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Carpal tunnel syndrome
This is a very common condition. The major sensory (feeling) nerve to the palm of the hand enters the wrist through a tunnel called the carpal (wrist) tunnel. This nerve, called the median nerve, shares the tunnel with ten other tendons. When the space in the tunnel gets smaller (which happens with a number of conditions... e.g. pregnancy, arthritis, injuries and soft tissue thickening that occurs with getting older), the nerve starts to "complain".
Symptoms are those of pain and/or numbness and/or tingling in the fingers, mainly the thumb and the next three fingers. This often occurs in the mornings. It is commonly in both hands.
Treatment consists of reducing any repetitive activities... e.g. typing, knitting or use of vibrating tools. A wrist splint can be quite helpful. Otherwise, a cortisone injection can be given. Finally, surgery can be done.
See Free Carpal Tunnel Exercises.
I obtain nerve tests prior to any surgery on a nerve because sometimes the problem can be due to something else (e.g. neck problems) and it is worthwhile making sure the diagnosis is correct before surgery.
There are two types of surgery for CTS - endoscopic (keyhole) and open.
Open surgery has been done for more than 60 years and remains the standard operation. It has about a 99% success rate (i.e. resolving the symptoms) but the main disadvantage compared to endoscopic surgery is that the wound tends to be sore for a few months, much more so than with endoscopic surgery. For this reason endoscopic surgery is preferred for people in manual jobs.
The success rate for endoscopic surgery is about 98%, the main risk being that open surgery may have to be done if the offending band has not been completely divided. Because the overall view is more limited with endoscopic surgery there are some small but definitely increased risks compared to open surgery: specifically, a 1-2% chance of injury to either the median nerve or injury to one of the 10 tendons running within the carpal tunnel.
If this occurred microsurgery would need to be done at a later date to repair the injury. There is about a 1-2% risk of infection with open surgery, a risk which is extremely low in endoscopic surgery.
1. Endoscopic carpal tunnel decompression
This is the more recent type of surgery using two very small cuts - one in the wrist and the other in the palm. An endoscope is inserted through these two holes and the carpal tunnel roof is divided under vision. Patients recover quicker with this surgery than with open surgery. However, I do not advise endoscopic surgery if the operation is a redo.
Post-operative guidelines for endoscopic carpal tunnel decompression
1. Keep the hand elevated until the next morning... e.g. by keeping it on a pillow or two overnight.
2. If you notice a definite increase in pain or numbness of the hand or fingers, you must contact Dr Popovic.
3. You are encouraged to keep your fingers and thumb moving so they don't become stiff. They don't have to be moved excessively. Just make sure you open and close your fingers and thumbs at least a few times a day.
4. Usually the bandage will be removed before you leave hospital. The thin tapes (Steristrips) will stay on and can be peeled off after three days.
5. Usually there'll be no stitches to remove.
6. You can wet your hand but don't let it get too soaked for two weeks (like a prune!).
7. It's important to keep your elbow and shoulder moving after the operation. Otherwise they may become stiff. You don't have to move them excessively. Just remember not to keep them immobile.
8. You are discouraged from using your hand for any heavy work for at least four weeks after surgery. Prior to this it is okay to use your hand for simple things... e.g. holding a fork or writing.
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2. Open carpal tunnel decompression
This is the operation that has been used for years and is very reliable. The main downside is that it requires a three or four centimetre cut on the palm and many patients find that the wound is sore for some months.
Post-operative guidelines for open carpal tunnel decompression
1. Keep the hand elevated until the next morning... e.g. by keeping it on a pillow or two overnight.
2. If you notice a definite increase in pain or numbness of the hand or fingers, you must contact Dr Popovic.
3. Keep your fingers still for the first post-operative night (the night of the operation) but after the dressing change the next day it's important for your healing and treatment to keep your fingers and thumb moving so they don't become stiff. They don't have to be moved excessively. Just make sure you open and close your fingers and thumbs at least a few times a day.
4. The bulky dressing will be changed in the neurosurgery ward of the Mount Hospital (Karri A ward) on the first day after the operation. The thin tape underneath the bulky dressing (Steristrip) will stay on, to be removed at home on the third day after the operation. Therefore the aim is to have no dressings on the wound from the third day after the operation.
5. You will be given three or four Primapore dressings (NOT occlusive dressings) to put on the wound if it oozes. Occlusive dressings do not allow the wound to breathe. I prefer that the wound be kept open and dry as soon as possible from the third day and onwards following operation. Usually there will be no stitches to remove. If you wish you may paint the wound with an antiseptic such as tea tree oil, which I prefer, or Betadine.
6. Please try not to get your wound wet, at least until your first review appointment.
7. It's important to keep your elbow and shoulder moving after the operation. Otherwise they may become stiff. You don't have to move them excessively. Just remember not to keep them immobile.
8. You are discouraged from using your hand for any heavy work for at least four weeks after surgery. Prior to this it's okay to use your hand for simple things... e.g. holding a fork or writing.
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Ulnar nerve compression
The 2nd most common peripheral nerve entrapment is that of the ulnar nerve at the elbow. People are aware of the "funny bone". This is at the inside of the elbow where the ulnar nerve passes around bone and can be compressed to cause pins and needles down the forearm into the little and ring fingers.
The ulnar nerve can be caught in scar tissue at the elbow. This can produce serious weakness and wasting of the small muscles of the hand, resulting in a useless hand if not treated. Unlike carpal tunnel syndrome, there are really no effective non-operative treatments... i.e. surgery is really the only treatment.
Post-operative instructions for ulnar neurolysis
1. Keep the arm elevated until the next morning... e.g. on a pillow or in a sling.
2. If you notice a definite increase in pain or numbness of the elbow or hand and fingers, you must contact Dr Popovic.
3. The bulky dressing will be changed in the neurosurgery ward of the Mount Hospital (Karri A ward) on the first day after the operation. The thin tape underneath the bulky dressing (Steristrip) will stay on, to be removed at home on the third day after the operation. Therefore the aim is to have no dressings on the wound from the third day after the operation.
4. You will be given three or four Primapore dressings (NOT occlusive dressings) to put on the wound if it oozes. Occlusive dressings do not allow the wound to breathe. I prefer that the wound be kept open and dry as soon as possible from the third day and onwards following operation. Usually there will be no stitches to remove. If you wish you may paint the wound with an antiseptic such as tea tree oil, which I prefer, or Betadine.
5. Please try to minimise wetting your elbow wound.
6. It's important to keep your shoulder, wrist and fingers moving after the operation. Otherwise they may become stiff. You don't have to move them excessively. Just remember not to keep them immobile. You can move the elbow within the limits of discomfort but are generally advised to minimise elbow movements and minimise driving. You are discouraged from using your arm for any heavy work for at least two weeks post-operatively, at which time your treatment will be reviewed.
7. Keep your elbow still for the first post-operative night (the night of the operation) but after the dressing change the next day it's important to try to move your elbow within the limits of discomfort. You are generally advised to minimise driving and other activities which may stress your wound until about two weeks after the operation.
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Meralgia Paraesthetica
Meralgia Paraesthetica means burning pain with pins and needles.
This occurs in the distribution of the lateral cutaneous nerve of the thigh - basically a hand-sized area on the front and outer side of the mid-thigh. This nerve only supplies feeling. It doesn't provide any movement.
The nerve becomes trapped below the inguinal ligament (the groin fold). This usually occurs for unknown reasons but can follow a significant gain or loss of weight, by wearing tight garments around the waist (e.g. a belt) or during pregnancy.
It usually occurs with standing or walking and is relieved by laying down with the hip flexed. It has nothing to do with the back.
Treatment involves attention to the above-mentioned causes. Otherwise a local anaesthetic plus cortisone injection can help.
Lastly, surgery can be performed as a day case under general anaesthesia to divide the tight portion of the inguinal ligament.
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Endoscopic thoracic sympathectomy
I no longer perform this procedure, which involves cutting sympathetic nerves along the front of the thoracic spine in the chest.
The procedure is done for hyperhidrosis (excessive sweating) affecting the hands or armpits, and is also sometimes done for facial blushing.
For further information, visit Sympathectomy.
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Thoracic Outlet Syndrome
This is a difficult diagnosis to make. Some doctors even doubt its existence, but I am sure that it exists.
The problem occurs when the nerves coming out of the neck (called the brachial plexus) get stretched over a prominent first rib or over an abnormality above the first rib, such as an extra (cervical) rib - see diagram.
The condition is usually associated with pain in the upper limb, especially along the inner aspect, and particularly into the little finger. The diagnosis is even more suspicious if there is numbness or tingling going into the little finger, although this symptom is usually due to ulnar nerve compression at the elbow ("funny bone"). The symptoms tend to get worse with elevation of the upper limb - e.g. hanging up washing, drying your hair.
Neck x-rays and MRI tend to be normal. Electrical tests are virtually always normal unless there is clinical evidence of nerve problems such as muscle-wasting in the hand.
Treatment is initially physiotherapy to help strengthen the shoulder girdle and reduce pressure on the brachial plexus running over the rib cage. Otherwise, surgery can be done. This involves a cut above the collar bone and exploration of the brachial plexus. If an abnormal band or extra rib is found, it is removed. Otherwise, I remove some of the first rib related to the brachial plexus to help free up the nerves.
The risks of surgery are small but include failure to improve, infection, punctured lung and, rarely, damage to the brachial plexus resulting in arm pain.
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