The indications for surgery for carpal tunnel would be: thenar atrophy - meaning if a patient comes in with atrophy of these muscles here *Demonstrates* - the thenar muscles (the intrinsic, small muscles of the thumb.) If these muscles are atrophied, that's a classic sign of severe carpal tunnel syndrome along with numbness and tingling in the thumb, index, middle, and this half of the ring finger. If a patient presents that way, that would be an indication for surgery. The problem is that once you get to that level of severe carpal tunnel syndrome, the changes to the nerve and the effects to the nerve can be permanent. Even if we do the surgery, there's no guarantee that the symptoms will improve. Generally, when a patient presents with thenar atrophy, I tell the patient that my goal is to hopefully help with the numbness and tingling and maybe the thenar atrophy can improve, but in my experience it generally does not get better but the numbness and tingling can get better. I also tell them that it's possible that the symptoms that they have might just not get worse - meaning that the surgery is to help it from progressing rather than actually making it better. Although obviously I'm always hopeful that it's going to make it better, but that's in cases of severe carpal tunnel syndrome. Moderate carpal tunnel syndrome, which would be the most common where patients don't have thenar atrophy, they just have numbness and tingling - generally the surgical indication for that would be failure of conservative management. I would start with a splint, activity modification, and a cortisone injection. If it's not helpful, then I would offer surgery for their carpal tunnel syndrome.
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