• The median nerve is one of the major nerves of the forearm and hand. It originates from the brachial plexus in the armpit and travels through the arm, and forearm to supply the hand.
• The median nerve can also be compressed at the wrist (most commonly) and near the elbow or in the forearm. Median nerve compression is a mononeuropathy that causes motor and sensory loss majorly in the hand.

Carpal tunnel syndrome is caused when the space (the carpal tunnel) in the wrist narrows. This presses down on the median nerve and tendons (located inside the carpal tunnel), which cuts off sensation in the fingers and hand. 

Symptoms usually begin slowly and can occur at any time.

 Early symptoms include:

• Numbness at night.
• Tingling and/or pain in the fingers (especially the thumb, index, and middle fingers).

In fact, because some people sleep with their wrists curled, nighttime symptoms are common and can wake people from sleep. Shaking the hands helps relieve symptoms in the early stage of the condition.

Common daytime symptoms can include:

• Tingling in the fingers.
• Decreased feeling in the fingertips.
• Difficulty using the hand for small tasks, like:
  • Handling small objects/ utensils.
  • Writing.

As carpal tunnel syndrome worsens, symptoms become more constant. These symptoms of progression include:

• Weakness in the hand.
• Inability to perform tasks that require delicate motions (such as buttoning a shirt).
• Dropping objects.

In the most severe condition, the muscles at the base of the thumb visibly shrink in size (atrophy) or the patient develops tiny ulcers due to burns on the fingertips.

Surgery is recommended when carpal tunnel syndrome does not respond to non-surgical treatments or has already become severe. 

The goal of surgery is to increase the size of the tunnel in order to decrease the pressure on the nerves and tendons that pass through the space.

After all the pre-operative investigations and management of diabetes and hypothyroidism, surgery is planned.

Surgery is done usually in brachial plexus block or General Anesthesia.

A small incision is given about the wrist and carpal tunnel is released. The ligament that covers the carpal tunnel at the base of the palm called the transverse carpal ligament is released/ cut.

Finger movements are started once the effect of the brachial plexus block is gone or when the patient is out from in anesthesia.

• You might be in brief discomfort for about 24 to 72 hours after surgery.
• People usually experience complete night-time symptom relief quickly—even the night after surgery
• Wrist immobilization is done till sutures are removed.
• Sutures are removed after a period of 10-12 days.
• Physiotherapy post-operative is most important for hand, wrist, and fingers
• The prognosis is good if muscle atrophy has not started.
• You might be unable to do heavier activities with the affected hand for about four to six weeks. 
• There may be some pain in the palm around the incisions that can last up to a few months. 

Recovery times can vary depending on your age, general health, severity of carpal tunnel syndrome, and how long you had symptoms. You will continue to gain strength and sensation in the following year after surgery.

Surgery for carpal tunnel syndrome has a very high success rate of over 95%. Many symptoms are relieved quickly after treatment, including a tingling sensation in the hands and waking up at night.

• Numbness may take longer to be relieved, even up to three months. 
• Surgery won’t help if carpal tunnel syndrome is the wrong diagnosis.
• When the carpal tunnel syndrome has become severe, relief may not be complete.

Only a small percentage of patients do not gain substantial relief from symptoms. These are the patients who either had-

• Severe carpal tunnel syndrome had a nerve that was not completely released during surgery or did not really have carpal tunnel syndrome.
• If the patient has presented very late, prolonged nerve compression can lead to median nerve palsy.  In such cases, the muscles of the hand (base of the thumb) have atrophied, then he or she would not be able to bring out the thumb in a perpendicular direction to the palm when the hand is placed flat on the table. 
• There would be a loss of coarse movements of the hand with complete loss of sensation over the thumb, index, middle, and half of the ring finger. 
• Such a condition is also usually seen in injuries of the median nerve or in patients with leprosy.

Release of the CTS and tendon transfers should be done to strengthen the weak portions of the hand.

A strong tendon of the hand is re-routed to substitute a weaker or lost movement of the hand.

How is the tendon transfer done for median nerve palsy?

During tendon transfers for median nerve palsy, one tendon from the front of the hand is taken, re-routed, and sutured to the tendon of the outer aspect of the thumb so that the patient can abduct (bring out thumb) and also make a meaningful pinch with the other fingers so as to hold objects with the thumb and fingers (OPPONENSPLASTY)

• The surgery is usually done under brachial block or general anesthesia and a splint or slab is given for immobilization in the post-operative period. 
• The patient is usually discharged on the second day after the surgery. 
• Sutures are removed 14 days after surgery.
• The splint is removed 3 to 4 weeks after the surgery and gradual training of the transferred tendon is started so that it may regain its newly assigned function.