Updated: 7 hours ago
Are you surfing the Web looking for the latest about the pros & cons of endoscopic carpal tunnel surgery? Welcome! You’ve come to the right place.
The more you know about carpal tunnel syndrome and how it's treated, the better equipped you’ll be to make the smartest decision. Toward that end, I wrote you a quick and user friendly tutorial.
We’ll talk about everything you need to know in a moment. For now, let’s get started with the most important point:
The entire field of carpal tunnel surgery has come under scrutiny. The above linked journal article is only one of many arguing against surgery as the go-to treatment. And it’s a hot button topic among hand surgeons for sure!
I myself led a clinical study showing only 3% of carpal tunnel patients actually need surgery.
The controversy has grown since the advent of endoscopic carpal tunnel surgery.
Previously, your only option was open carpal tunnel release surgery. In open release, surgeons open your hand to expose the transverse carpal tunnel ligament to sever it in half.
Using the new technology, surgeons make one or two small incisions in the hand. They pass a camera and scalpel through the holes. As a result, the procedure is faster and less invasive, meaning patients recover sooner. But there are drawbacks.
The pros & cons of endoscopic carpal surgery were debated in the early 2000s. Even so, the relative ease and (arguably) the additional profitability of the endoscopic procedure made it the winner.
Quick & user-friendly carpal tunnel tutorial
First off, carpal tunnel syndrome is a disease and it’s incurable.
Don’t worry – even though you may have it — it doesn’t mean you have to suffer. You CAN be symptom-free and we’ll talk about that later too.
Back to it’s being incurable.
Although carpal tunnel is a permanent condition, its symptoms can be reversed and essentially “cured.” In that respect, carpal tunnel is like type 2 diabetes.
Without media fanfare, studies proved carpal tunnel can also be naturally reversed.
But in both cases, once you have the disease, you’ll always be predisposed to symptoms returning.
The question of predisposition and carpal tunnel is controversial.
Formerly, experts (including myself) were certain carpal tunnel is a repetitive strain injury caused by overuse. It seemed obvious – people who do repetitive tasks with their hands get the disease.
The problem is that many people spontaneously come down with the disease idiopathically — meaning there is no apparent cause (like overuse).
While I find this subject fascinating, no one else will unless they’re in pain. So I’m really glad to be here for you.
Now back to the tutorial.
Endoscopic carpal tunnel surgery controversy
Dr. Ring’s story
It isn’t often a Harvard Medical School professor goes head-to-head with the medical mainstream. David Ring, MD and PhD is an exception.
Back in 2008, Dr. Ring was chief of hand surgery at Massachusetts General Hospital while teaching orthopedic surgery at Harvard. He first bucked the system when he went public with a serious medical mistake.
He performed the wrong surgery on a patient. His patient was scheduled for trigger finger surgery and he performed carpal tunnel. Typically, these kinds of mistakes are kept under wraps. They’re called wrong-site surgeries and occur at a rate of 40 times per week.
But Dr. Ring went public and went so far as to publish a journal article in the New England Journal of Medicine detailing what and why things went wrong.
I find him really interesting! A man after my own heart, he earned his PhD in the psycho-social aspects of arm illness while holding down his jobs at Mass General and Harvard Med.
Here’s a copy of his PhD thesis. In it he argues doctors “invented” repetitive strain injury and calls on surgeons to reign in the knife. Dr. Ring cites his personal experience and the percentage of patients he saw whose arm pain was psycho-social.
Or more bluntly — their pain was “in their head.”
According to Dr. Ring, the “in their head” incidence is partly due to doctors themselves. When the medical profession gave chronic hand pain a name (repetitive strain injury), they elevated its status to a disease.
One of the psycho-social consequences of validating pain as a disease worsens the perceived experience of pain. What was once uncomfortable becomes unbearable. Calling attention to anything heightens the experience of it – hence the expression: let sleeping dogs lie.
Dr. Ring’s research hit the carpal tunnel surgery industry in the pocketbook
Carpal tunnel is a type of repetitive strain injury. And carpal release operations are bread-and-butter money for many specialists.
In effect, Dr. Ring undermined the hand clinic industry arguing many procedures are unwarranted. Worse, he implies that there’s something dishonest about the fact carpal tunnel surgery is the 2nd most widely performed orthopedic procedure (back operations are first).
What do you think?
Inherited or acquired carpal tunnel syndrome
Dr. Ring was the first to challenge the conventional wisdom that carpal tunnel is caused by overuse. If it isn’t caused by overuse, then it can’t be a repetitive strain injury.
Again citing personal patient experience, Dr. Ring noted that small carpal tunnels run in families.
Anyone with a small carpal tunnel is likely to develop adhesions that rub up against the median nerve. The ensuing friction and inflammation produce the classic pain, numbness, and tingling.
Having a small carpal tunnel explains the spontaneous cases of carpal tunnel caused by no apparent reason.
Thus, Dr. Ring concludes: carpal tunnel is inherited. Although his science isn’t conclusive, medical opinion is trending toward agreement that people are predisposed to the disorder.
Endoscopic carpal tunnel surgery procedure
Think of the carpal ligament as a rubber band. When it snaps (or is halved) it retracts unto itself. However the carpal ligament is living tissue and over time, it forms scar tissue and reconnects. Only this time (because it’s scar tissue) it’s much less supple and fibrous which makes the pain, tingling and numbness worse than before the surgery.
Okay, so now you have the short answer for why 50% of patients end up back at the drawing board within two years of the surgery. Incredibly, 25% of these go on to have a second surgery – almost as certain to fail!
Now surgeons can insert an endoscope into a small incision and use a camera to go looking for the ligament. Depending on the surgeon’s skill (more on that later), he or she will either insert a scalpel in the same hole or make a second incision just for the scalpel. The outcome is the same – slice the carpal ligament in half.
Although the procedure costs more than the traditional operation, it’s less invasive. So the surgery goes quicker and the patient experiences less trauma. But as far as the American Academy of Orthopedic Surgeons (AAOS) is concerned – it’s too much of a good thing.
For over 20 years the AAOS has warned that the burgeoning hand surgery industry encourages a factory approach to patient care. The result is a lot of unnecessary surgeries.
These surgeries are unnecessary because:
1. There’s a 50% surgery failure rate from the perspective of the patient.
Believe it or not, the clinical definition of whether or not the surgery is successful is whether or not the transverse carpal tunnel ligament was severed. That accounts for all the glowing statistics for the efficacy of the operation. All a surgeon has to do is destroy the ligament by cutting it into two. But from the perspective of patient satisfaction, it’s an entirely different story. Most people are fine for the first six to 18 months. But about half complain symptoms return after two years and many end up back at square one.
2. There are many non-surgical methods that work as well as surgery – some, even better. For example, myofascial release therapy is specialized massage that cures symptoms, and the Carpal Rx therapy device gives you the same physical therapy from the comfort & convenience of home.
So to try and curb unnecessary surgeries, the AAOS published guidelines on the treatment of carpal tunnel syndrome. They tell surgeons not to perform surgery until the patient has tried every non-surgical intervention for at least 6 months. No one is listening though – family doctors routinely refer patients to orthopedic surgeons who don’t listen to the guidelines because they want to get paid.
Okay, now you’ve had a heads-up and your eyes are open.
Sincere best wishes!
Good luck with whichever way you decide to take care of your aching hand. Regardless of your decision, keep in mind that surgery is not a cure for carpal tunnel syndrome. That’s why surgery fails as often as it does.
Carpal tunnel is a disease without a cure. The main problem underlying the disease is tendon inflammation. Surgery doesn’t address this inflammation. It only addresses how to relieve pressure on the median nerve. If your tendons are prone to inflammation, you’ll more than likely find only temporary relief from surgery.
The pros & cons of endoscopic carpal tunnel surgery for carpal tunnel syndrome are many. You and your doctor should discuss the risks (there are many!) and benefits of having it. Today, most doctors are opting for non-surgical treatments to cure symptoms. These include night bracing, hand and finger exercises, and myofascial release massage. All work extremely well in most patients to manage this condition.
Dr. Z (Dr. Maik Zannakis) is a neurophysiologist and bio-engineer with over 40 years of research experience. His primary focus is discovering methods to heal tissues damaged by pathology or injury. An expert in the nervous system, Dr. Z has hundreds of publications and dozens of international patents for products and techniques to restore body parts like the brain, spinal cord, nerves, and tendons. The Carpal Rx is his most recognized invention, helping thousands eliminate the symptoms of carpal tunnel syndrome without surgery.