Carpal Tunnel Surgery
How much does carpal tunnel surgery cost?
What is carpal tunnel syndrome?
Carpal tunnel syndrome is the compression of the median nerve as it passes into the hand. The median nerve is located on the palm side of your hand (also called the carpal tunnel). The median nerve provides sensation (ability to feel) to your thumb, index finger, long finger, and part of the ring finger. It supplies the impulse to the muscle going to the thumb. Carpal tunnel syndrome can occur in one or both of your hands.
Swelling inside your wrist causes the compression in carpal tunnel syndrome. It can lead to numbness, weakness, and tingling on the side of your hand near the thumb.
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What is Carpal tunnel release surgery?
Carpal tunnel release surgery is an operation to relieve symptoms of carpal tunnel syndrome (CTS). These can include numbness, tingling and pain in your hand. The operation involves dividing a ligament in your wrist to relieve pressure on a nerve that controls movement and feeling.
Carpal tunnel release surgery (carpal tunnel decompression) involves cutting your carpal ligament. This ligament is connected to bones in your wrist to form the carpal tunnel. Several tendons and your median nerve run through this tunnel to your fingers. If pressure builds up in the carpal tunnel, your median nerve can’t work properly and causes tingling, numbness or pain. Dividing the carpal ligament releases the pressure and eases your symptoms.
General information about Carpal tunnel release surgery
The following table describes general information about Carpal tunnel release surgery including Carpal tunnel release surgery cost in Iran, recovery time, and to name but a few.
| General Information | |
| Cost | Starts from $ 400 |
| Anesthesia | General/Local |
| Hospital Stay | The same day |
| Back to Work | 2 Weeks |
| Duration of Operation | 20 Minutes |
| Minimum Stay in Iran | 3 Days |
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About Iranian Surgery
Iranian surgery is an online medical tourism platform where you can find the best Surgeons and hospitals to treat your carpal tunnel syndrome in Iran. The price of Carpal Tunnel Release Surgery in Iran can vary according to each individual’s case and will be determined by the type of surgery you undergo and an in-person assessment with the doctor. So if you are looking for the cost of Carpal Tunnel Release Surgery in Iran, you can contact us and get free consultation from Iranian surgery.
Before Carpal Tunnel Release Surgery
Symptoms of carpal tunnel syndrome
Symptoms of carpal tunnel syndrome include:
. Pain in your hand and wrist, which may spread to your forearm, your upper arm and your shoulder.
. Numb hands
. A tingling sensation
. Weakness
Your carpal tunnel syndrome symptoms may feel better if you shake your wrist or change its position.
Both hands can be affected by carpal tunnel syndrome. Your hand will look normal, so you can’t see any physical signs. You’re most likely to feel symptoms in your hands, thumb and fingers. At first, your symptoms may be mild but they may gradually get worse. And they might come and go. You can get symptoms at any time but carpal tunnel syndrome is often worse at night and may wake you up.
The weakness associated with carpal tunnel syndrome usually affects movements that involve your thumb, so you may find it difficult to grip things. Over time, your hand muscles can get weaker. And if your carpal tunnel syndrome is really serious, your thumb muscles may start to waste away, or your median nerve may be permanently damaged. But this doesn’t happen often – ask your doctor for more information.
If you have any of these symptoms, contact your GP for advice.
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Causes of carpal tunnel syndrome
Carpal tunnel syndrome is caused by pressure on the median nerve.
The median nerve runs from your forearm through a passageway in your wrist (carpal tunnel) to your hand. It provides sensation to the palm side of your thumb and fingers, except the little finger. It also provides nerve signals to move the muscles around the base of your thumb (motor function).
Anything that squeezes or irritates the median nerve in the carpal tunnel space may lead to carpal tunnel syndrome. A wrist fracture can narrow the carpal tunnel and irritate the nerve, as can the swelling and inflammation caused by rheumatoid arthritis.
Many times, there is no single cause of carpal tunnel syndrome. It may be that a combination of risk factors contributes to the development of the condition.
Risk factors
A number of factors have been associated with carpal tunnel syndrome. Although they may not directly cause carpal tunnel syndrome, they may increase the risk of irritation or damage to the median nerve. These include:
. Anatomic factors. A wrist fracture or dislocation, or arthritis that deforms the small bones in the wrist, can alter the space within the carpal tunnel and put pressure on the median nerve.
People who have smaller carpal tunnels may be more likely to have carpal tunnel syndrome.
. Sex. Carpal tunnel syndrome is generally more common in women. This may be because the carpal tunnel area is relatively smaller in women than in men.
Women who have carpal tunnel syndrome may also have smaller carpal tunnels than women who don’t have the condition.
. Nerve-damaging conditions. Some chronic illnesses, such as diabetes, increase your risk of nerve damage, including damage to your median nerve.
. Inflammatory conditions. Rheumatoid arthritis and other conditions that have an inflammatory component can affect the lining around the tendons in your wrist and put pressure on your median nerve.
. Medications. Some studies have shown a link between carpal tunnel syndrome and the use of anastrozole (Arimidex), a drug used to treat breast cancer.
. Obesity. Being obese is a risk factor for carpal tunnel syndrome.
. Body fluid changes. Fluid retention may increase the pressure within your carpal tunnel, irritating the median nerve. This is common during pregnancy and menopause. Carpal tunnel syndrome associated with pregnancy generally gets better on its own after pregnancy.
. Other medical conditions. Certain conditions, such as menopause, thyroid disorders, kidney failure and lymphedema, may increase your chances of carpal tunnel syndrome.
. Workplace factors. Working with vibrating tools or on an assembly line that requires prolonged or repetitive flexing of the wrist may create harmful pressure on the median nerve or worsen existing nerve damage, especially if the work is done in a cold environment.
However, the scientific evidence is conflicting and these factors haven’t been established work as direct causes of carpal tunnel syndrome.
Several studies have evaluated whether there is an association between computer use and carpal tunnel syndrome. Some evidence suggests that it is mouse use, and not the use of a keyboard, that may be the problem. However, there has not been enough quality and consistent evidence to support extensive computer use as a risk factor for carpal tunnel syndrome, although it may cause a different form of hand pain.
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Diagnosis
Your doctor may ask you questions and conduct one or more of the following tests to determine whether you have carpal tunnel syndrome:
. History of symptoms. Your doctor will review the pattern of your symptoms. For example, because the median nerve doesn’t provide sensation to your little finger, symptoms in that finger may indicate a problem other than carpal tunnel syndrome.
Carpal tunnel syndrome symptoms usually occur while holding a phone or a newspaper or gripping a steering wheel. They also tend to occur at night and may wake you during the night, or you may notice the numbness when you wake up in the morning.
. Physical examination. Your doctor will conduct a physical examination. He or she will test the feeling in your fingers and the strength of the muscles in your hand.
Bending the wrist, tapping on the nerve or simply pressing on the nerve can trigger symptoms in many people.
. X-ray. Some doctors recommend an X-ray of the affected wrist to exclude other causes of wrist pain, such as arthritis or a fracture. However, X-rays are not helpful in making a diagnosis of carpal tunnel syndrome.
. Electromyography. This test measures the tiny electrical discharges produced in muscles. During this test, your doctor inserts a thin-needle electrode into specific muscles to evaluate the electrical activity when muscles contract and rest. This test can identify damage to the muscles controlled by the median nerve, and also may rule out other conditions.
. Nerve conduction study. In a variation of electromyography, two electrodes are taped to your skin. A small shock is passed through the median nerve to see if electrical impulses are slowed in the carpal tunnel. This test may be used to diagnose your condition and rule out other conditions.
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Prevention
There are no proven strategies to prevent carpal tunnel syndrome, but you can minimize stress on your hands and wrists with these methods:
. Reduce your force and relax your grip. If your work involves a cash register or keyboard, for instance, hit the keys softly. For prolonged handwriting, use a big pen with an oversized, soft grip adapter and free-flowing ink.
. Take short, frequent breaks. Gently stretch and bend hands and wrists periodically. Alternate tasks when possible. This is especially important if you use equipment that vibrates or that requires you to exert a great amount of force. Even a few minutes each hour can make a difference.
. Watch your form. Avoid bending your wrist all the way up or down. A relaxed middle position is best. Keep your keyboard at elbow height or slightly lower.
. Improve your posture. Incorrect posture rolls shoulders forward, shortening your neck and shoulder muscles and compressing nerves in your neck. This can affect your wrists, fingers and hands, and can cause neck pain.
. Change your computer mouse. Make sure that your computer mouse is comfortable and doesn’t strain your wrist.
. Keep your hands warm. You’re more likely to develop hand pain and stiffness if you work in a cold environment. If you can’t control the temperature at work, put on fingerless gloves that keep your hands and wrists warm.
Preparing for carpal tunnel release surgery
Before your carpal tunnel release surgery, you’ll meet the surgeon carrying out your operation to discuss your care. It may be different to what’s described here, as it will be designed to meet your individual needs.
Carpal tunnel release surgery is a day-case procedure. This means you’ll have the operation and go home on the same day. There’ll be no need to pack an overnight bag or make any arrangements for being away. You won’t be able to drive immediately after your surgery, so make sure you arrange to get a lift home.
Carpal tunnel release surgery is usually done under local anaesthesia. This means you will be awake for the operation, but won’t feel anything. Make sure that you clean your hands and remove any jewellery on your wrist or fingers beforehand.
Your surgeon will discuss with you what will happen before, during and after your surgery. If you’re unsure about anything, this is your chance to ask any questions you have. If you’re happy to go ahead with the operation, you will be asked to sign a consent form. If you are taking any anticoagulant (blood thinning) medicines such as warfarin, it is important that you tell your surgeon before your surgery.
You will usually be asked not to eat or drink anything for 6 to 12 hours before the surgery.
If you’re a smoker, try to quit before to the surgery. Smoking can delay healing.
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Side-effects of carpal tunnel release surgery
Side-effects are the unwanted, but often mild and temporary problems you may expect to happen as a result of surgery. Carpal tunnel surgery can cause some side-effects. These may include:
. Pain and discomfort along the cut on your hand
. Stiffness in your hand
. Swelling – keeping your hand up should help to reduce this
. A noticeable scar that will gradually fade
. Your scar feeling tender after the operation – this usually settles down within a few months.
. Having a weaker grip than you had before surgery – this should return to normal as your hand heals.
Complications of carpal tunnel release surgery
Complications are unexpected problems that may happen during or after your treatment. As with every procedure, there is a risk of certain complications. This may include the risk of complications linked to having an allergic reaction to the anaesthetic. Outlined below are complications that are more specific to carpal tunnel release surgery. If you are unsure about any of the following complications, ask your surgeon to explain how these may apply to you.
. A tender and sensitive scar. Your scar may be tender and sensitive for a while after surgery. This is a minor complication and you may find that this sensitivity doesn’t interfere with your day-to-day activities, but for some people, it does.
. Damage to nerves in your wrist. This may cause pain and numbness, which should eventually disappear.
. Pain when putting pressure on your hand. This is called pillar pain, and may be caused by a tender, raised scar and swelling at the base of your palm. The pain may affect your grip, but should ease after three to four months.
. Bowstringing. You may notice that when you flex your wrist after the surgery, your tendons are more visible. This may cause some pain, a snapping sensation when you flex your wrist or pins and needles.
. Complex regional pain syndrome (CRPS). This rare condition can cause many symptoms, including swelling, burning pain, sensitivity to touch and changes in skin temperature and colour. Your movement may become more limited. CRPS is usually triggered by surgery or accidental damage and can usually be managed with painkillers and other medicines, as well as physiotherapy and counselling.
. Re-occurrence. Most people find their symptoms disappear after surgery, but there’s a chance that your symptoms may continue or come back. This may be because your carpal ligament wasn’t cut deeply enough to release the pressure. If this happens, you may need to have more surgery.
During Carpal Tunnel Release Surgery
Treatment
Although it is a gradual process, for most people carpal tunnel syndrome will worsen over time without some form of treatment. For this reason, it is important to be evaluated and diagnosed by your doctor early on. In the early stages, it may be possible to slow or stop the progression of the disease.
Nonsurgical Treatment
If diagnosed and treated early, the symptoms of carpal tunnel syndrome can often be relieved without surgery. If your diagnosis is uncertain or if your symptoms are mild, your doctor will recommend nonsurgical treatment first.
Nonsurgical treatments may include:
. Bracing or splinting. Wearing a brace or splint at night will keep you from bending your wrist while you sleep. Keeping your wrist in a straight or neutral position reduces pressure on the nerve in the carpal tunnel. It may also help to wear a splint during the day when doing activities that aggravate your symptoms.
. Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such as ibuprofen and naproxen can help relieve pain and inflammation.
. Activity changes. Symptoms often occur when your hand and wrist are in the same position for too long—particularly when your wrist is flexed or extended.
If your job or recreational activities aggravate your symptoms, changing or modifying these activities can help slow or stop progression of the disease. In some cases, this may involve making changes to your work site or work station.
. Nerve gliding exercises. Some patients may benefit from exercises that help the median nerve move more freely within the confines of the carpal tunnel. Specific exercises may be recommended by your doctor or therapist.
. Steroid injections. Corticosteroid, or cortisone, is a powerful anti-inflammatory agent that can be injected into the carpal tunnel. Although these injections often relieve painful symptoms or help to calm a flare up of symptoms, their effect is sometimes only temporary. A cortisone injection may also be used by your doctor to help diagnose your carpal tunnel syndrome.
Surgical Treatment
If nonsurgical treatment does not relieve your symptoms after a period of time, your doctor may recommend surgery.
The decision whether to have surgery is based on the severity of your symptoms—how much pain and numbness you are having in your hand. In long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage.
Surgical Procedure
The surgical procedure performed for carpal tunnel syndrome is called a “carpal tunnel release.” There are two different surgical techniques for doing this, but the goal of both is to relieve pressure on your median nerve by cutting the ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve.
In most cases, carpal tunnel surgery is done on an outpatient basis. The surgery can be done under general anesthesia, which puts you to sleep, or under local anesthesia, which numbs just your hand and arm. In some cases, you will also be given a light sedative through an intravenous (IV) line inserted into a vein in your arm.
. Open carpal tunnel release. In open surgery, your doctor makes a small incision in the palm of your hand and views the inside of your hand and wrist through this incision. During the procedure, your doctor will divide the transverse carpal ligament (the roof of the carpal tunnel). This increases the size of the tunnel and decreases pressure on the median nerve.
After surgery, the ligament may gradually grow back together—but there will be more space in the carpal tunnel and pressure on the median nerve will be relieved.
. Endoscopic carpal tunnel release. In endoscopic surgery, your doctor makes one or two smaller skin incisions—called portals—and uses a miniature camera—an endoscope—to see inside your hand and wrist. A special knife is used to divide the transverse carpal ligament, similar to the open carpal tunnel release procedure.
The outcomes of open surgery and endoscopic surgery are similar. There are benefits and potential risks associated with both techniques. Your doctor will talk with you about which surgical technique is best for you.
After Carpal Tunnel Release Surgery
What to expect afterwards
After a local anaesthetic, it may take several hours before the feeling comes back into your wrist and hand. Take special care not to bump or knock your hand, and be extra careful around anything hot such as kettles or radiators. You may feel tingling in your hand as the anaesthetic wears off and the feeling in your wrist and hand returns.
Carpal tunnel release surgery isn’t usually painful. But you may need pain-relief medicines such as ibuprofen or paracetamol to ease any discomfort.
Your bandage will protect and support your hand, but you will still be able to wriggle your fingers. Keeping your arm up will help to reduce any swelling. Wriggle your fingers regularly to keep your blood flowing properly, and to reduce any stiffness.
Before you go home, your nurse will give you some advice about caring for your healing wound. It’s important to keep your bandage dry after your operation. This means wearing a rubber glove or plastic bag when you have a bath or shower.
You’ll usually be able to leave the hospital when you feel ready. Before you leave, you may be given a date for a follow-up appointment. This is usually six to eight weeks after your surgery.
Recovering from carpal tunnel release surgery
Carpal tunnel surgery recovery time varies from person to person, as everyone responds to surgery differently. It’s important to take it easy at first, but moving your fingers, hand and wrist as soon as possible will help you recover more quickly.
If you need pain relief during your recovery, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information leaflet that comes with your medicine, and ask your pharmacist for advice if you have any questions.
One or two days after surgery. The cut on your hand may feel a bit sore. When you’re not using your hand, keep it up at all times. Try to get your fingers moving and use your hand for light tasks such as holding your glass or a book. You could even try using a computer keyboard, though only gently.
Three to 14 days after surgery. You can now remove the bandage, but you’ll still need to keep the wound dry until the stitches have been taken out. Try building up to activities like brushing your teeth or your hair. Keep doing this while your hand heals. If you’re feeling pain during movement, stop for a while in case you’re doing too much too soon. You need to build up gradually, so use pain as a guide for what you can and can’t do.
From two weeks after surgery. Your stitches will be removed around 10 to 14 days after your operation. If your surgeon has used dissolving stitches, these will usually disappear on their own after around two to three weeks. You’ll now be able to get your wound wet, which will make it easier for you to have a bath or shower.
When your stitches are removed, you may notice your scar is:
. Firm
. Tender
. Lumpy
. Pink
It’s normal for your scar to feel tender after the operation, but this usually settles down within a few months. Massaging your scar and the area around it with a simple cream such as E45 can help to make it feel less tender. Your scar should begin to look better after around three months.
You may find your grip is weaker than it was before your surgery. So bear in mind that gripping too hard may be painful at first – avoid doing this when you can. Your grip should return to normal between six and 12 weeks after your operation.
You may be able to return to light work after around 12 days, and your full working activities after around 19 days. But obviously this will depend on how quickly you recover from the surgery, and what your job involves. See our section: Returning to work after carpal tunnel release surgery.
Driving
After carpal tunnel release surgery, there’s no right or wrong time to return to driving.
Before you drive, you should:
. Have fully recovered from the local anaesthetic
. Make sure any pain or discomfort isn’t affecting your concentration or movement.
. Make sure any painkillers you’re taking aren’t making you feel tired
. Make sure you can move your hand and wrist well enough to drive safely
Check that you can:
. Sit in the driving seat in a comfortable position
. Grip and control the steering wheel properly
. Perform an emergency stop
When you feel comfortable to start driving again, begin with a short journey. Perhaps try driving to the local shops with a friend or family member.
Returning to work
After your surgery, you may need to take time off from work to recover. Everyone recovers at a different speed, so speak to your surgeon and physiotherapist to discuss how and when you should go back to work. Many people find they’re ready to go back to work after around 12 days, but you might feel ready to return to work sooner. This will depend on what type of job you do and how long it takes you to recover from the surgery. Most people are able to go back to their full job after around 19 days. It’s important to be guided by how you feel.
When you return to work, you may need to take things easy at first. For example, you may have to avoid anything that puts too much strain on your hands, such as typing, using a telephone or lifting heavy items.
Carpal Tunnel release Surgery cost
How much does a Carpal Tunnel Release Surgery cost in Iran?
The cost of a Carpal Tunnel Release Surgery in Iran starts from $400. But the cost of Carpal Tunnel release surgery in other countries starts from $2000 and reach $10000.
On average, the cost of Carpal Tunnel release surgery in Iran is 190% less than its global price.
How much does Carpal Tunnel release Surgery cost in different countries?
The overall Carpal Tunnel release surgery cost in Iran vs. other countries
Carpal Tunnel release surgery cost in Iran vs. carpal tunnel release surgery in the USA
The average cost of Carpal Tunnel release surgery in Iran is 250 percent less than the cost of Carpal Tunnel release surgery in the USA.
Carpal Tunnel release surgery cost in Iran vs. carpal tunnel release surgery in the UK
The average cost of Carpal Tunnel release surgery in Iran is 280 percent less than the cost of Carpal Tunnel release surgery in the UK.
Carpal Tunnel release surgery cost in Iran vs. carpal tunnel release surgery in India
The average cost of Carpal Tunnel release surgery in Iran is 50 percent less than the cost of Carpal Tunnel release surgery in India.
Carpal Tunnel release surgery cost in Iran vs. carpal tunnel release surgery in Mexico
The average cost of Carpal Tunnel release surgery in Iran is 65 percent less than the cost of Carpal Tunnel release surgery in Mexico.
Carpal Tunnel release surgery cost in Iran vs. carpal tunnel release surgery cost in Canada
The average cost of Carpal Tunnel release surgery in Iran is 450 percent less than the cost of Carpal Tunnel release surgery in Canada.
Carpal Tunnel release surgery cost in Iran vs. carpal tunnel release surgery cost in Australia
The average cost of Carpal Tunnel release surgery in Iran is 280 percent less than the cost of Carpal Tunnel release surgery in Australia.
Carpal Tunnel release surgery cost in Iran vs. carpal tunnel release surgery cost in Turkey
The average cost of Carpal Tunnel release surgery in Iran is 70 percent less than the cost of Carpal Tunnel release Surgery in Turkey.
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18 Responses
Is it true that the average recovery time of carpal tunnel surgery is tooo long?
Your doctor will take out your stitches in 1 to 2 weeks. Your hand and wrist may feel worse than they had felt. But the pain should begin to go away. It usually takes 3 to 4 months to recover and up to 1 year before hand strength returns.
Are Weakness and Atrophy normal in carpaol tunnel surgery?
As your symptoms progress, you may discover you don’t have as much grip strength and it becomes difficult to hold objects and do tasks where you need manual dexterity. You may find yourself dropping things. You may feel you are becoming clumsy; while this may be due to weakness and numbness, it also because the nerves can’t maintain a sense of where your hand is in space, which is known as proprioception.
Nerves have three primary functions: sending messages to the brain about pain and sensations and sending messages from the brain to contract muscles.
When carpal tunnel syndrome is severe, messages sent from the brain to the small muscles in the palm of the hand can be interrupted, causing the muscles at the base of the thumb to atrophy (weaken). You can see this shrinkage in the muscle when you compare the meaty part of your palm on one hand with that on the other hand. It is considered a late finding of the most severe cases of carpal tunnel syndrome. When muscle atrophy is present, recovery tends to be partial, even when surgical treatment is pursued
WHAT EXACTLY IS CARPAL TUNNEL SYNDROME?
Carpal tunnel syndrome is a common cause of hand and finger pain. It often causes numbness and tingling. It is caused by pressure on the median nerve as it passes through a space in the wrist known as the carpal tunnel.
HI,dear docor a I have a lot of pain,Does massage help carpal tunnel?
Massage therapy for carpal tunnel is the most non-invasive, cost-efficient and highly beneficial long-term treatment for Carpal Tunnel Syndrome. Massage therapy can address the inflammation, pain and numbness by softening and lengthening the muscles and fascia of the neck, shoulder, upper arm, elbow, forearm, wrist and hand.
How is Carpal Tunnel Syndrome Diagnosed?
Before surgery, you will need a definitive diagnosis of carpal tunnel syndrome. There are several ways to test this situation. These are three very common tests:
Compression Test
As your wrist is pressed, more pressure is applied to the media nerve. If this condition causes symptoms, then you have Carpal Tunnel Syndrome.
Falun Test
In this test, the wrist is pressed for about a minute to produce signs and symptoms.
Tinel test
In this test, your doctor will put a blow into your wrist that is above the carpal tunnel. If you feel something like an electric shock, then you have carpal tunnel syndrome.
Sometimes these tests are not convincing enough. In these cases, surgeons may perform more advanced tests, including electromyography (EMG) or electroonography (ENG), both of which pass electricity through the nerve to determine whether it is really compressed.
How does carpal tunnel syndrome or carpal tunnel syndrome develop?
Carpal tunnel syndrome is a disease caused by pressure on the median nerve when passing through the carpal tunnel.
In the wrist there is a duct and a tunnel called the carpal canal or wrist tunnel. On one side of this tunnel are the wrist bones. These bones are arranged in such a way that they form an arc or crescent or a vessel.
Why is carpal tunnel worse at night?
Carpal tunnel symptoms are often worse at night. Lying down and moving very little can lead to the accumulation of fluid in the arm and hand, which puts additional pressure on the median nerve.
I have had surgery for three weeks and Is it normal to have numbness after carpal tunnel surgery?
One reason is that the transverse carpal ligament is not completely released. This complication is more common with endoscopic carpal tunnel surgery. Some people who have long-standing carpal tunnel syndrome may have persistent numbness and tingling even after carpal tunnel release surgery.
hello
Is heat good for carpal tunnel?
To help ease the symptoms of carpal tunnel syndrome, you may want to put ice on your wrist or soak it in an ice bath. Try it for 10 to 15 minutes, once or twice an hour. You can also gently shake your wrist or hang it over the side of your bed for pain that wakes you up at night.