Traditional methods of treating Carpal Tunnel Syndrome include wearing a splint at night or injections of cortisone to reduce swelling. If these measures are not successful, carpal tunnel release surgery, which sections the tough transverse carpal ligament and relieves pressure on the median nerve, may be performed. Despite some people having good success with surgery, there have been many patients who have presented to my office with worse symptoms after they had the carpal tunnel surgery.
Study: Surgeons confident Carpal Tunnel Surgery is a good option for patients, but not for them.

Surgeons less confident in the surgery if they, the surgeon, were the patient

Here is a study from hand surgeons and post-surgical therapists.

Published in the Journal of plastic surgery and hand surgery, one of the objectives of this survey was to see if a surgeons’ eagerness to convince a patient of the benefit of six different surgical procedures differed if they, the surgeons themselves were recommended to get one of the six surgeries as a patient with hand/wrist pain. One of the 6 procedures was Carpal Tunnel Release.

• The surgeons in the study were divided into two groups.
  • Group 1: Surgeons who were told to “pretend to be a patient being recommended to Carpal Tunnel surgery.”
  • Group 2: Surgeons who were told to continue on being surgeons and make recommendations for Carpal Tunnel Syndrome treatments.
• The study’s findings: “Surgeons who considered themselves as patients had less confident perception on the benefit of carpal tunnel release compared with surgeons, who considered treating patients.”(1)

When can I return to work after carpal tunnel release surgery? Conflicting opinion causes problems for patients

Here is another problem with surgical intervention. Many people with carpal tunnel syndrome have it because of repetitive work related movements. So the question many of these people present to their surgeon is, “when can i go back to work?”

October 2018: The Journal of hand surgery, European volume. (2)

• In this study, over 300 surgeons and therapists responded to a request for what each one of them would recommend to a patient who asked: “When can I go back to work?,” following carpal tunnel release surgery
• The average recommendations were:
  • 7 days for desk-based duties,
  • 15 days for repetitive light manual duties and
  • 30 days for heavy manual duties.
• However, the responses these patient received from their health care provider were wide-ranging:
  • 0-30 days for desk-based;
  • 1-56 days for repetitive light manual; and
  • 1-90 days for heavy manual.
• The study authors suggested these variations were a problem: “Variation in the recommended timescales for return to work and other functional activities after carpal tunnel release suggests that patients are receiving different and possibly even conflicting advice.”
• The study’s conclusion: “There is a limited evidence base from which to derive recommendations for safe and effective return to different types of occupation after carpal tunnel release surgery.”(2)

When can you return to work after carpal tunnel surgery? No one is quite sure.

Is there a connection between carpal tunnel syndrome and trigger finger?

A May 2020 study (3) reviewed the connection between Carpal tunnel release and trigger finger. The authors of the study wrote: “Carpal tunnel release is acknowledged as a predisposing factor for the development of the trigger finger. However, the incidence of new-onset trigger finger after Carpal tunnel release surgery has been inconsistently reported. In this study, we aimed to evaluate the prevalence of Carpal tunnel release as a risk factor of the development of the trigger finger.”

• Post-Carpal tunnel release trigger finger was detected in 26.3% of the 57 patients of this study
• The trigger finger occurred approximately six months after Carpal tunnel release surgery. The thumb and ring fingers were the most commonly involved fingers.
• Ten out of 15 (66.7%) patients who developed a post-Carpal tunnel release trigger finger had mild-to-moderate Carpal tunnel syndrome, and five (33.3%) patients had severe Carpal tunnel syndrome. No significant difference was found between the patients who did and did not develop a trigger finger after Carpal tunnel release surgery.

“The rate of developing a post-Carpal tunnel syndrome trigger finger was remarkable in our study.” The authors of this study suggested that patients under going Carpal tunnel release be advised of the potential of developing trigger finger.

Possible treatment options

In the beginning of this article we discussed surgery and return to work. Now let’s look at some possible remedies

Injection of simple dextrose more effective than cortisone

Cortisone is not considered a good long-term solution to Carpal Tunnel Syndrome. Studies show that any pain relief cortisone provides is short-lived.

In September 2018, doctors compared cortisone injections against that of simple dextrose (Prolotherapy) and published their findings in the Annals of Neurology.

• Fifty-four people with mild-to-moderate carpal tunnel syndrome were randomly divided into a dextrose injection group and steroid injection group.
• The patients were administered one session of perineural injection with 5 cc of dextrose or 3 cc triamcinolone acetonide mixed with 2 cc normal saline (steroid group), under ultrasound guidance.
• Using various scoring tools, patients were assessed for response to treatment at 1, 3, 4, and 6 months post-injection.

RESULTS:

• All patients (27 wrists per group) completed the study. Compared with the steroid group, the dextrose group exhibited a significant reduction in pain and disability through 4th to 6th month.
• This study demonstrates that perineural injection of 5 cc of dextrose is more beneficial than that of corticosteroid in patients with mid-to-moderate carpal tunnel syndrome , 4 to 6 months post-injection.(4)

Platelet Rich Plasma PRP injections and hydrodissection

• Nerve hydrodissection for carpal tunnel syndrome is a technique used when median nerve gets compressed in the wrist . It involves using an anesthetic or saline solution to separate the nerve from the surrounding tissue, specifically the tendon and fascia.We use a tiny needle under ultrasound guidance

A study from Athens University in Greece published in the journal Neural regeneration research (5) investigated whether a single injection of platelet-rich plasma would improve the clinical symptoms of carpal tunnel syndrome.

• Fourteen patients with median nerve injury who had suffered from mild carpal tunnel syndrome for over 3 months were included in this study.
• Under ultrasound guidance, 1–2 mL of platelet-rich plasma was injected into the region around the median nerve at the near edge of the carpal tunnel.
• At 1 month after single injection of platelet-rich plasma, results showed that pain almost disappeared in eight patients and it was obviously alleviated in three patients.
• Simultaneously, the disabilities of the arm, shoulder and hand questionnaire showed that upper limb function was obviously improved.
• In addition, no ultrasonographic manifestation of the carpal tunnel syndrome was found in five patients during ultrasonographic measurement of the width of the median nerve.
• During 3-month follow-up, the pain was not greatly alleviated in three patients of the 14 patients.
• These findings show very encouraging mid-term outcomes regarding use of platelet-rich plasma for the treatment of carpal tunnel syndrome.

Earlier in 2018,(6) the same researchers released similar findings in which they tested whether a single injection of platelet-rich plasma (PRP), under ultrasound guidance, can improve the clinical symptoms of patients with a mild to moderate carpal tunnel syndrome.

• In this study 50 patients suffering from mild to moderate carpal tunnel syndrome for a minimum of 3 months were randomly divided into 2 groups:
  • Group A (26 patients) received an ultrasound-guided PRP injection into the carpal tunnel, whereas
  • Group B (24 patients) was injected with placebo (0.9% normal saline). T
• Group A patients demonstrated a 76.9% success in treatment whereas Group B patients demonstrated 33.3% success, which was significantly less than Group A
• The findings of this study suggest that a single PRP ultrasound-guided injection has positive effects in patients with carpal tunnel syndrome.

It appears PRP can be an effective treatment for Carpal Tunnel Syndrome as attested to by a December 2019 (6) which suggested: “PRP represents a promising therapy for patients with mild to moderate Carpal Tunnel Syndrome; however, included studies were limited as follow-up was short, the studies included patients that were heterogeneous, and the number of included studies was low.” Confirmation would come with more research.

Stem Cell Therapy for Carpal Tunnel Syndrome

Stem cell therapy is a more advanced treatment for degenerative conditions. Often a patient with Carpal Tunnel Syndrome will also exhibit mild to advancing osteoarthritis of the wrist and thumb.

• In a study from March 2018 researchers found that degenerative osteoarthritis of the wrist was strongly associated with carpal tunnel syndrome.(7)
• In some instances surgeons will perform a thumb joint replacement and carpal tunnel release in the same procedure.(8)

When a patient comes into our office with wrist pain, thumb or hand pain, and carpal tunnel, we may recommend the use of stem cell treatments to treat the entire area. We have found this treatment to be effective and reliable in degenerative conditions of the wrists and hands. Our findings will be published in our paper “Treatment of Hand and Wrist Osteoarthritis with Bone Marrow Concentrate: A Case Series”

Do you have questions? Ask Dr. Darrow

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

References:

1 Leppänen OV, Jokihaara J, Jämsen E, Karjalainen T. Survey of hand surgeons’ and therapists’ perceptions of the benefit of common surgical procedures of the hand. Journal of plastic surgery and hand surgery. 2018 Jan 2;52(1):1-6.
2 Newington L, Francis K, Ntani G, Warwick D, Adams J, Walker-Bone K. Return to work recommendations after carpal tunnel release: a survey of UK hand surgeons and hand therapists. The Journal of Hand Surgery (European Volume). 2018 Jun 10.
3 Shafaee-Khanghah Y, Akbari H, Bagheri N. Prevalence of Carpal Tunnel Release as a Risk Factor of Trigger Finger. World Journal of Plastic Surgery. 2020 May;9(2):174.
4 Wu YT, Ke MJ, Ho TY, Li TY, Shen YP, Chen LC. Randomized double‐blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Annals of neurology. 2018 Sep 5.
5 Malahias MA, Johnson EO, Babis GC, Nikolaou VS. Single injection of platelet-rich plasma as a novel treatment of carpal tunnel syndrome. Neural Regeneration Research. 2015;10(11):1856-1859. doi:10.4103/1673-5374.165322.
6 Malahias MA, Nikolaou VS, Johnson EO, Kaseta MK, Kazas ST, Babis GC. Platelet‐rich plasma ultrasound‐guided injection in the treatment of carpal tunnel syndrome: A placebo‐controlled clinical study. Journal of tissue engineering and regenerative medicine. 2018 Mar;12(3):e1480-8.
7 Bacle G, Marteau E, Corcia P, Garaud P, Laulan J. Are Carpal Tunnel Syndrome and Regional Degenerative Osteoarthritis Linked? Results of a Case-Control Study. The Journal of Hand Surgery (Asian-Pacific Volume). 2018 Mar;23(01):41-6.
8  Ingari JV, Romeo N. Basal Joint Arthroplasty and Radial-sided Carpal Tunnel Release Using a Single Incision. Techniques in hand & upper extremity surgery. 2015 Dec 1;19(4):157-60. (1856)