Gabby Cinnamon (Host): Welcome back to the Well Within Reach podcast. I'm your host, Gabby Cinnamon, and today I'm very excited to be joined by Dr. Jonathan Cotton, an Orthopedic Surgeon at Riverside, to talk about in-office carpal tunnel procedures. Thank you so much for coming on the podcast today, Dr. Cotton.

Jonathan Cotton, MD: Thank you for having me.

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Host: So before we get into the episode, can you tell us a little about yourself, your training, specialty, all that?

Jonathan Cotton, MD: Sure. So I'm an Orthopedic Surgeon and um, originally from Omaha, Nebraska, and I've been at Riverside for six years now. And in terms of my training, I did my medical school in Nebraska where I'm from. And then my residency was in Kansas in orthopedic surgery. I do have additional training in sports medicine. However, a lot of my actual practice would be considered general orthopedics, where I do a lot of different things, which I really enjoy the variety.

Host: Awesome, well we're excited to talk to you today. Before we get into the actual procedure, can you talk about what carpal tunnel syndrome is and kind of what can casue that?

Jonathan Cotton, MD: Sure. So carpal tunnel syndrome, it is a syndrome, which means, you know, it's not a disease where you can take a biopsy and really prove someone has it. It's a constellation of symptoms and signs and that includes numbness and tingling in the hand in a specific set of fingers that includes the thumb, index, long finger, and part of the ring and patients who have carpal tunnel syndrome, that numbness and tingling can also be burning. Tends to occur oftentimes at night. It wakes people up often, which really drives them crazy and why they tend to come and see me. However, a lot of patients can get symptoms from repetitive activities, so certain occupations, even trauma can sometimes cause carpal tunnel syndrome, and the symptoms for carpal tunnel can be relatively mild.

Most people have found their hand to go numb intermittently, whether it's holding a newspaper or a tablet or driving, but some people, if it's more persistent and really affecting their quality of life, usually start to seek treatment for that.

Host: I guess, yeah, kind of what I would think of carpal tunnel, I'd think of people who sit at a keyboard all day, but there are other things, like you said, that can cause it too. So it's kind of good to be aware of that.

Can you kind of talk about the activities that someone might be doing that might increase their risk for carpal tunnel? I mentioned the keyboard, but I'm sure there are other things too, that maybe listeners can be aware of?

Jonathan Cotton, MD: Yeah, I think, you know, historically a lot of people do think about like what you said, where someone who's having to do the same task over and over again, we think that that sort of repetitive motion can irritate the median nerve because the median nerve lies deep in the wrist next to some flexor tendons.

And if those tendons are constantly, rubbing in that area, we think that can cause some compression and swelling in there. However, really, anybody can get this. You can be completely sedentary and have carpal tunnel syndrome. So we don't always really know what does cause it, but we do know anybody can have it.

However, again, certain occupations, certain diseases um, folks tend to have more carpal tunnel syndrome. A lot of ladies will get carpal tunnel syndrome during pregnancy because they retain fluid and that fluid also includes the carpal tunnel. So it really can affect a wide range of people. And you know, it's not that we would tell someone, Oh, don't go into a career where you're going to have to do repetitive activity, because that doesn't mean you'll get carpal tunnel syndrome.

I think that's just something we always kind of think about.

Host: So if someone, you know, maybe is going to be involved in a career like typing or something else where they're going to be doing a lot of repetitive activities, like you said, is there anything that they can do to prevent this from happening?

Or is it kind of just like, it happens to some people, it happens to not others?

Jonathan Cotton, MD: I think probably the latter statement is more correct than the former. There's really not a lot of prevention for carpal tunnel syndrome. I mean, there are people who throughout history probably had to work these terrible repetitive jobs cause it was the only option and there was no workman's comp back then and they didn't get carpal tunnel.

But no, there's really not anything you can do. I mean, we've looked at different like ergonomics as maybe playing an important role. There's so many things available on Amazon to mess around with the height of your keyboard and your mouse and all these crazy keyboards were developed, but it never really was shown to make a big difference.

But I think the nice thing is, you know, the surgery to relieve carpal tunnel syndrome has gotten so much better now that I think a lot of patients are not having to suffer as much and they're not as scared about the procedure, which is nice.

Host: Good to know. So can carpal tunnel go away on its own, or does it always require surgery?

Jonathan Cotton, MD: It definitely does does not always require surgery. I have a lot of patients that will have carpal tunnel at one point in their life, and it gets better, and they can live with it, and then sometimes years later it will come back. So, most patients who do have it, they will try to live with it for a while before they decide like, okay, this, this is not getting better.

It's getting progressively worse. So it definitely can come and go. And again, some of that is related to activities. So by no means, if you have carpal tunnel once, are you guaranteed to have it for the rest of your life. And it doesn't mean there's a mandatory need for surgery or, invasive treatment.

Host: Before we get into our next question, we're going to take a quick break to talk about primary care at Riverside. Riverside knows that health is your greatest asset, and having a primary care provider you trust is important to maintaining your overall health and well being. Don't have a primary care provider or looking for a new one? Great news, Riverside has a team of primary care providers accepting new patients. To find a primary care provider at Riverside, visit riversidehealthcare.org/primary care.

Now back to our episode with Dr. Cotton. So we're here today because you perform in-office carpal tunnel surgery at Riverside's Orthopedic and Spine Center here in Bourbonet. Can you kind of explain what that procedure entails?

Jonathan Cotton, MD: Yes, so just to kind of start off about the minimally invasive in office procedure. So, you know, normal carpal tunnel surgery, we have to make an incision on the wrist and you have to be sort of at the hospital, put to sleep for that.

And then, the surgery itself, although technically quite easy, there is a decent amount of recovery that occurs just because the location of the incision is fairly inconvenient just with normal activities, having to take care of yourself. You have to be careful with water and so washing your hands can be difficult. Self-care is difficult. For me, having to empty the dishwasher could be difficult at home. So, that was something that, you know, prompted me to kind of learn about this new procedure called Sonex, which is the in-office carpal tunnel procedure. One of the reasons I looked into this Sonex procedure was when I learned about it, it did seem like a minimally invasive option that kind of reminded me a lot of what I was trained in sports medicine, just like how we used to do open rotator cuff repair and big open knee surgeries. Now everything is done arthroscopically. This struck me as a minimally invasive procedure for patients that could really be something that could enhance people's recovery, shorten their need for pain medication and things like that. So what the procedure actually is, is we use ultrasound both for the diagnosis and the treatment.

And historically to diagnose carpal tunnel syndrome, you'd have to have an EMG, which is a study where they actually put needles into different muscles and then they shock you and they look for slowing of basically the nerves. Now that sounds kind of like torture to me. But unfortunately that was the only option.

But with the ultrasound machine we can now measure your median nerve in the office. It takes about 10 minutes. And if that nerve is enlarged from being compressed, that supports the diagnosis in conjunction with our history and our exam. So, that definitely is a nice thing for the patients just to not have to have that EMG, which is something that can take months to get done and it's painful.

And it really is not a very good test because it's dependent on like the patient's skin temperature. The providers who do it can do it differently. So it's just very convenient to have it in the office and have it take five minutes. So once we have the diagnosis, the procedure with the in-office carpal tunnel called Sonex is essentially basically making a small incision on the wrist with just local anesthetic. The device we introduce into the carpal tunnel, using the ultrasound we make sure that the anatomy is favorable and everything is safe. And then this device has a very small knife blade that actually cuts that ligament that's constricting the nerve from the undersurface. And what that does is it opens up the space in that carpal tunnel and now that nerve is not being compressed. And the nice thing is that the whole procedure takes about 20 minutes for a single wrist.

You don't need any pain medication afterwards. You can drive yourself home. You just have a bandage that you wear for two weeks. And sometimes we've had manual laborers go back to their job at three days.

Host: Oh my gosh, wow. That's amazing. Sounds a lot better than the um, shocking that you had talked about there. What are some of the risks associated with in-office carpal tunnel surgery?

Jonathan Cotton, MD: It's a relatively low risk procedure. Again, the nice thing is we're not exposing a patient to an anesthetic. They don't need to have an IV. They don't need to have pain medications. And those are all things that can introduce increased risk.

With the procedure, we do use the ultrasound to make sure that we're not going to damage any surrounding structures, including the nerve or tendons or arteries. So it is very, very safe. We do make a small incision, and anytime there's any incision or any sort of a cut, you do worry about an infection.

But because it is so small the risk of infection is extremely low. So, some patients who typically I would not have offered an open carpal tunnel surgery to because they have uncontrolled diabetes or other medical issues, like lots of blood thinners, we can do this procedure because it is so much safer. So, it is a very low risk procedure. And knock on wood, we've not had really, so far any complications.

Host: Oh, that's amazing. And that kind of, I guess, gets to my next question. So are there certain criteria that a patient has to meet to qualify for in, off in-office, carpal tunnel surgery? Is there maybe a time where someone might have to have a traditional surgery instead of the Sonex procedure

Jonathan Cotton, MD: Yeah, that's a good question. Sometimes patients also have another nerve compression syndrome called cubital tunnel, which is compression of the ulnar nerve at the elbow. And that procedure currently we only are able to do in the operating room making a formal incision. However, the company that makes this current device for the Sonex carpal tunnel is working on a device for the elbow. So that might be a situation where it is better to have someone be taken to the operating room if they have other procedures that need to be performed at the same time.

Host: You talked about being able to get back to regular activities and even work relatively quickly after this procedure. Can you just kind of talk about the recovery process, what people can expect, maybe that day and in the days after the procedure?

Jonathan Cotton, MD: Definitely. So, I think it's best to discuss that in context of what an open carpal tunnel and the hospital would be like. So with open carpal tunnel, usually it takes about two to three weeks for that skin to heal.

You have to keep it very clean, very dry, limited use of your hand during that time. And then once the incision is healed, grip strength returns in about six weeks. But with the in-office procedure, the incision heals very quickly. We tell patients that they can take their bandages off after 24 to 48 hours.

They can get their hand and wrist wet at that time. And then we have let patients go back to again, manual labor at three days. I do remind the patients that we still are releasing tissue and that there can be some pain, but they really can't cause any damage to the surgery.

And that's what makes it so attractive, especially for laborers who really cannot take off much time. They get the procedure, they recover over the weekend and they can go back to work.

Host: Oh, that's amazing. So maybe, you know, if someone's listening, and they think that, hey, this might be a great option for me, what should they do, what should be their next steps, and how can they schedule an appointment to get this procedure done?

Jonathan Cotton, MD: Well, it's very straightforward. It's really quite easy to get in to see someone like me at Riverside, just cause we really work hard on providing access. Sometimes patients do require a referral depending on their insurance, but if they request to be seen for in-office carpal tunnel, our front desk and our staff are really good at making sure we get the patients to the right providers, which includes myself and Dr. Crawford for this procedure.

Host: Awesome. Is there anything else you would like to add before we go?

Jonathan Cotton, MD: You know I would just say one of the early success stories when I first started doing this, you know I was sort of drinking the Kool Aid with the company thinking that it was going to be, the world's best procedure. And I didn't know until I had my first probably 20 patients under my belt that it was going to work great and what I found was that patients were taking pictures of their incisions at day three and they were so happy.

And I had one patient who had the surgery on Friday and went out and golfed on Saturday. And he said it was the best golf he'd ever had because he could finally feel the golf club. So what's really nice with the procedure is, the standard surgery, the recovery is quite long. There's a lot of pain. With this procedure, the numbness and tingling gets better almost immediately. And because there's such little pain to worry about, they're just very satisfied very early.

Host: I think that's a great place to end off on. Thank you so much for coming on the podcast today, Dr. Cotton.

Jonathan Cotton, MD: Thanks for having me.

Host: And, thank you listeners for tuning in to Well Within Reach brought to you by Riverside Healthcare. To learn more about in-office carpal tunnel surgery and orthopedics at Riverside, visit riversidehealthcare.org. Also, make sure to rate and leave a review for Well Within Reach on Apple, Spotify, or wherever you listen to podcasts.