SALT LAKE CITY — After decades of sewing and crafting, Peggy Stewart’s hands decided they’d had enough. For 10 years, the Salem, Utah, grandmother suffered from the effects of carpal tunnel syndrome, a painful condition caused by pressure on a nerve in the wrist.
“If I was shopping at a grocery store and would hit my wrists on the cart, it was electrifying, such horrible pain. I had excruciating pain in my hands if I went and did anything with them,” Stewart said. “I couldn’t do up buttons, or anything.”
Stewart, a mother of five and grandmother of 25, now refers to her pain in past tense because she is one of a handful of Utahns who have undergone a new treatment for carpal tunnel syndrome developed by a pair of doctors at the Mayo Clinic in Minnesota. Using a special device with a retractable blade, the doctor uses ultrasound to navigate around the tendon and nerve in the wrist, then snips the ligament putting pressure on the nerve.
The incision doesn't need stitches, only a bandage, and pain medication is rarely needed. A local anaesthetic is given during the procedure, which takes less than an hour.
“This device, I think, will become the standard of care in releasing the carpal tunnel,” said Dr. Craig Chappell, the first Utah physician to offer the procedure.
Patients can resume normal activity within days, unlike invasive surgeries from which recovery may take weeks, said Chappell, who practices in Pleasant Grove. Not everyone is a candidate for the procedure, however, and some hand surgeons are expressing concern that people performing it might not be qualified.
"Surgery should never be taken lightly. With every surgery, even the most common ones, there are risks," said Dr. Rachel S. Rohde, a wrist, hand and elbow surgeon in Michigan.
Contrary to conventional wisdom, most people don't get carpal tunnel syndrome by spending too much time on a computer or smartphone. If you've got it, here's what may have caused it — and what your options for treatment look like.
'The million-dollar nerve'
The carpal tunnel is the pathway of ligaments, tendons and bone that connects the wrist with the hand. Over time, vigorous hand motions performed frequently can cause the tendons and ligaments to become swollen and inflamed, pressing into the nerve that allows us to feel sensations in our fingers and thumbs.
That nerve, the median nerve, is sometimes called “the million-dollar nerve” because of lawsuits against physicians who accidentally sever it during surgery. This can happen because the path of the nerve can be different for each individual.
Carpal tunnel syndrome is marked by pain, numbness and tingling that occurs when the nerve is compressed. Women are more likely to suffer from it than men, possibly because their carpal tunnels are smaller; they're also more likely to experience it during pregnancy.
People with diabetes, rheumatoid arthritis and hypothyroidism, and people who are obese, are also more likely to suffer from carpal tunnel syndrome, and its incidence is greatest among people ages 45 to 64, according to the Centers for Disease Control and Prevention.
Rohde, the hand, wrist and elbow specialist in Michigan and a spokeswoman for the American Academy of Orthopaedic Surgeons, said it's not known why women are at increased risk, or why the risk increases with other factors. "The pregnancy co-existence could be related to excess edema, or swelling, or might also have hormonal components; we don't know," Rohde said.
Most cases related to pregnancy resolve after the woman gives birth. In other cases, the condition may improve with physical therapy, splints and/or steroid injections.
But, Chappell said, “The more severe the disease, the more unlikely it is that conservative management is going to be able to fix the problem.''
In severe cases, patients experience relief when the transverse carpal ligament, which stretches across the base of the wrist, is cut, or, as doctors euphemistically say, "released." (You can watch a video of the procedure on Chappell's website, in2itmedical.com.)
The ligament eventually grows back together, and is typically longer, and more accommodating of the nerve, when it does.
Each type of surgery for carpal tunnel syndrome works by severing the ligament, but they vary by the size of the incision, the time it takes the patient to recover and how many layers the surgeon has to cut.
Originally, this type of surgery involved a 4-centimeter incision across the palm, and the doctor had to dissect through several layers of tissue and tendon to reach the ligament. Healing took four to six weeks. Improvements in technique gradually reduced the incision to 1-2 centimeters, then to 1 to 1½ centimeters, and recovery time shrank to two to four weeks.
Using ultrasound and a device called a SX-One MicroKnife, the incision is a half-centimeter or less and recovery is four to six days, Chappell said. “I had a guy back doing drywall four days later,” he said.
Pain is significantly reduced, too. Chappell said he does not prescribe painkillers for patients who have the procedure, and Stewart, the grandmother in Salem, said she didn't need over-the-counter pain medicine after her treatment. "If they need anything, I encourage Tylenol," Chappell said.
Not for everyone
Carpal tunnel syndrome was first described in the 1940s by the late Dr. George S. Phalen, who practiced at the Cleveland Clinic at the time. Phalen also developed a protocol for diagnosing the condition, called Phalen’s maneuver.
In a 1966 paper published in the Journal of Bone & Joint Surgery, Phalen described the typical patient as “a middle-aged housewife with numbness and tingling in the thumb and index, long, and ring fingers, which is worse at night after excessive activity of the hands.”
Although the prevalence of carpal tunnel syndrome is sometimes thought to be associated with computer use, several studies have shown no correlation. ("Keyboarding no longer takes the same force as a typewriter, thankfully," Rohde said.)
Instead, most people with the condition do repetitive factory work, or jobs that involve vibrating tools, like chain saws or drills. The incidence of CTS in all workers is 2 percent or less, but it was 34 percent among people who work at poultry-processing plants, one study found.
While there is no surefire method to prevent carpal tunnel syndrome from occurring in people at high risk for the condition, the National Institutes of Health recommend that workers regularly do stretching exercises, take frequent breaks and pay attention to posture and wrist position. The NIH also says wearing fingerless gloves also keeps hands flexible and warm.
The treatment offered by Chappell, which is usually covered by insurance, won't work for everyone. In about 2 percent of people, the medial nerve goes through the transverse carpal ligament, and the surgery required is more complex, Chappell said.
Rohde, speaking for herself and not on behalf of the AAOS, expressed concern about the marketing of the device by Sonex Health as "micro-invasive."
"Whether the incision is a few millimeters, centimeters, or longer, this is still surgery. 'Minimally invasive' techniques are not necessarily better," she said, adding that people should ask doctors about the risks and potential complications of the procedure, how many times they've performed the surgery and what previous outcomes have been.
"We all need to understand that there is much more to having surgery than the size of the incision, and there is much more to being a surgeon than making that skin incision. It is more important that one has a skilled, qualified surgeon than a tiny scar," she said.
Chappell said there's nothing wrong with other types of surgery that are still being done, but that he believes this technique will become the gold standard of care over time.
"The procedure that is being done now is a very good procedure," said Chappell, who has no financial interest in the SX-One MicroKnife, nor the company that developed it. "I just believe this is the evolution of the procedure."