Certain nerve entrapment conditions may require surgery – especially if conservative treatment options have not been successful. There are four common surgical releases: carpal tunnel in the wrist, cubital tunnel release in the elbow, radial tunnel in the forearm, and tarsal tunnel in the ankle. When these nerves become pinched, because of tissue or scar tissue pushing on the nerve or inflammation in the tunnel it can cause pain, weakness, and numbness or tingling. Often times, the location of the pain, weakness, or tingling is not where the nerve is pinched but actually where the nerve provides feeling. There are many conservative options that you and your surgeon can explore prior to surgery including bracing, padding, physical therapy, and activity modification. Sometimes the nerve is pinched so badly that permanent damage can occur to both the nerve and the muscles that the nerve provides strength for. Often times, this makes surgery the only long-term option.
Evaluating Nerve Pain
Nerve Release Surgery
Evaluation for nerve pain starts with you giving us a history of your problem: when and how it started, how it currently feels, and which treatments you have tried so far. We also ask you about other medical conditions that may contribute to your nerve pain. We do a physical exam to test the structures of the affected body part. We check your range of motion, strength and do special tests which can uncover specific problems. We also often evaluate the neck for upper extremity conditions and the lower back for lower extremity conditions. Sometimes a nerve is pinched in the spine causing similar symptoms to these more common conditions.
Based on the findings of your physical exam, we may need input from other specialists (particularly Neurologists) who can evaluate and test the nerve supply to the affected arm or leg and determine the severity of the injury. This helps us locate the specific location of where the nerve is being pinched. If it is being pinched in the neck or low back we may refer you on to a spine specialist for further treatment other than surgical intervention.
If testing shows that surgical release of the nerve is necessary, your surgeon will meet with you to review these results of your neurologic testing and go over treatment options. Sometimes multiple conditions can be treated with one operation. For example, cubital and carpal tunnel releases on the same arm can be done together. Nerve entrapment can often affect both the right and left sides of your body. If this is the case, we can operate on each side a few weeks apart to lessen your overall recovery time. Your surgeon will typically wait until you are well enough to provide simple self-care tasks-like cooking and light cleaning—before they would operate on the opposite side.
Nerve release surgeries are done as an outpatient procedure, which means you do not have to stay overnight in the hospital. For these procedures, you will arrive at the facility about a half hour to an hour and a half before your actual surgery time. Our staff will check you in and conduct a brief health check; we will listen to your heart and lungs and check your blood pressure, pulse, and temperature. We will then start an IV to give you fluids and medications. The anesthesia staff will discuss your options for medications during surgery. Often times, a general anesthetic will be used to put you to sleep. With a carpal tunnel surgery, a local anesthetic can be used which allows you to wake up faster and leave the surgery center sooner. A general anesthetic typically takes longer to wear off but allows deeper relaxation during surgery for the radial, cubital, or tarsal tunnel releases. Your surgery time can vary depending on how much tissue needs to be released but can last anywhere from thirty minutes to one hour.
After surgery, your surgeon will explain what they found in the operating room to your family and discuss any limitations you will have in using your arm or leg. You may be placed in a sling or on crutches depending on the nature of your surgery. Usually, your surgeon will ask you to just rest and recover for a few days after surgery. After those few days, you may take off the bulky dressing from surgery and are allowed to shower. As you can imagine, it can be difficult to care for yourself after surgery, and you may find you need extra help. Your surgeon will be sure to tell your family if you have any specific restrictions after surgery.
Patients can expect to be seen by either their surgeon or a Physician Assistant in 10-14 days after surgery. Physician Assistants are often used to assist the surgeon during your surgery and understand exactly what was done during your procedure. At your first post-operative visit, they will discuss with you what they found during your surgery, what was done, and your recovery process. On average, it takes most patients just a few weeks before they are back to their everyday activities, but scar tenderness can take up to six months to resolve completely. If you had severe damage or loss of sensation to an area, it can take up to a year for you to reach the full potential recovery.
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Carpal Tunnel Syndrome and Open or Endoscopic Release
Your wrist is made up of a series of bones called carpals. On the palm side of your hand, there is a band that runs across your wrist, creating a tunnel between the carpal bones. A group of tendons and the median nerve travel through this tunnel. Sometimes you can get inflammation or swelling in this tunnel, causing the nerve to become trapped or pinched, resulting in carpal tunnel syndrome. This causes numbness or tingling in the palm of your hand. Other times, it can cause weakness in your hand, making it difficult to grip or pick things up. Repetitive movements like typing on a computer can cause this condition, however, other times it is simply genetics and based on your anatomy.
There are two type of surgery that can be done to fix this condition; open or endoscopic release. An open release is more common. During the open release surgery, an incision is made perpendicular to the wrist and the ligament band covering the carpal tunnel (on the palm side of the wrist) is released allowing more space for the nerve. During the endoscopic release, your surgeon will make two smaller incisions at your wrist. Through one incision, an endoscope or small surgical camera is placed into your wrist. Through the second incision, a surgical tool is used to release the ligament. Both surgeries have similar recovery times, getting you back to your desired activities in two to six weeks. Depending on the severity of the damage to your nerve, it can take up to a year before you reach maximum recovery of sensation in your hand. Even after surgery, sometimes full sensation never returns, which is why it is important to be evaluated sooner rather than later.
After this procedure, stitches are used to close your incision or incisions and it is covered with a bulky bandage. Typically, you can remove the bandaging 24-48 hours after surgery and are allowed to bathe, however, the hand should not be soaked in water. Your stitches will be removed 10-14 days after surgery when you meet with a Physician Assistant or your surgeon to review what was found during your surgery. At that time, you are able to use the hand as tolerated, though the incision may be sore for up to a few months. Your surgeon will tell your family exactly what your restrictions are after surgery.
Cubital Tunnel Syndrome and Ulnar Nerve Release and Transposition
The ulnar nerve runs on the inside of the elbow; when you think you have hit your “funny bone”, you are actually hitting your ulnar nerve. The nerve provides sensation to your little finger and half of your ring finger. This nerve can become pinched in the elbow, particularly when you bend your elbow. Occasionally the ulnar nerve can snap over the bone on the inside of your elbow (medial epicondyle) which causes pain and numbness in your little finger and ring finger. When this happens it is called cubital tunnel syndrome.
A cubital tunnel release is an outpatient procedure that is done with a general anesthetic in conjunction with a nerve block. This helps provides initial pain relief after your surgery. Your surgeon will create an incision along the inside of your elbow to allow them to view the muscles, blood vessels and nerve in the arm. They will separate the muscle and soft tissue until they reach the nerve, at which point they will release the structures pinching it—typically bands of soft tissue. This allows the nerve to glide freely in the arm and relieves the pain. Often times, your surgeon will also reposition or move the nerve to the top side of the medial epicondyle. This creates less stress on the nerve when your elbow is bent. After the surgery, your surgeon will close the incision with stitches, place a bulky dressing over the area and your arm will be placed in a sling. Typically, you can remove the bandaging in 24-48 hours after surgery and can shower at that point. The stitches are removed about 10-14 days after surgery when you will meet with a Physician Assistant or your surgeon to review what was found during surgery. You are able to use the arm as tolerated after that point, but the incision may be sore for up to a few months. Your surgeon will tell your family exactly what your restrictions are after surgery.
Radial Tunnel Syndrome and Release
The radial nerve runs on the top side of the forearm under the muscles. The nerve helps to extend the wrist and bring your hand back. This nerve provides sensation to the back side of your hand. There are a variety of reasons why this nerve can become pinched in the muscles of the forearm. This can cause pain in the forearm and loss of sensation on the backside of your hand.
A radial tunnel release is an outpatient procedure that is done with a general anesthetic in conjunction with a nerve block. This helps provides initial pain relief after your surgery. Your surgeon will create an incision on the forearm near the elbow to view the muscles in the arm. They will separate the muscles until they reach the nerve, at which point they will release the structures pinching it; typically bands of soft tissue. This allows the nerve to glide freely in the arm and relieves pain. After the surgery, your surgeon will close the incision with stitches and place a bulky dressing over the area. Typically you can remove the bandaging 24-48 hours after surgery and can shower at that point. The stitches are removed about 10-14 days after surgery when you will meet with a Physician Assistant or your surgeon to review what was found during surgery. You are able to use the arm as tolerated after that point, but the incision may be sore for up to a few months. Your surgeon will tell your family exactly what your restrictions are after surgery.
Tarsal Tunnel Syndrome and Tarsal Tunnel Release
The tibial nerve runs down the inside of your ankle and provides sensation to the bottom of the foot. This nerve can become compressed by soft tissue bands or anatomical variants. When you suffer from tarsal tunnel, you can experience numbness, tingling, pain, and/or burning on the undersurface of your foot.
A tarsal tunnel release is an outpatient procedure that is done with a general anesthetic in conjunction with a nerve block. This helps provide initial pain relief after your surgery. Your surgeon will start with an incision on the inside of your ankle to locate the nerve. Once it is spotted, they will release the nerve from any soft tissue or anatomical variant that is compressing it. Once the surgery is completed, the incision will be sewn up and a bulky dressing with be applied.
After this procedure, you will be placed in a CAM boot and will use crutches, not placing any weight on the ankle. When you go for your first post-operative visit, your stitches will be removed and you will discuss with a Physician Assistant or surgeon beginning to bear weight on your ankle again. Typically patients are back to their everyday activities in a few weeks, but it can take up to a year to fully recover, as the nerve heals very gradually. Your surgeon will tell your family exactly what your restrictions are after surgery.