Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods

Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome

While developments continue in the surgical management of carpal tunnel syndrome, little emphasis has been placed on the evaluation of a comprehensive non-surgical treatment. In this study, 197 patients (240 hands) presenting for treatment of carpal tunnel syndrome were divided into two groups. Patients in both groups were treated by standard conservative methods, and those in one group were also treated with a program of nerve and tendon gliding exercises. Of those who did not perform the nerve and tendon gliding exercises, 71.2% underwent surgery compared with only 43.0% of patients who did perform them. Patients in the experimental group who did not undergo surgery were interviewed at an average follow-up time of 23 months (range, 14-38 months). Of these 53 patients, 47 (89%) responded to this detailed interview. Of the 47 who responded, 70.2% reported good or excellent results, 19.2% remained symptomatic, and 10.6% were non-compliant. Thus, a significant number of patients who would otherwise have undergone surgery for failure of traditional conservative treatment were spared the surgical morbidity of a carpal tunnel release (p = 0.0001).

The results of revision carpal tunnel release following previous open versus endoscopic surgery

This study compared the outcomes of revision open carpal tunnel release following previous open versus endoscopic release to determine whether revision surgery has different results based on the type of initial surgical treatment. Thirty revision carpal tunnel releases were performed in 13 wrists that had previous endoscopic release and in 17 wrists with prior open release. At a follow-up visit an average of 30 months after surgery, self-assessment questionnaires demonstrated improved or complete symptom relief in 77% of the postendoscopic release group versus 47% in the previous open release group. Combining both groups, 18% of workers' compensation patients improved after revision surgery compared with 84% of those with conventional insurance (p < .05). Patients having persistent or recurrent symptoms following a previous endoscopic carpal tunnel release have a greater chance of symptom improvement or resolution compared with patients who had previous open carpal tunnel surgery. Our results support the observation that a higher incidence of incomplete release of the carpal tunnel is found with endoscopic surgery than with open release.

Maine Carpal Tunnel Study: outcomes of operative and nonoperative therapy for carpal tunnel syndrome in a community-based cohort

A prospective, community-based, observational study of the outcome of surgical and nonoperative management was conducted. The study included 429 patients with carpal tunnel syndrome recruited in physicians' offices throughout Maine. Patients were assessed at baseline and at 6, 18, and 30 months following presentation using validated scales that measured symptom severity, functional status, and satisfaction. Seventy-seven percent of eligible survivors from the original cohort were monitored for 30 months. Surgically treated patients demonstrated improvements of 1.2 to 1.6 points on the 5-point Symptom Severity and Functional Status scales (23% to 45% improvement in scores), which persisted over the 30-month follow-up period. The nonoperatively managed patients showed little change in clinical status at 6, 18, and 30 months. While workers' compensation recipients had worse outcomes than nonrecipients, 36 of 68 (53%) workers' compensation recipients were completely or very satisfied with the results of the procedure 30 months after surgery. There were no significant differences in outcome between patients treated with endoscopic versus open carpal tunnel release. Among worker's compensation recipients, 12 of 68 (18%) surgical patients and 4 of 32 (13%) nonoperatively treated patients remained out of work because of carpal tunnel syndrome at 30 months. Thus, carpal tunnel surgery offered excellent symptom relief and functional improvement in this prospective community-based sample, irrespective of the surgical approach, even in workers' compensation recipients. Work absence remained high in both surgically and nonoperatively managed workers' compensation recipients.

Open Carpal Tunnel Release: Comparison of a Long Versus Short Incision

VL Kruger, MTM Rebot. Open carpal tunnel release: Comparison of a long versus short incision. Can J Plast Surg 1998;6(2):89-92.

A total of 225 adults with carpal tunnel release of 313 wrists were studied to compare the outcome of a long (at least 3.5 cm) with that of a short (2.0 cm or less) incision technique. The two groups were compared for postoperative complaints, length of time until full function was regained, rate of referral to rehabilitation and the effect of Workers’ Compensation status. The surgical technique and rehabilitation protocol are described. The number and severity of postoperative complaints were significantly reduced in the short incision group. In the non-Workers’ Compensation group, 96% of short incision patients resumed full function within 28 days. This finding compares favourably with published results for endoscopic release, and is superior to results obtained with the long incision. Workers’ Compensation patients required longer to recuperate, with 78% regaining full function within 28 days. of those with Workers’ Compensation, 47% of the long incision group and 27% of the short incision group required out-patient therapy. for the non-Workers’ Compensation group, this percentage decreased to 21% of those with the long incision and 3% with the short incision. A history of vocational or avocational repetitive motion patterns was the most common indicator for therapy and accounted for 67% of rehabilitation referrals.

Occupational upper extremity disorders in the federal workforce. Prevalence, health care expenditures, and patterns of work disability

Upper extremity disorders (UEDs) account for a significant number of work-related illnesses in the US workforce. Little information exists on the distribution of UEDs, their associated health care and indemnity costs, or patterns of work disability. The study presented is an analysis of upper extremity claims within the federal workforce. In this study, the universe consisted of all claims accepted by the US Department of Labor, Office of Workers' Compensation Programs (OWCP), from October 1, 1993, through September 30, 1994. A total of 185,927 claims of notices of injury were processed during the study period, and of these, 8,147 or 4.4% had an UED diagnosis coded according to the International Classification of Diseases, Clinical Modification (ICD-9-CM). 5,844 claims involved a single UED diagnosis and were the only claims field by these employees between October 1, 1990, and September 30, 1994. These single claims with single diagnoses comprised the sample for further analysis. Mononeuritis and enthesopathies of the upper limb were the most common diagnoses, accounting for 43% and 31% of the claims, respectively. Women had a higher proportion of carpal tunnel syndrome, "unspecified" mononeuritis, and "unspecified" enthesopathies. The majority of claimants for both the mononeuritis- and enthesopathy-related diagnoses were between 31 and 50 years of age, received only health care benefits, and did not incur wage loss. Health care costs for mononeuritis and enthesopathy claims were $12,228,755 (M = $2,849). Carpal tunnel syndrome (CTS) and enthesopathy of the elbow were the most costly diagnoses, accounting for 57% and 16% of the total, respectively. Surgical services represented the highest expenditures in CTS claims. Physical therapy accounted for the majority of health care costs for enthesopathy cases. The mean number of workdays lost for CTS and enthesopathy claims were 84 and 79, and the average indemnity costs were $4,941 and $4,477, respectively. These findings indicate that while UEDs represent a relatively small percentage of all workers' compensation cases, the health care and indemnity costs are considerable. Also mean duration and pattern of work disability revealed that these disorders can result in chronic work disability similar to that observed in low back pain. The results highlight the need to determine whether interventions that account for the majority of costs significantly impact long-term outcomes. There is also a need to identify risk factors for prolonged disability in those who experience problems with delayed recovery.

Endoscopic treatment of carpal tunnel syndrome: a critical review

OBJECT

The goal of this paper is to present a critical review of the endoscopic procedures currently in use for the treatment of carpal tunnel syndrome. Endoscopic techniques and outcomes are discussed.

METHODS

An extensive review of published articles on the subject of endoscopic carpal tunnel release surgery is presented, encompassing six endoscopic techniques used to treat carpal tunnel syndrome. Since the first report in 1987, 7091 patients have undergone 8068 operations. The overall success rate has been 96.52%, with a complication rate of 2.67% and a failure rate of 2.61%. The mean time to return to work in patients not receiving Workers' Compensation was 17.8 days, ranging between 10.8 and 22.3 days. The most common complications were transient paresthesias of the ulnar and median nerves. Other complications included superficial palmar arch injuries, reflex sympathetic dystrophy, flexor tendon lacerations, and incomplete transverse carpal ligament division. In many studies in which open and endoscopic techniques were compared, it was reported that patients in the the latter group experienced significantly less pain and returned to work and activities of daily living earlier.

CONCLUSIONS

Success and complication rates of endoscopic carpal tunnel release surgery are similar to those for standard open procedures.

Self-administered outcome instrument in carpal tunnel syndrome. Reliability, validity and responsiveness evaluated in 102 patients

We evaluated a Swedish version of a self-administered disease-specific outcome questionnaire for carpal tunnel syndrome regarding reliability, validity and responsiveness to clinical change. It consists of multi-item scales assessing symptom severity, function, patient satisfaction and quality of life. It was given to 102 patients before and 3 months after carpal tunnel release. Test-retest reliability, studied in a subsample of 22 patients on two occasions with a 1-3-week interval, showed good agreement between the scores. Internal consistency of the scales was high (Cronbach alpha 0.80-0.95). Validity of the scales was evaluated using the SF-36 general health questionnaire in a subgroup of 48 patients as well as items concerning patient satisfaction, showing the expected relationships between these measures. Responsiveness of the scales to clinical change, estimated by the effect size and standardized response mean, was large (0.94-1.7). We conclude that this questionnaire can provide a standardized measure of symptom severity and functional status, as well as patient satisfaction and quality of life in the carpal tunnel syndrome.

Safe carpal tunnel release via a limited palmar incision

Despite its demonstrated advantages in postoperative recovery, endoscopic carpal tunnel release has not been adopted by most surgeons because of the associated complications of neurovascular injury. A technique of carpal tunnel release is presented that utilizes a 1.0 to 1.5-cm palmar incision and a specially designed carpal tunnel "tome." Any aberrant anatomy of adjacent neurovascular structures may be identified under direct vision. Anatomic dissection in 28 cadaveric specimens following the procedure showed complete decompression of carpal tunnel and preservation with safe margins of the palmar cutaneous branch and thenar motor branch of median nerve, ulnar artery and nerve, and superficial palmar arch. Clinical experience with the technique in two centers consisted of 525 patients and 694 hands over a 29-month period. The great majority of patients derived complete (72.6 percent) or near-complete (19.6 percent) symptomatic relief from the procedure, and two complications (0.29 percent) of median nerve lacerations occurred. Postoperative incisional and pillar tenderness and grip, key pinch, and three-point pinch strengths were comparable with those in published series of endoscopic carpal tunnel release. We conclude that this technique of carpal tunnel release combines the simplicity and safety of traditional open release and the reduced tissue trauma and improved postoperative recovery of the endoscopic modality.

Median nerve contusion during endoscopic carpal tunnel release

Median nerve contusion occurred in two patients treated by endoscopic carpal tunnel release. We discuss the possible cause of this complication and how to avoid it.

Patient satisfaction and return to work after endoscopic carpal tunnel surgery

One hundred twenty-eight patients with idiopathic carpal tunnel syndrome were evaluated before surgery and 3 and 6 months after unilateral endoscopic carpal tunnel release. The variables analyzed included patient demographics, symptoms and signs, activities of daily living (ADL), sensibility and strength measurements, preoperative distal motor latency of the median nerve, operating surgeon, postoperative palmar pain and tenderness, return to work, and patient satisfaction with the results of surgery. Multivariate statistical analyses were performed, with patient satisfaction at 6 months after surgery and the time until return to work after surgery as the dependent variables. On stepwise logistic regression analysis of all preoperative variables, significant predictors of patient dissatisfaction at 6 months after surgery were higher age, heavy vibration exposure, worse ADL score, and better distal motor latency. Analysis of all preoperative and 3-month postoperative variables showed heavy vibration exposure, better distal motor latency, and worse 3-month postoperative ADL score to have the strongest independent correlation with patient dissatisfaction at 6 months. No significant independent association was found between any of the preoperative variables studied and the length of time until return to work after surgery.

Pillar pain as a postoperative complication of carpal tunnel release: a review of the literature

Carpal Tunnel Syndrome (CTS) has been referred to as the most common peripheral entrapment neuropathy. As Mirza and colleagues note, its incidence continues to increase. Einhorn and Leddy cite Palmer's estimated incidence of 1% in the general population and 5% or more of workers in certain industries which require repetitive use of the hands and wrists. Conservative treatment of CTS includes splinting and modification of activities. However, surgical release of the transverse carpal ligament or the flexor retinaculum is an extremely common procedure. The open surgical technique has been used since 1924 and is still considered by many to be the gold standard. In 1989 Oksuto introduced the endoscopic carpal tunnel release (ECTR) with the rationale of potentially decreasing the prevalence of complications. In the ensuing years, endoscopic results have generated a tremendous amount of study and controversy. Berger reported that many "passionate arguments both for and against the use of ECTR" exist. This paper briefly reviews the literature generated by this debate, focusing on one potential postoperative complication: pillar pain. Various definitions of pillar pain are noted, and suggested etiologies are grouped into four categories. This is followed by a brief discussion of the treatment approaches and issues.

Sensory function after median nerve decompression in carpal tunnel syndrome. Preoperative vs postoperative findings

The sensory recovery was monitored for up to 1 year after decompression of the median nerve in 69 patients with carpal tunnel syndrome. Special attention was paid to the rate of recovery, the importance of constant or intermittent numbness or paraesthesiae preoperatively and the influence of gender. Most patients with numbness/paraesthesiae and those with abnormal two-point discrimination recovered within 10 days. Perception of touch and vibration recovered within 3 weeks in most patients but those with abnormal nerve conduction/sensory amplitude recovered slowly during follow-up. After 1 year patients with intermittent preoperative symptoms were significantly more likely to achieve normal nerve conduction and perception of touch. Women were more likely to achieve normal nerve conduction and perception of touch. A comparison of recovery between matched men and women with identical preoperative status showed no significant difference. The results indicate the importance of early treatment of carpal tunnel syndrome.

Ultrasonographically assisted carpal tunnel release

An operative technique of carpal tunnel release using intraoperative ultrasonography is described. In this technique, "safe line" is defined in the transverse carpal ligament and the adjacent deep forearm fascia midway between the ulnar margin of the median nerve and the radial margin of the ulnar artery. After ultrasonographic design of a 1.0 to 1.5-cm skin incision along the safe line at the distal carpal tunnel, the distal ligament is released under direct vision. Proximal release is performed along this line under ultrasonographic monitoring using a device that consists of a basket punch and an outer metal tube. In a prospective randomized study, the outcomes were compared for carpal tunnel release using either this technique in 50 hands of 50 patients or conventional open release in 53 hands of 53 patients. Follow-up assessment at 3, 6, 13, 26, 52, and 104 weeks showed no significant difference with respect to numbness and paresthesias, static two-point discrimination, findings on Semmes-Weinstein monofilament testing, findings on manual muscle testing of the abductor pollicis brevis, and electrophysiologic findings. The ultrasonographic-release group had better outcomes regarding pain, tenderness of the scar, and key-pinch strength at 3, 6, and 13 weeks, and grip strength at 3 and 6 weeks after surgery. The scar was more aesthetic in this group. There were no complications with either technique.

Complications in the treatment of carpal tunnel syndrome

Complications may result from every facet of the management of carpal tunnel syndrome. The authors review the common errors in diagnosis, nonoperative management, and operative treatment, with emphasis on prevention and resolution of complications. In general, surgeons can minimize complications by taking a thorough patient history, performing a comprehensive physical examination, and possessing a precise knowledge of the appropriate anatomy. Endoscopic techniques appear to offer some advantage over conventional open techniques with regard to the patient's postoperative incision pain, preservation of grip strength, and time to return to work; however, these advantages may be potentially negated by the risk of injury to neurovascular structures and tendons.

Microsurgical carpal tunnel release

The author reports on a series of 482 patients who underwent primary carpal tunnel release (CTR) surgery beginning in 1987. Two hundred twenty-five patients underwent CTR in the right hand, 169 patients underwent CTR in the left hand, and 88 patients underwent bilateral CTR surgery, for a total of 570 hands. These surgeries were performed on an outpatient basis. After application of a local anesthetic, a microsurgical technique using a 2-cm longitudinal incision that did not cross the wrist flexion crease was accomplished. In five patients the recurrent thenar branch exited through the middle or ulnar portion of the ligament and this branch was preserved in all five. Perioperative complications included stitch abscesses in nine hands (2%), which were managed on an outpatient basis; deep wound infections occurred in three hands (0.5%) and these patients were admitted for intravenous antibiotic administration and wound care. One steroid-dependent patient suffered wound dehiscence due to a fall and the wound was primarily repaired. One patient required a second minor procedure to remove a retained suture. Two patients developed “trigger finger” 6 months postoperatively. The mean time until return to work for those patients not receiving Workers' Compensation was 3 weeks and for those receiving Workers' Compensation it was 6.5 weeks. Complete disappearance of painful dysesthesias occurred in 431 (89%) of 482 patients. Marked improvement occurred in another 33 (7%) patients, yielding an overall improvement rate of 96%. Motor improvement was noted in 438 (96%) of 454 patients with preoperative motor weakness. Bilateral symptoms resolved on the contralateral side following unilateral surgery in seven patients. Fifteen patients (12 of whom were receiving Workers' Compensation) experienced persistent dysesthesias and/or incision pain and did not return to work. An additional eight procedures were performed in patients who had previously undergone surgery at another institution; four showed no evidence of their transverse carpal ligament being sectioned. Five of the eight patients undergoing reexploration noted postoperative improvement in their symptoms. Finally, 14 (3%) patients presented 1 to 5 years postsurgery with thenar/hypothenar pain. These patients have responded to local steroid injections and are being followed by a hand surgeon.

The reimbursement of the surgeon's fee is $253.00 from Medicaid, $360.00 from Medicare, and $560.00 from preferred provider insurance. The mean total time in the outpatient operating room is 35 to 40 minutes. The outcome and time to return to work are equal, if not superior, to those reported for endoscopic CTR surgery. Microsurgical CTR is thought to be safer and probably more cost-effective.

Patients' preferences and their relationship with satisfaction following carpal tunnel release

Patients' preferences for specific health outcomes in carpal tunnel syndrome (CTS) and their association with demographic factors and satisfaction with the results of surgery after 6 months were evaluated. Two hundred fifty subjects with CTS and enrolled in a prospective community-based cohort study in Maine completed a preference questionnaire before surgery. Patients were asked to specify the single most important reason they decided to undergo surgery and to rate the importance of improvement in 10 areas, including lessening of specific symptoms and improvement in specific functional states related to CTS. The single most important reason for CTS patients to have surgery was relief of night pain (37%), followed by relief of numbness (21%) and relief of daytime pain (13%). When patients were asked to rate the importance of obtaining relief from specific symptoms and improvement in specific functional states, relief of numbness received the highest rating, with 94% of the patients answering that it was extremely or very important. Workers' compensation recipients, patients with less than a college level of education, and patients with more severe symptoms and functional impairment at baseline assigned higher importance to symptom relief and functional improvement. Controlling for other predictors, higher preference for improved strength was associated with lower satisfaction with the results of the surgery at 6 months. Most CTS patients undergoing surgery have realistic preferences for health outcomes that are influenced by demographic and clinical characteristics; however, physicians should pay attention to unrealistic preferences that might influence patients' satisfaction with surgical results.

Endoscopic treatment of carpal tunnel syndrome: a critical review

An extensive review of published articles on the subject of endoscopic carpal tunnel release surgery is presented, encompassing six endoscopic techniques used to treat carpal tunnel syndrome. Since the first report in 1987, 7091 patients have undergone 8068 operations. The overall success rate has been 96.52%, with a complication rate of 2.67% and a failure rate of 2.61%. The mean time to return to work in patients not receiving Workers' Compensation was 17.8 days, ranging between 10.8 and 22.3 days. The most common complications were transient paresthesias of the ulnar and median nerves. Other complications included superficial palmar arch injuries, reflex sympathetic dystrophy, flexor tendon lacerations, and incomplete transverse carpal ligament division. All studies in which open and endoscopic techniques were compared reported that patients in the latter group experienced significantly less pain and returned to work and activities of daily living earlier. The reported success and complication rates of endoscopic carpal tunnel release surgery are similar to those for standard open procedures. Endoscopic techniques and outcomes are discussed.

[The endoscopic release of the transverse carpal ligament for carpal tunnel syndrome.]

GOAL OF SURGERY

Complete division of the flexor retinaculum for decompression of the medial nerve to restore normal neurologic function.

INDICATIONS

Idiopathic and posttraumatic carpal tunnel syndrome.

CONTRAINDICATIONS

Postoperative recurrence, carpal tunnel syndrome in patients with rheumatoid arthritis, with tumors or with carpal canal compromise due to bony causes.

POSITIONING AND ANAESTHESIA

Supine General or regional anaesthesia.

SURGICAL TECHNIQUE

Identification of the palmaris longus tendon. 1.5 cm long incision along the flexor crease of the wrist. If the palmaris longus is absent the incision should be made 1.5 cm medial to the flexor carpi radialis tendon. Introduction of the scope and exploration of the ulnar border of the carpal canal with a special instrument until the hook of the hamate has been identified. Endoscopic identification of the distal end of the retinaculum and insertion of the cutter. Complete division of the retinaculum.

POSTOPERATIVE MANAGEMENT

Posterior plaster splint for 7 days. Elevation of the limb. Active exercises of fingers, elbow and shoulder and, after cast removal, also of the wrist. Lifting and carrying of heavy objects should be avoided for 4 to 6 weeks.

POSSIBLE COMPLICATIONS

Injury of the median nerve or one of its branches, of the superficial palmar arch, and of the flexor tendons.

RESULTS

Prospective randomized study of 120 patients of which 101 could be followed up. Forty-five patients (group A) had an open decompression and 47 (group B) were decompressed endoscopically. Average follow-up period for group A 271 days, for group B 275 days. Mean age of both groups: 53 years. There were 13 men and 41 women in group A and 17 men and 30 women in group B. No complications or night pain in either group. No significant difference in atrophy of the thenar eminence in the strength of the hand or in the 2 point discrimination. Results of pre- and postoperative nerve conduction and of temporary disability are listed in Figures 10 and 11. At follow-up 6 to 12 weeks postoperatively no difference could be found between the 2 groups in respect to scar pain, grip power and range of motion. Main advantage of the endoscopic approach: reduced postoperative pain and shorter disability.

Bilateral fast magnetic resonance imaging of the operated carpal tunnel

Our aim was to quantify the structural changes of the carpal tunnel including area and volume after surgical release. We studied 28 patients who underwent 31 operations for carpal tunnel syndrome (CTS), mean age 54.7 years (range 32-78). All had abnormal nerve conduction studies. Magnetic resonance imaging (MRI) of both wrists was done before and after operation using two fast imaging sequences, turbo spin echo (TSE) and fast field echo (FFE). The same surface coils and parameters were used in both instances. With a computerised analyser we calculated the volume of the whole tunnel from inlet to outlet before and after operation and the wrist volume:carpal tunnel volume ratio. The intensity of the magnetic resonance signal emitted by the median nerve was assessed in all wrists before and after operation. The mean (SD) volume of the tunnel in 31 wrists with CTS was 11511.7 (2857) mm3 before and 13803.4 (3034.9) mm3 after operation (p = 0.0001). The mean (SD) relative signal intensity of the median nerve was 1.7 (1.8) preoperatively and 1.3 (1.1) postoperatively (p = 0.19). Other postoperative changes included persistent nerve enlargement (n = 21), misalignment of the tendons (n = 20), fibrous tissue deposits (n = 20), fat tissue deposits (n = 21), and muscle oedema (n = 6). The modifications of the carpal canal as a consequence of open surgical release (including increased volume and displacement of the flexor tendons) argue for the use of an endoscopic procedure in the treatment of CTS.

Touch allodynia following endoscopic (single portal) or open decompression for carpal tunnel syndrome

We investigated if single-portal endoscopic carpal tunnel decompression equipment (Agee, 3M, USA) would cause increased carpal tunnel pressure during the release and if endoscopic release would reduce postoperative touch allodynia. Measurements on cadavers of the pressure produced during endoscopic release showed similar pressures to those produced during maximal range of motion. One hundred patients underwent either open or endoscopic decompressions. Twenty normal individuals served as controls. At 1 month after surgery both groups had significant allodynia compared with the controls, but at 3 months the endoscopic group had returned to normal though the open group was still significantly abnormal. The reported endoscopic release may therefore be of particular advantage to patients who would seriously be disadvantaged if postoperative touch allodynia should develop. The Agee endoscope is unlikely to cause disturbance of the nerve function due to increased carpal pressure during the release.

Results of open carpal tunnel release: a comprehensive, retrospective study of 188 hands

BACKGROUND

Many recent reports of the results of decompression of the median nerve in the carpal tunnel have concentrated on only one aspect of recovery (numbness, grip etc.), and there are no reports of a comprehensive study of outcome. The aim of the present study was to review comprehensively the results of the direct visualization method of decompression of the carpal tunnel and to compare them with the published results of endoscopic release.

METHODS

Patients' perceptions of the severity of pain, numbness and paraesthesiae due to carpal tunnel syndrome (CTS), before and after open carpal tunnel release (CTR) in 188 hands were reviewed retrospectively at a minimum time of follow-up of 18 months. Motor and sensory testing, provocation testing and measurement of scar tenderness in 135 hands were performed at a clinical review.

RESULTS

Subjective results showed that 70% experienced a reduction in the severity of pain after CTR, 78% of hands experienced a reduction in the severity of paraesthesiae and 77% experienced a reduction in the severity of numbness. A total of 49% had improvements in all three symptoms after CTR. At the clinical review, sensory testing revealed that 59% of hands had normal or slightly diminished light touch, 35% had normal static two-point discrimination and 61% had normal dynamic two-point discrimination. Results for Tinel's test, Phalen's test and pressure provocation testing were positive in 10% of hands. There was no scar tenderness in 38%, no persisting thenar atrophy in 90%. Normal grip strength was found in 93% and 91% had normal pinch strength.

CONCLUSIONS

It was concluded that open carpal tunnel release remains a safe and reliable treatment for carpal tunnel syndrome. The very low incidence of serious complications from the open technique of CTR, when compared with endoscopic CTR as published by different authors in the literature, and the comparable clinical results, appears to make the open technique a safer and preferable option. However, a properly controlled trial of both techniques is necessary to compare them.

Value of the carpal compression test in the diagnosis of carpal tunnel syndrome

In order to determine the efficacy of the carpal compression test (CCT) in the diagnosis of the carpal tunnel syndrome (CTS), we conducted a prospective study on 200 consecutive hands diagnosed as having CTS. A control group of 100 healthy volunteers with no symptoms of CTS were also assessed. The results of the CCT in the patients and controls were compared with those obtained with Phalen's and Tinel's tests. CCT achieved a sensitivity of 87%, and a specificity of 95%. It is a simple, fast and very reliable provocative test, and should be routinely used in the diagnosis of CTS. This test is also an appropriate manoeuvre in wrists with limited range of motion or pain that cannot be assessed with Phalen's wrist flexion test.

Endoscopic carpal tunnel release: prospective assessment of 255 consecutive cases

A prospective study was conducted to evaluate the efficacy and safety of two-portal endoscopic carpal tunnel release. Two hundred and fifty-five consecutive hands (204 patients) were operated on by one surgeon using general or regional anaesthesia in the first 48 hands and local anaesthesia in the following 207 hands. The patients were evaluated preoperatively and 3 and 6 months postoperatively by an independent examiner. At the 6-month follow-up, 83% reported complete relief of symptoms and 89% were satisfied with the results of surgery. The median time until return to work was 17 days. Complications included five postoperative digital neurapraxias, all occurring under general or regional anaesthesia, and four open reoperations due to persistent symptoms. Two-portal endoscopic carpal tunnel release can be effective and safe and appears to shorten the time until return to work. The use of local anaesthesia might be important in avoiding neurological complications.

Flexor carpi radialis approach for carpal tunnel release

A technique for dividing the transverse carpal ligament has been developed in order to decrease the incidence of pillar pain. The carpal ligament splits around the flexor carpi radialis (FCR) tendon into two leaves as it approaches its radial attachments. The new approach uses the FCR as a guide to divide these attachments under direct visualization, thereby releasing the carpal tunnel. This technique has been used on 87 hands, with 79 (91%) obtaining complete or partial relief of preoperative symptoms. Pillar tenderness resolved quickly and there were few complications. The FCR approach to carpal tunnel release couples the advantages of direct visualization of the carpal canal contents with the decreased disruption of palmar skin and soft tissues, thereby reducing pillar pain without increasing the risk of surgical complications.

Transillumination in minimally invasive surgery for carpal tunnel release. Technical note

An alternative technique for performing minimally invasive release of carpal tunnel syndrome is described. The suggested methodology is based on transillumination of the carpal tunnel during surgery. The advantages of the technique are discussed and compared with other available surgical procedures including endoscopy. The authors also describe preliminary operative results in 50 consecutive patients.

Carpal tunnel syndrome: unusual contraindications to endoscopic release

Endoscopic carpal tunnel release has become an increasingly popular method of surgical treatment of carpal tunnel syndrome. Consequently, the contraindications to this technically challenging procedure continue to evolve. We describe two patients with carpal tunnel syndrome and unusual anomalies and pathology of the hook of the hamate that we believe represent relative or absolute contraindications to endoscopic carpal tunnel release.

Complete endoscopic carpal tunnel release in long-term haemodialysis patients

The roof of the carpal tunnel (or canal) consists of the distal portion of the flexor retinaculum, the flexor retinaculum (or the transverse carpal ligament) and the proximal portion of the flexor retinaculum. We tried to determine which anatomical structures were relevant to complete endoscopic carpal tunnel decompression in long-term haemodialysis patients with carpal tunnel syndrome. Carpal tunnel pressure was measured using the continuous infusion technique before and after endoscopic release of the flexor retinaculum, distal portion of the flexor retinaculum and the proximal portion of the flexor retinaculum respectively in 257 hands. We concluded that release of the distal portion of the flexor retinaculum, in addition to the flexor retinaculum, is essential for complete carpal tunnel decompression in long-term haemodialysis patients.

A severe infection following endoscopic carpal tunnel release

A 59-year-old patient underwent endoscopic carpal tunnel release by Chow's two-portal technique. He developed a pyogenic tenosynovitis and an infection within the ulnar and radial bursae, an abscess in the middle palmar, thenar and Parona's space, and a pyogenic wrist arthritis. Surgical treatment included a wide exposure of the infected region, débridement, irrigation, application of a resorbable collagen sponge containing gentamicin, insertion of two drains and primary wound closure. The infection was brought under control and hand function restored.

Incidence and natural history of touch allodynia after open carpal tunnel release

Open surgical decompression is believed to be a safe treatment with few complications. However, it was our subjective impression that its morbidity had been underestimated. Fifty one consecutive patients with carpal tunnel syndrome were evaluated prospectively for three years after operation. Twenty one patients (41%) experienced allodynia of the operated hand at one month after surgery, 13 (25%) at three months, and three (6%) at 12 months. These were confirmed by significantly lowered pressure-pain thresholds over both the thenar and hypothenar eminences (p < 0.005). During the first month after operation all patients were relieved of nocturnal pain, and all clinical signs had disappeared at three months in all 51 patients. Our results confirm that open carpal tunnel decompression has a high success rate, but highlights a previously underestimated morbidity of postoperative allodynia.

Carpal tunnel release with and without epineurotomy: a comparative prospective trial

A prospective, comparative study of epineurotomy as an adjunctive procedure to transverse carpal ligament release for the treatment of carpal tunnel syndrome was conducted. Eighty-six patients with 117 involved hands were entered into the study. After entry, all patients completed an extensive preoperative questionnaire, a detailed physical examination, and preoperative neurophysiologic testing. Seventy-five hands were followed for a minimum of 24 months. The operative findings were similar between the group of those undergoing epineurotomy and the group that did not undergo epineurotomy. Postoperatively the twopoint discrimination values for all fingers averaged 5.3 mm and 5.15 mm, respectively, for the epineurotomy and nonepineurotomy groups. The physical findings, neurophysiologic findings, and patient perceptions of outcome after surgery were similar. It was concluded that the study data do not support the use of epineurotomy as an adjunctive procedure during carpal tunnel release.

The cutaneous innervation of the palm: an anatomic study of the ulnar and median nerves

Twenty-five fresh-frozen cadaveric hands without obvious deformity were dissected using 3.5x loupe magnification. Median and ulnar nerves were identified in the proximal forearm and dissected distally to the midpalm. Cutaneous branches of median and ulnar nerves were described relative to an incision for carpal tunnel release. The palmar cutaneous branch of the median nerve was present in all 25 specimens. In a single specimen, the palmar cutaneous branch of the median nerve was isolated as it crossed the incision, and in another two specimens, the terminal branches of the nerve were identified at the margin of the incision. In 4 hands, a classic palmar cutaneous branch of the ulnar nerve was found an average of 4.9 cm proximal to the pisiform. In 10 specimens, a nerve of Henle arose an average of 14.0 cm proximal to the pisiform and traveled with the ulnar neurovascular bundle to the wrist flexion crease. In 24 specimens, at least one-usually multiple-transverse palmar cutaneous branch was identified originating an average of 3 mm distal to the pisiform within Guyon's canal. The origin and destination of these nerves was highly variable. In 16 specimens, an incision in the axis of the ring finger would likely have encountered at least one branch of the ulnar-based cutaneous innervation to the palm. Cutaneous branches of the ulnar nerve would be expected to cross the line of dissection frequently during open carpal tunnel release. Decreased levels of discomfort in patients undergoing endoscopic and subcutaneous types of carpal tunnel release may be in part due to the preservation of the crossing cutaneous nerves with these procedures.

Comparison of techniques for detecting digital neuropathy

A complication of endoscopic carpal tunnel release (6/53 consecutive cases) is rupture of a digital branch. The objective of this study was to find a method for detecting neuropathy of the digital branch innervating the radial side of the fourth digit and the ulnar side of the third digit. This study examined whether the following sensory nerve conduction techniques would enhance diagnosis of this neuropathy: (1) recording with standard digital ring electrodes; (2) recording with ring electrodes from two adjacent fingers; and (3) disc electrodes placed between two fingers. Ten healthy individuals were studied before and after lidocaine anesthesia of the digital branch between the ring and middle finger. Statistical analysis was performed with a two-tailed, paired t test. Results show that after lidocaine injection there was a decrease in antidromic amplitude of 94% for ring electrodes on the fourth digit, 62% for rings on the third digit, 77% for disc electrodes between the fourth and third digits, and 74% for rings on digits 4 and 3 (P < 0.005), with no significant change in peak latency (P > 0.3). In conclusion, although all techniques used in this model yielded a significant change in amplitude, rings on the third digit compared with the second and discs between digits 4/3 compared with 3/2 were most specific without false-positives from normal data. It is hoped this study will aid the electromyographer in postoperative diagnosis.

Outcome assessment for carpal tunnel surgery: the relative responsiveness of generic, arthritis-specific, disease-specific, and physical examination measures

Clinical evaluation of outcome after treatment of carpal tunnel syndrome has not been standardized. To assess the value of various clinical and questionnaire measures for the assessment of outcome after carpal tunnel surgery, we surveyed 22 patients 1 day before and 3 months after carpal tunnel release with the following measures: the Medical Outcomes Study 36-item short form health survey, the Arthritis Impact Measurement Scale, the Brigham and Women's Hospital carpal tunnel questionnaire, wrist range of motion, power pinch grip strength, pressure sensibility, and dexterity. Significant changes, all in the direction of improved health status postoperatively, were noted in the following scales or measures: the Arthritis Impact Measurement Scale pain, satisfaction, health perception, arthritis impact, and symptom scales; the Brigham and Women's Hospital symptom and function scales; the short form health survey's physical role, emotional role, and bodily pain scales; and the measurement of dexterity. In this study, standardized questionnaires were more sensitive to the clinical change produced by carpal tunnel surgery than many commonly performed physical measures of outcome. The condition-specific questionnaire was more sensitive to change than were more generic questionnaires.

A prospective, randomized study with an independent observer comparing open carpal tunnel release with endoscopic carpal tunnel release

In order to define the role of two-portal endoscopic carpal tunnel release, a prospective randomised study with an independent observer was performed to compare endoscopic and open surgery. Thirty-two hands in 29 patients, with symptoms, clinical signs and EMG changes consistent with idiopathic carpal tunnel syndrome were randomised to either endoscopic carpal tunnel release or open release. No significant difference in sick leave between the two groups could be found, being a mean of 17 days (range 0-31 days) with endoscopic surgery, and 19 days (range 0-42 days) with open conventional surgery. No differences in surgical results were found, but three patients in the endoscopic group suffered transient numbness on the radial side of the ring finger.

[Use of endoscopy in plastic surgery]

Now that endoscopic techniques have been established in visceral and trauma surgery under the concept of minimal invasive surgery, plastic surgery has also begun to accept these techniques since minimal invasive surgery is very important in this field. In contrast to abdominal and thoracic surgery, plastic surgery cannot be done in preformed cavities. Therefore, it was necessary to develop new techniques and instruments. We present the most important operations in the field of plastic surgery that can so far be carried out endoscopically. The development phase is only at the beginning, and new indications are being added daily since the technical equipment can also only be gradually adapted to the needs that arise.

Endoscopic carpal tunnel release using a single-portal system

In this prospective clinical study, we present our experience with a new single portal carpal tunnel release kit. The safety and efficacy of this new device was assessed and compared with a consecutive control group treated with conventional open carpal tunnel release. 126 patients were enrolled in this study, 64 of them were treated endoscopically (group 1) and 62 by open release of the carpal ligament (group 2). Follow-ups were conducted at 1, 3, 6, 12 and 24 weeks postoperatively. A serious intraoperative complication in group 1 was a transection injury of a branch of the superficial palmar arch. No intraoperative complications were noted in group 2. Postoperative evaluation revealed significantly less scar tenderness in group 1 at 1 week (P < 0.001), 3 weeks (P < 0.001) and 24 weeks (P < 0.05) compared to group 2. Functional status at 1 week was significantly (P < 0.05) better in group 1 than in group 2 but not at later times. Grip strength at 1 week (P < 0.001), 3 weeks (P < 0.05) and 12 weeks (P < 0.05), and pinch strength at 3 weeks (P < 0.001) were significantly higher in group 1. No significant differences between the groups were obtained regarding postoperative symptom severity. The new device provides a reliable tool for single portal carpal tunnel release, although the risk of inadvertent damage to the neurovascular structures always remains a possibility with the endoscopic carpal tunnel technique.

Early results of conventional versus two-portal endoscopic carpal tunnel release. A prospective study

The authors compare in a prospective, randomized study the early outcome of carpal tunnel release using either a conventional palmar open release (n = 40) or a two-portal endoscopic release (n = 56). Both groups were similar. No statistically significant differences were found regarding pain, disappearing of paraesthesiae or time to return to work. However, better recovery of grip strength was observed in the endoscopic group at 1 and 3 months. No surgical complications were observed in either group.

A new technique for endoscopic carpal tunnel decompression

A new one-portal technique for endoscopic carpal tunnel release (ECTR) is introduced with its clinical results. The incision is made at the palmar aspect of the hand. A custom-made glass tube with a groove is inserted, and under endoscope observation, a meniscus knife is pushed forward along the groove to release the flexor retinaculum. This new technique has been studied in ten fresh cadaver hands and used in 123 patients' hands. Results of the cadaver study showed that the flexor retinaculum was released completely in all ten hands. No injuries to tendons, nerves, or arteries were noted. In one case the cotton tip was lost from the stick. All clinical releases were performed uneventfully except for three cases of neuropraxia of the digital nerve of the radial side of the ring finger, one laceration of the motor branch of the median nerve, one mild infection, one loss of cotton tip from the cotton swab stick, and one case of chipping of the glass tube. The case with the laceration of the motor branch of the median nerve occurred early in the series and required the conventional open incision to repair the nerve. The cases with loss of cotton from the stick and chipping of the tube also required a conventional incision to remove the cotton and glass chip. Advantages of this one-portal technique with the glass tube include less scar tenderness than with two-portal techniques, decreased risk of injury to the superficial palmar arch and ulnar nerve because of the distal approach, a view of pathology in the carpal tunnel through the glass tube, and confirmation of release of the flexor retinaculum.

Risk and complications in endoscopic carpal tunnel release

Single portal endoscopic carpal tunnel release was carried out in 107 hands of 88 patients. There were 11 complications. These included incomplete release (2), post operative scarring around the median and ulnar nerves (2), laceration of the superficial palmar arterial arch (1), reflex sympathetic dystrophy (2), palmar fasciitis (1), and wound inflammation (3). In two cases there was no relief of symptoms. In one there was incorrect diagnosis and in another, incorrect indication for endoscopic carpal tunnel release. The follow-up was from 3 to 18 months with an average of 6.8 months. The overall results of the patients in this series are being presented in another paper. Of the 107 procedures, 73 were rated as having an excellent, 25 good, three fair, and six poor results. The case of laceration of the superficial palmar arterial arch is discussed in detail in the paper. The two cases of reflex sympathetic dystrophy and the one case of palmar fasciitis had mild clinical features and resolved within 3 months. The inflammation in three of the wounds at the wrist resolved within 2 days of removal of the percutaneous sutures. These three patients had returned to heavy hand activities within a few days of surgery.

The use of topographical landmarks to improve the outcome of Agee endoscopic carpal tunnel release

A modified approach to endoscopic carpal tunnel release has been developed and tested in 60 cadaveric specimens by three surgeons using the Agee endoscopic carpal tunnel release system. The modified approach, which includes specific localization of the hook of the hamate, flexor retinaculum, and the superficial palmar arch utilizing topographical landmarks, avoids entry into Guyon's canal and injury to the ulnar artery and nerve, median nerve, and common digital nerves. Use of the anatomic approach resulted in significantly superior results. There were fewer incomplete releases, and fewer surgical passes were required, for the inexperienced surgeons. When these anatomic considerations were not included, the learning curve was much steeper. For surgeons planning endoscopic surgical release of the transverse carpal ligament, the described topographical approach improves the technical competence with the procedure and reduces the number of complications and learning curve associated with new procedures. We recommend the use of topographical landmarks and other anatomic considerations during endoscopic carpal tunnel release.