Carpal Tunnel Syndrome

In many cases, the cause is idiopathic (unknown). Contributing factors include:

• Female sex and older age — the most consistent risk factors
• Repetitive wrist flexion and extension — occupational or recreational activities involving prolonged wrist loading
• Pregnancy — fluid retention increases carpal tunnel pressure; CTS often resolves after delivery
• Obesity
• Hypothyroidism, diabetes mellitus, rheumatoid arthritis — metabolic and inflammatory conditions increase risk
• Wrist fracture or dislocation — previous trauma can alter tunnel geometry
• Cysts or masses within the carpal tunnel — rare

Symptoms are caused by compression of the median nerve and affect its distribution — the thumb, index finger, middle finger, and radial half of the ring finger:

Numbness and Tingling

Numbness and tingling (paraesthesia) in the thumb, index, middle, and part of the ring finger are the hallmark symptoms. Symptoms are often worse at night, waking patients from sleep — the classic nocturnal paraesthesia pattern. Shaking or elevating the hand may temporarily relieve symptoms.

Pain

Pain in the hand and wrist, sometimes radiating up the forearm. May be described as aching or burning.

Weakness

In more advanced cases, weakness of the thenar muscles (the muscles at the base of the thumb) causes difficulty with pinch grip, dropping objects, and fine motor tasks. Thenar muscle wasting (visible flattening of the thumb base) indicates severe, longstanding compression.

Diagnosis is based on clinical history and examination, confirmed by nerve conduction studies:

• Clinical examination — Tinel's sign (tapping over the carpal tunnel reproduces tingling), Phalen's test (prolonged wrist flexion provokes symptoms), and assessment of thenar muscle bulk and strength
• Nerve conduction studies (NCS) and EMG — the gold standard diagnostic test; objectively confirms median nerve compression at the wrist, determines severity, and excludes other conditions (cervical radiculopathy, peripheral neuropathy). This test is performed by a neurologist or neurophysiologist.

Imaging is not routinely required. Wrist ultrasound may demonstrate median nerve enlargement and can identify structural causes within the tunnel.  Sometimes MRI may be required in complex cases or in recurrent carpal tunnel syndrome.  

Non-Surgical Treatment Options

Mild to moderate CTS may improve with conservative management:

• Nocturnal wrist splinting — keeping the wrist in a neutral position at night is the simplest and most effective conservative treatment; reduces nocturnal symptoms in some patients
• Activity modification — avoiding repetitive wrist flexion and prolonged pressure on the wrist
• Corticosteroid injection — injection of corticosteroid into the carpal tunnel provides effective but often temporary relief, useful as a diagnostic test and short-term treatment
• Management of contributing conditions — thyroid replacement, diabetes management, treatment of inflammatory arthritis

Surgical Treatment — Carpal Tunnel Decompression

Surgery is recommended when symptoms are severe and persistent despite conservative treatment, or when there is thenar weakness or muscle wasting indicating significant nerve injury. Carpal tunnel decompression (release) is one of the most commonly performed and most successful procedures in neurosurgery — more than 90% of patients experience significant improvement or complete resolution of symptoms.

Endoscopic Carpal Tunnel Decompression

The preferred technique at One Brain and Spine. Using a small camera introduced through a minimal incision at the wrist, the transverse carpal ligament is divided under direct visualisation — releasing pressure on the median nerve. Advantages over open surgery include smaller incision, faster return to activity, and less postoperative scar tenderness. This technique is usually performed as a day case under local or general anaesthesia.

Open Carpal Tunnel Decompression

Through a small incision in the palm, the transverse carpal ligament is divided under direct vision. The traditional open technique is equally effective to endoscopic surgery.  The open technique may be preferred in revision cases or when additional pathology is present. This technique usually performed as a day case under local or general anaesthesia.

Recovery

• Hospital stay — day case procedure, home the same day
• Driving — typically 1–2 weeks post-operatively
• Return to light work — 1–2 weeks
• Return to manual work — 3-4 weeks
• Improvement in symptoms is usually by 90% or more — numbness and tingling typically improve within weeks; weakness recovers more slowly, particularly if muscle wasting was present preoperatively