A Quick and Effective Carpal Tunnel Syndrome Treatment with M. Lance Tavana, MD.

A surgical procedure for carpal tunnel syndrome is now being offered at MUSC Health as a same-day treatment with little downtime and recovery. M. Lance Tavana, MD, a hand, plastic, and reconstructive surgeon at MUSC Health, talks about this surgical procedure called endoscopic carpal tunnel release and the immediate relief it brings to so many patients.

“We have made this a procedure so patients can come in, they can drive themselves, they can eat breakfast in the morning, they can come to our facility within one hour they're walking out of the door, having a procedure which takes the pressure off the nerve and alleviates their symptoms. Post-operative downtime is anywhere from a couple days to one to two weeks, as opposed to what most people think they're going to be taking a month to two months off from their activities.”
—M. Lance Tavana, MD

Topics covered in this show:

• Tavana explains what carpal tunnel syndrome is and some of the different treatments for the condition such as a steroid injection, open carpal tunnel release and endoscopic carpal tunnel release.
• The most common signs to look for are numbness, tingling in the fingers and hands. He says a telltale sign is difficulty buttoning a shirt or clamping a necklace.
• He says carpal tunnel syndrome most often affects people in their 40s and 50s, but can also impact women during and after pregnancy due to changes in hormones. Carpal tunnel syndrome can also be familial. He says wrist size and carpal tunnel size can sometimes run on a small scale across some families causing carpal tunnel syndrome.
• Tavana explains the differences between the procedures endoscopic carpal tunnel release and surgery and open carpal tunnel release. Endoscopic carpal tunnel release is performed in the procedure room by making a small incision while under local anesthetic using a small camera. Open carpal tunnel release is when the surgeon cuts open the wrist and performs the surgery.
• He discusses how endoscopic carpal tunnel release is a faster procedure and allows for people to return to work sooner. In most cases, postoperative care is one-to-two weeks versus one-to-two months like some patients may think.
• Carpal tunnel syndrome often impacts people who work with their hands such as chefs, gardeners and hairstylists. In fact, Tavana says carpal tunnel can impact any profession where the use of fine motor skills are valuable to the person’s ability to perform their jobs successfully.
• He has many patient testimonials on his website from patients who have undergone the procedure with success.

Read the show transcript below:

Erin Spain, MS [00:00:04] Welcome to Advance with MUSC Health, I'm your host, Erin Spain. This show's the mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Carpal tunnel syndrome is a condition affecting one of the main nerves and the wrist area that causes pain in the hand and arm with numbness or tingling. If left untreated, it can cause permanent damage and impact a person's career and quality of life. Here to talk about the newest innovation in treating carpal tunnel syndrome with little to no downtime is Dr. Lance Tavana, a hand, plastic and reconstructive surgeon here at MUSC health. Welcome to the show.

M. Lance Tavana, MD: [00:00:47] Thanks, Erin. Thanks for having me.

Erin Spain, MS: [00:00:48] So what's happening inside the hand and the wrist during carpal tunnel syndrome? What's going awry?

M. Lance Tavana, MD: [00:00:55] Carpal tunnel syndrome is compression of the median nerve, in which there are three main nerves that go to the arm, the radial, the ulnar and the median nerve. And the median nerve is the one that goes through your wrist, mainly to your thumb, index, middle and part of your ring finger. It's also responsible for some of the muscles in your hand that allow your thumb to move into, to come out of the plane in the hand and let you grasp things. So as that nerve travels through the wrist under what we call the transverse carpal ligament, along with all the tendons that go to your fingers, in some patients, you get increased pressure within that space, which is called the carpal tunnel. There's then compression on the median nerve. And imagine it's sort of like a electrical cable or a garden hose which is getting squeezed so that the flow through that hose or cable is impeded just by that pressure. What happens is you get tingling in the tips of the fingers, you get weakness of the hand, you get the inability to bring the thumb around in order to pinch objects.

Erin Spain, MS: [00:01:53] Who's at the greatest risk of developing it?

M. Lance Tavana, MD: [00:01:56] It affects women about three times as much as men. It significantly affects women in pregnancy. Hormonal changes can can induce it. We see it’s familial, carpal tunnel. So patients will have a smaller wrist or smaller carpal tunnel that sort of runs through the family. And you'll see parents and children having carpal tunnel. It usually doesn't show itself until you're about 40 or 50 years old. We sometimes see it in younger patients. I've seen patients as young as 20 or 22 years old with it. But that's really infrequent and I've also treated patients in their nineties with carpal tunnel so it really you know, your entire adulthood carpal tunnel could really affect you.

Erin Spain, MS: [00:02:32] So when people come to see you. What are they experiencing? What does it feel like? Why are they seeking out treatment?

M. Lance Tavana, MD: [00:02:38] The most common complaint is tingling of the fingertips, mostly in the index, middle and ring finger and the thumb and nighttime symptoms are a significant part of this. Patients wake up in the middle of the night, their hands get numb or tingly and wake them up, and they feel like they have to shake their hands out or hang them over the side of the bed for a little while until that stops and they can get back to sleep. We have patients who, when they're driving or are talking on the phone, their hand goes numb and they feel like they can't feel the phone or where they can't feel the steering wheel. We also have patients who just have a sense of weakness in their hands. They can't open jars. They can't do small, fine tasks. Some of the questions I ask my patients to sort of get a good history of their disease is do they have a difficulty buttoning the buttons on their shirt? Do they have difficulty putting on a necklace and doing the little clasp on the necklace or putting in their earrings? All of these things require the sensory part of the nerve in order for you to feel the fine motions that you need to do the activity with. But also it affects the motor aspects as well. So you need to be able to control the fingers and have the strength to do things. And both of those things are affected by carpal tunnel syndrome.

Erin Spain, MS: [00:03:42] So how do you diagnose it?

M. Lance Tavana, MD: [00:03:44] Majority of cases are diagnosed through history and physical. So for a very classic carpal tunnel syndrome where patients come in with a very straightforward case of carpal tunnel, most hand surgeons will diagnose it through physical exam and history. Any time we have either a severely advanced carpal tunnel syndrome or we have a picture that might be outside of the normal realm of the symptomatology. And what I mean by that is the patient might have neck pain or shoulder pain or have other numbness within their hand, arm or other parts of the body. We can get what's called a nerve conduction study or an EMG in which we send a patient to a neurologist to do a specific test which analyzes the nerves and the rate of transmission within the nerves. And we can get a more specific diagnosis for carpal tunnel through that test.

Erin Spain, MS: [00:04:30] So for some people, this is an inconvenience. It doesn't feel good. It might impede them during some daily tasks, but for other people, this can really impact their careers. Tell me about that.

M. Lance Tavana, MD: [00:04:43] We have a lot of patients who require the use of their hands on a fine motor aspect that if they can't feel what they're doing, they can't perform their activities. In Charleston, specifically, we have a lot of patients in the food and bev industry. A lot of chefs come to us with the inability to hold their knives correctly in order to do their job. Hairstylists have a difficulty performing the task because they can't hold the scissors correctly. A lot of people have a hard time using a keyboard for extended periods of time with carpal tunnel syndrome. So it runs the gamut through every single profession that we see. The issues with long standing carpal tunnel, if you're feeling it throughout the day, is the potential for atrophy of the hand or when the carpal tunnel syndrome starts to affect the muscles in the hand and you get permanent damage is when we really need to treat this disease.

Erin Spain, MS: [00:05:32] So how is carpal tunnel syndrome treated today?

M. Lance Tavana, MD: [00:05:34] There are several ways we treat carpal tunnel syndrome. First, conservatively, we can do that with bracing of the wrist or splinting the wrist because wrist flexion or wrist extension accentuates the pressure on the nerves in the risk of making it worse. So people who sleep at night sort of curl up in a ball and they keep their wrists flex. That could significantly contribute to carpal tunnel syndrome. So the first step is usually to try bracing at night to see if we can make the symptoms go away. Oftentimes that gets rid of the daytime symptoms, but sometimes it doesn't. And we might suggest carpal tunnel surgery, which is the release of the ligament over the nerve in the wrist, usually performed historically in the operating room. And in the past, we did this through what we call the open technique, which was about one inch incision in the palm where we went down into that ligament and and divided it. In 1990, the surgical technique was improved with the advent of endoscopic and laparoscopic surgery, where we now make a smaller, about half centimeter incision in the wrist, just proximal to the palm, and use a small camera inserted into the carpal tunnel to cut that ligament. Traditionally, that has been done in the operating room with use of anesthesia, sedation and the resources involved with that. The newest technique is now to take that out of the operating room and put it into a procedure room under local anesthetic, reducing your wait times from a couple of hours at the hospital to less than an hour at the clinic, and the total procedure times about 10 minutes.

Erin Spain, MS: [00:07:04] How surprised are your patients who require surgery when you tell them that this could just be a ten minute procedure and they could be out the door and on with their day?

M. Lance Tavana, MD: [00:07:13] So a lot of people have this idea in their head that carpal tunnel surgery is this big step they need to take with a lot of downtime. So a lot of patients are afraid to even seek advice from a surgeon regarding the condition just from the fear of having to have a surgery and recovery time and downtime. We've really by taking it out of the operating room, we have made this a procedure so patients can come in, they can drive themselves, they can eat breakfast in the morning, they can come to our facility within one hour they're walking out of the door, having a procedure which takes the pressure off the nerve and alleviates their symptoms. Post-operative downtime is anywhere from a couple days to 1 to 2 weeks, as opposed to what most people think they're going to be taking a month to two months off from their activities.

Erin Spain, MS: [00:07:57] So after the procedure, what do you tell your patients? What do they have to do for the days following the procedure? How do they care for their incision and how do they care for their wound after the surgery?

M. Lance Tavana, MD: [00:08:09] The incisions are about a half inch long in the wrist. We close it with a single stitch and some steri strips, which are basically butterfly bandages in a soft wrapper on the hand. Patients usually take that down on the first postoperative day. Some of them tend to leave it on for a couple of days, and I'm a little bit more of a commonsense surgeon. So I usually tell my patients, If it hurts, don't do it. Know your limitations. So some patients really have no pain and get back to their daily lives. Others take it a little bit more easy. So I don't put any specific restrictions on any of my patients because there's so many activities that you do throughout your life that I can't really address every single one, whether that be driving, whether that be brushing your teeth, whether that be weight lifting, whether that be going back to work. There's too many things that people do in their lives that I can't be too prescriptive in my restrictions. So I sort of tell people, you know, you got that little angel on one shoulder and you got the devil on the other shoulder. And if the angel says, don't do something, try to listen to them. But if the angels say, you know, I think we can do that, then, then go ahead and do it.

Erin Spain, MS: [00:09:14] Can you share a few stories with me? You mentioned that you have folks who are chefs, hairdressers. What has recovery been like for them and how has it changed their lives in order to have the surgery and regain function and feeling in the wrist and hands?

M. Lance Tavana, MD: [00:09:30] It varies from patient to patient. I have had a couple of chefs who have had the procedure on Friday and are back to work on Monday. Now, obviously, they still have a little bit of tenderness and pain in their palm, but chefs and people in the food and bev industry really don't want any downtime. Their income is based very directly on getting back to work. A lot of them don't have sick time. A lot of them don't have the ability to take four weeks off from work. So they're usually very surprised. At first when I tell them and some of them don't even believe me that they're going to be able to go back to work that soon. But usually I check on them, you know, a week or two weeks after surgery and they've already been back to work after a couple of days.

Erin Spain, MS: [00:10:12] Are there instances where the surgery isn't the right match for somebody, and who would that be and why?

M. Lance Tavana, MD: [00:10:18] Usually the only time I'm going to be doing these in the operating room outside of the procedure room is when it's combined with another procedure. So there are other conditions of the upper extremity that go along with carpal tunnel, which require more extensive surgical intervention, such as what we call cubital tunnel syndrome, which is entrapment of the ulnar nerve at the elbow, and that usually affects the small finger and part of the ring finger. It can happen at the same time as carpal tunnel, so that if we are surgically treating the carpal tunnel and the cubital tunnel, we usually do that in the operating room. Otherwise, for isolated carpal tunnel syndrome, there really is nothing to prevent us from treating a patient in a procedure room because it's under local anesthetic. So some of our patients who have significant reactions to anesthesia or have increased risks because of anesthesia can undergo this procedure without the risks of sedation or the risks of any of the medications which we might give to them in the operating room.

Erin Spain, MS: [00:11:25] What is the rate of recurrence? Would someone have to come back at some point and have the surgery again?

M. Lance Tavana, MD: [00:11:30] Recurrence is a possibility, but it's usually 10 to 20 years before it comes back. Recurrence rates between the old open technique as well as the endoscopic technique are about the same. The risks are the same. The overall recovery, the long term, is the same. The biggest difference is the return to work time.

Erin Spain, MS: [00:11:49] You know, you are one of the few surgeons in the country doing the surgery this way as a procedure in the way that you're doing it. What do you like about treating this condition and offering the surgery to your patients?

M. Lance Tavana, MD: [00:12:03] So by doing this procedure under local anesthetic, the patient's awake the entire time. So I'm on stage the entire time, which means I'm sitting right next to the patient. They're looking at me, I'm looking at them. They're fully aware what's going on. So it's sort of an experience that I have with the patient for every single procedure, and they can literally watch the procedure being done if they want to because it's on a large TV right in front of them. And the reports I get back from patients with how much it has changed their lives in such little time really makes it worthwhile to me. I get patients who immediately say I just slept better last night or my hand doesn't go numb while I'm doing my job anymore. So for a very minimal risk procedure with a minimal amount of time, it's quite life changing for a lot of my patients and that's really why I like doing it.

Erin Spain, MS: [00:12:57] How many of these procedures have you done now in this way?

M. Lance Tavana, MD: [00:13:00] Endoscopic carpal tunnel I've been doing since I left training in 2012 and rough estimates of the procedure itself in the operating room and out of the operating room somewhere between two and 3000. This new way in the procedure room under local anesthetic, I'm doing about 20 to 30 a month at this point. So I've been doing it for a good 6 to 12 months. So we're probably already in the hundreds at this point.

Erin Spain, MS: [00:13:27] People may have seen videos of some of your patients on YouTube or Facebook. You've created some videos with patient testimonials about this procedure. Tell me about those videos and how impactful they are and why why produce them?

M. Lance Tavana, MD: [00:13:45] I feel the patient experience is something that can't be translated just by static images or descriptions. I feel like hearing patients stories and people's stories rather, and how it affects their lives both prior to the procedure and after the procedure, really can give somebody a sense of a how easy and simple the process is compared to what they might think it is, as well as how much of a difference in their lives it has made after the procedure when it comes down to it medicines about people. There's all this technology and all the science behind it, and every day new things are happening in medicine. But it really comes down to treating people, being able to see somebody else tell their story. I think it gives people a much better idea of what we're doing and what's available to them.

Erin Spain, MS: [00:14:36] How hopeful are you that other surgeries can soon be done as procedures as well for other conditions affecting the hands or other extremities?

M. Lance Tavana, MD: [00:14:45] Very helpful. The major driving hand surgery these days, and it's really been driven by the Canadian surgeons, is to bring a lot of the procedures out of the operating room and perform them under local anesthetic in a procedure room. The availability of operating rooms in Canada is significantly restricted in comparison to the United States. So the Canadians have really been the vanguard in developing local only procedures that are slowly being accepted by hand surgeons in the United States. And we're starting to do more and more procedures in a procedure room such as trigger finger or ganglion cyst surgeries. And even some fracture care has been now being done in procedure rooms under local anesthetic.

Erin Spain, MS: [00:15:29] What would you say to someone who might still be hesitant? They're still a little worried about coming to get the procedure.

M. Lance Tavana, MD: [00:15:35] The initial consultation with us is really just to get more information and to discuss their symptoms and to get a better idea of where on that course of carpal tunnel syndrome they are. If it's a mild case or they only have symptoms every now and then, we might not prescribe surgical treatment and try different therapies, such as bracing at night or hand therapy or even a steroid injection. That being said, in cases where we feel that surgical intervention is warranted, we've made it to the point where it doesn't impact your life as much as it used to. We're able to get patients in and out a lot easier and with limited downtime. So that fear of having a large surgery and that fear of having your wrist wrapped up for a month is just no longer evident. So trying to make carpal tunnel syndrome a minor condition as opposed to a major condition in the eyes of the patient is really what we're trying to do. And it's something that is easily and safely treated.

Erin Spain, MS: [00:16:35] What do you do to optimize your health and live well?

M. Lance Tavana, MD: [00:16:38] It's a matter of work hard, play hard in regards to overall stress levels and anxiety. So I am somebody who dedicates myself to my work when I'm at work 100%. But at the same time, once I'm away from work, I dedicate myself to those things that I enjoy in my life. I try not to bring my work home and I try to reduce the amount of anxiety and stress in my life by focusing on my family, my activities, specifically cooking and cuisine, which is why I sort of relate to all the food and bev people in Charleston. And I feel by it just by reducing that stress and anxiety, my health is that much better.

Erin Spain, MS: [00:17:22] For more information on this podcast, check out advance.muschealth.org.