Patients and friends often ask me if the pain in their hand could be from carpal tunnel syndrome. I find that, while many people have heard of carpal tunnel or have known someone who has dealt with it, there is a lot of misinformation about the condition and how it is best treated.
In its simplest form, carpal tunnel syndrome is a condition whereby a person experiences numbness, tingling, and sometimes pain from an increase in pressure on their median nerve as it travels through the carpal tunnel. This most commonly will cause decreased sensation in the thumb, index, long and half of the ring finger. Sometimes, people describe their whole hand feeling numb. People may complain that this sensation wakes them up at night, or bothers them using a keyboard, bike riding, driving or other activities.
When I first meet someone with carpal tunnel, I usually ask if they have tried sleeping in a splint or brace. The American Academy of Orthopaedic Surgeons created a focus group that produced evidence-based clinical guidelines for carpal tunnel syndrome in 2016. While the entire report was over 700 pages and reviewed over 100 aspects of carpal tunnel risk factors, diagnosis and care, one conclusion was that brace immobilization showed strong evidence for improving patient-reported outcomes. If patients still continue to have persistent numbness and tingling despite using a brace at night, or if patients begin to experience weakness, we then discuss carpal tunnel surgery.
One recent advancement in carpal tunnel surgery has been the adoption of performing surgery with the patient wide awake, using local anesthesia with no tourniquet (WALANT). Often, patients would like to have carpal tunnel surgery, but are nervous about anesthesia. Some patients have difficulty in arranging for a ride to pick them up after they have undergone the sedation or others believe that they are too high risk to undergo anesthesia secondary to a significant cardiac or pulmonary co-morbidities.
WALANT utilizes one percent lidocaine with 1:100,000 epinephrine to provide both local anesthesia to the hand or digit and to also provide hemostasis for the surgeon. This allows the surgeon to avoid using a tourniquet, which is often the most painful aspect of the surgery for patients that are having a procedure done under light sedation.
For years, medical students have been taught to never inject lidocaine with epinephrine into the fingers for fear of causing irreversible ischemia and digit necrosis. The familiar adage of no epinephrine into “fingers, nose, penis and toes “ has been passed down through generations of medical professionals. Dr. Don Lalonde, a hand surgeon from Canada debunked this myth when he published his results of over 2000 cases using epinephrine in the finger without a single case of digit necrosis. Dr. Lalonde has even published his research into the myth and there is evidence that origin of the myth stems from the use of procaine (Novocaine) in the early 1900’s before the introduction of lidocaine in 1948. Procaine started with a pH of 3.6 and became more acidic as it sat on the shelf. It is highly likely that the reports of digit necrosis after “epinephrine” injection in the early 1900’s were actually cases of highly acidic procaine causing the digit necrosis.
Some of the advantages of WALANT carpal tunnel surgery include:
For those patients who do require carpal tunnel surgery, we’ve seen that the ability to perform the procedure under WALANT decreases the logistical burden and medical stress of surgery. When this is coupled with the ability to use one’s hand immediately after surgery, I find my patients are most satisfied.
Michael Smith, MD is a hand surgeon with Southlake Orthopaedics Sports Medicine and Spine Center, PC.
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