. Patients will usually complain of symptoms only in the green area shaded, but sometimes due to the diffuse nature of nerve pain, it can sometimes be difficult for patients to pinpoint the pain.

Causes/ risk factors:

Generally, there isn’t an exact cause of CTS. It can often be a combination of causes that increase the pressure inside the carpal tunnel. Almost anything that increases inflammation/ fluid retention in the wrist can be thought of as a risk factor:

• Repetitive hand/wrist movement in an unnatural position (e.g. using a computer, musical instruments)
• Previous hand or wrist injury
• Having a smaller carpal tunnel (women and inherited)
• Older in age
• Medical conditions
  • Rheumatoid arthritis - causes inflammation in joints
  • Diabetes - increasing risk of nerve damage
  • Hypothyroidism
• Pregnancy - due to fluid retention
• Obesity - Increased weight around the wrist
• Smoking

What are the goals of carpal tunnel release?

• Relieve pressure inside the carpal tunnel
  • By cutting the roof of the carpal tunnel (transverse carpal ligament)
• Relieve symptoms such as pain, pins and needles, and numbness
• Improve hand strength

Although the aim is always to relieve all symptoms, patients that have had severe symptoms for a long time are less likely to achieve this. Most patients report a significant improvement following surgery, even in the more severe cases.

How much does carpal tunnel surgery cost privately?

The price of surgery with a private orthopaedic surgeon is usually between £2000 and £3000. A procedure for one wrist will most likely cost less than a procedure for both wrists.

Prices can change depending on pre-existing health conditions, the surgeon's expertise and which highly rated CQC hospital the procedure takes place. After a consultation with a surgeon, patients will be given a customised price for their surgery.

Which patients are suitable for carpal tunnel release?

Carpal tunnel surgery is a minor elective surgery, and there are few barriers to patients that want to have the surgery. Most patients that have surgery will typically fill one of these criteria:

• Carpal tunnel symptoms have not gone away on their own
• Non-surgical treatments have not worked
• Need surgery to prevent irreversible damage to the nerve

Patients with mild symptoms for the first time would be recommended to try non-surgical treatments before having surgery. But patients with severe symptoms mustn’t put off having surgery to prevent irreversible nerve damage.

Non-surgical treatments for patients are tailored to the individual, but they all aim at reducing inflammation and pressure in the carpal tunnel:

• Treatment of underlying medical condition, e.g. rheumatoid arthritis, losing weight
• Modifying behaviour that triggers pain, e.g. using a neutral hand position when using a mouse/keyboard,
• Stop smoking
• Hand/wrist exercises designed to alleviate pressure
• Anti-inflammatory medication like Ibuprofen prescribed for short term use
• Wrist brace/splint
  • Worn when sleeping for at least four weeks (often at least eight weeks)
• Corticosteroid injection with or without a local anaesthetic
• Physiotherapy

For patients that are pregnant, surgery is unlikely to be recommended. Carpal tunnel syndrome for these patients is likely due to fluid retention, which will resolve itself after the pregnancy.

How is carpal tunnel surgery performed?

Overview

Carpal tunnel surgery is a minor surgery where the roof of the carpal tunnel (transverse carpal ligament) is cut. The cut is stitched up, a dressing applied, and a tight bulky bandage is wrapped around the hands (fingers and thumb can still move).

The procedure takes around 10 to 30 minutes and is performed using a local anaesthetic, so patients go home the same day. In rare cases, a general anaesthetic (dreamless sleep) can be used. One or both hands may be operated on in the same procedure.

The procedure in more depth

The two most common techniques for surgery are called open surgery and endoscopic surgery. In both surgeries, a local anaesthetic is injected into the area to numb it. In both techniques, the surgeon may alter the position or length of the incision, but they will always try to make the incision in a natural crease in the skin to help hide the scar.

Open surgery

One small vertical incision about the size of a matchstick is made in the lower palm or upper wrist. The carpal tunnel is exposed, and the transverse carpal ligament is cut with a scalpel.

Endoscopic surgery (Keyhole surgery)

One small horizontal incision, smaller than the size of a penny, is made in the upper wrist and a small camera called an endoscope is guided through the opening. A cutting tool can be attached to the camera to cut the transverse carpal ligament, or a second very small horizontal incision is made higher up in the palm for a cutting tool to enter to make the cut. Healing times are thought to be faster with this type of surgery compared to open surgery.

What will happen at an initial consultation with an orthopaedic surgeon?

In the consultation, the surgeon will discuss the patient’s symptoms and examine their hand(s). The surgeon may ask the patient to perform some hand exercises to help pinpoint the symptoms. This can be used to confirm carpal tunnel syndrome. The surgeon will also discuss what treatments patients have tried before and if they have had any scans or tests. Patients are encouraged to bring any test results and have a clear account of their medical history, including carpal tunnel syndrome.

In many cases, a physical examination and patient history is enough information for the surgeon to decide if it’s appropriate to operate. In certain cases, however, some scans or tests might be needed:

• EMG (Electromyography) measures electrical activity in muscles
• Nerve conduction studies measure the speed of impulse through the carpal tunnel
• Ultrasound and MRI to rule out structural issues

The surgeon will also discuss how the procedure will take place, the patient’s individual recovery time, and the potential risks and complications.

Risks and complications

Carpal tunnel release is considered minor surgery, but it does not come without risks and complications that patients need to be aware of.

• Infection
• Bleeding from the incision site
  • If this happens, it will most likely be in the first few days as the wound heals
• Sensitive scar and surrounding tissue
  • This usually improves with time
• Pillar pain
  • This is a common complication where pressing down on either side of the scar causes deep pain in the wrist. If felt, this lasts about four to six weeks but, in some cases, can last a few months.
• Hand stiffness
  • This is common, and patients often benefit from physiotherapy
• Damage to the nerves
  • There is a small risk the nerves in the hand/wrist may be damaged during the surgery leading to long term tingling, pain and numbness. Having an experienced and skilled surgeon will reduce this risk.
• Failure to resolve/improve symptoms
  • Due to Irreversible nerve damage prior to the surgery or
  • The carpal tunnel roof (transverse carpal ligament) is not fully cut. A second surgery may be performed to correct this
• Bowstringing
  • In rare cases the tendon may ‘bow’ away from the finger, causing an inability to fully bend the finger and grip properly.

Aftercare

Exact timeframes are different from patient to patient and are very dependent on how severe the symptoms were and how long the patient suffered prior to surgery. It is important to follow the surgeon’s and post-op team’s advice. Some general points are bullet-pointed here, and a more detailed timeframe can be found below.

General points

• In many cases, carpal tunnel syndrome associated pain is relieved immediately or within a few days
• Full function often returns gradually between 6 and 12 weeks but can be up to six months
• A bulky bandage and stitches will be removed in the first follow up appointment one to two weeks after surgery
• Returning to office work after one to three weeks
• Returning to manual work at least one month
• Time off from light repetitive tasks two to four weeks

First 2 weeks

Following the procedure, a dressing is applied to the wound and a bulky bandage is wrapped around the hand, but the fingers and thumb are free to move and is encouraged. Some patients may need to wear a sling for a few days to help prevent swelling.

Patients will be given hand exercises to aid recovery and help prevent complications. Patients need to follow these exercises and, importantly, do not squeeze a ball persistently; this can actually slow recovery.

As the numbness from the local anaesthetic wears off, many patients notice relief from the carpal tunnel associated pain, but tingling and numbness may persist. Each patient recovers at different speeds following carpal tunnel release, some slower and some faster. Pain from the operation is managed with simple pain relief and has usually resolved within a few days to weeks.

A follow-up appointment with the surgeon, hand therapist, or post-op nurse is often one to two weeks after the surgery. During this appointment, the bandage, dressing and stitches (if not dissolvable) will be removed. The wound is also assessed, and any symptoms discussed to ensure all is going to plan. Sometimes a splint may need to be worn for a few weeks following the appointment.

It’s not uncommon for patients to continue seeing a hand therapist or physiotherapist during their entire recovery and, in more severe cases, to continue for years.

Weeks 2 to 6

During this time, most patients will be able to return to most daily activities. Some patients may feel confident returning to the office to perform light desk duties immediately after their follow-up appointment, but often leaving two to three weeks is recommended.

Returning to manual work is often more difficult to gauge; light repetitive tasks are usually manageable after two to four weeks, but heavy lifting may take longer.

After a few weeks, the pain has usually subsided, but weakness in the hand and altered sensation may persist.

6 weeks to 12 weeks

During his time, much of the sensory disruption, such as numbness and tingling, will gradually improve. It’s common for the soreness to persist when deep pressure is applied to the scar, but the pain caused when gripping is usually fully relieved.

6 to 12 months

Patients’ hands have usually have settled after 6 to 12 months, and patients can expect this to be their ‘new normal’. Not all symptoms may fully resolve, especially for patients that had severe symptoms for a long time before surgery. This happens when the nerve damage is irreversible. The majority of patients will experience great relief and have prevented permanent or further damage to the nerve.

Driving and sports

Most patients can drive as soon as they feel comfortable, which is often after a few days. It’s important patients check with their insurance company, though, as they may have their own rules.
Depending on the sport, many patients will feel comfortable playing again from around two to six weeks following surgery; for sports involving tight grips, this may be a bit longer.

All of the information found on our website is sourced from highly reputable experts, government-approved authorities and is widely used by healthcare professionals.

• NHS: https://www.nhs.uk/conditions/carpal-tunnel-syndrome/
• NHS: https://www.ouh.nhs.uk
• NHS: https://www.guysandstthomas.nhs.uk
• Royal College of Surgeon: https://www.rcseng.ac.uk
• British Orthopaedic Association: https://www.boa.ac.uk

Our content is written by our Medical Quality Managers and Patient Care Advisers, all of who have medical backgrounds and training. Before publishing, all the information is reviewed by a surgeon specialised within the relevant field.