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

Early mobilization following carpal tunnel release. A prospective randomized study

A prospective randomized study was undertaken of 50 consecutive patients undergoing surgery for idiopathic carpal tunnel syndrome to determine the value of splintage of the wrist following open carpal tunnel release. Patients were randomized to either be splinted for 2 weeks following surgery or to begin range-of-motion exercises on the first post-operative day. Subjects were evaluated at 2 weeks, 1 month, 3 months, and 6 months after surgery by motor and sensory testing, physical examination, and a questionnaire. Variables assessed included date of return to activities of daily living, dates of return to work at light duty and at full duty, pain level, grip strength, key pinch strength, and occurrence of complications. Patients who were splinted had significant delays in return to activities of daily living, return to work at light and full duty, and in recovery of grip and key pinch strength. Patients with splinted wrists experienced increased pain and scar tenderness in the first month after surgery; otherwise there was no difference between the groups in the incidence of complications. We conclude that splinting the wrist following open release of the flexor retinaculum is largely detrimental, although it may have a role in preventing the rare but significant complications of bowstringing of the tendons or entrapment of the median nerve in scar tissue. We recommend a home physiotherapy programme in which the wrist and fingers are exercised separately to avoid simultaneous finger and wrist flexion, which is the position most prone to cause bowstringing.

Endoscopic carpal tunnel release: a prospective study of complications and surgical experience

A 63-center prospective study of endoscopic carpal tunnel release using the Agee Carpal Tunnel Release System was conducted in 1049 procedures in 988 patients. Prior experience with endoscopic release varied significantly among surgeon participants. Surgeons evaluated the newly redesigned system for blade visibility, blade height, and mechanical function. Data on patient complications were collected at the time of surgery and 3-4 weeks postoperative. The results indicated minimal complications and no confirmed injuries to vessels or nerves; the symptoms from one possible digital nerve injury eventually resolved completely. Surgeons were able to observe the point of entry of the blade into the transverse carpal ligament in 97.5% of procedures. Introduction of the blade assembly into the carpal tunnel was rated easy or adequate in 90.6% of procedures, and blade height was rated adequate in 97.4% of procedures.

Comparison of proximal and distal one portal entry techniques for endoscopic carpal tunnel release. A cadaver study

Reported complications of endoscopic carpal tunnel release have increased as more surgeons use this technique to release the flexor retinaculum. We used a cadaver model to compare the results of endoscopic carpal tunnel release through a one-portal distal (Group A, 15 specimens) and a one-portal proximal (Group B, 15 specimens) entry site with a new endoscopic technique. Our custom-made glass tube of three different sizes (5, 7, and 9 mm in diameter) is designed to house an endoscope and accommodate a meniscus knife for releasing the flexor retinaculum. Complete release of the flexor retinaculum was obtained in all limbs in both groups. In Group A the one complication (7%) was loss of the cotton tip from the cotton swab stick within the carpal tunnel. In Group B, there was a single case of injury to the superficial palmar arch in one hand and breakage of a glass tube in another hand, for a total complication rate of 13%. No other damage to anatomical structures was noted.

A preliminary scoring system for assessing the outcome of carpal tunnel release

Multiple outcomes are assessed in most studies of carpal tunnel syndrome, yet there are no validated methods of synthesizing these distinct measures into a single global score. We report a global score in which outcomes were selected and weighted according to their independent association with patient satisfaction with the results of surgery. Preoperative and 3-month follow-up data were analyzed on 104 subjects in a randomized controlled trial of open vs endoscopic carpal tunnel release. Patient satisfaction with surgery and a variety of subjective and objective outcome parameters were measured. In multivariate analyses, independent correlates of dissatisfaction included persistent numbness and paresthesia, incisional pain at follow-up evaluation, and decrease in grip strength. A global score was calculated by rounding to the nearest integer the model coefficients for these three variables. The global score correlated with patient satisfaction with surgery and time until return to work or full activities in patients undergoing open carpal tunnel release.

Prospective review of 278 endoscopic carpal tunnel releases using the modified chow technique

The results of 278 endoscopic carpal tunnel releases using the extrabursal dual portal Chow technique were analyzed prospectively. The majority of patients were pain free by the 57th postoperative day. The perioperative complication rate was 1.7%. The late complication rate was 2.8%. Two cases were converted to open carpal tunnel release. The average time to return to full-duty work was 65 days in those patients covered by worker's compensation, whereas it was 21 days in the privately insured (non-worker's compensation) patients. The endoscopic release of the transverse carpal ligament is an effective technique for the treatment of carpal tunnel syndrome with a low complications rate. Return to full employment requires more time in those patients covered by worker's compensation.

Endoscopic Carpal Tunnel Release

On the basis of clinical outcome measures, endoscopic carpal tunnel release is an effective operation for treating idiopathic carpal tunnel syndrome. Patients who have undergone bilateral carpal tunnel operations have routinely preferred endoscopic release over the open release. An endoscopic release allows many patients to return to work sooner. However, the benefits of more rapid functional recovery and return to work are tempered by the increased cost and higher complication rate of the procedure. Endoscopic carpal tunnel release is a technically demanding procedure with low tolerances for error. Despite its widespread use, its role is not yet clearly defined.

Nerve Entrapment Syndromes in the Wrist

The patient with compression neuropathies of the median and ulnar nerves at the wrist commonly presents with pain, paresthesias, and weakness in the hand and digits. Diagnosis of these conditions is becoming more widespread with the increased attention given to "cumulative trauma disorders" during the past decade. Successful management requires a thorough understanding of the pathophysiology of compression neuropathy and how it relates to the various diagnostic tests available today. The authors review the epidemiology, etiology, and evaluation of compression neuropathy and discuss common clinical presentations, treatment recommendations, and controversies surrounding carpal and ulnar tunnel syndromes.

[Endoscopic decompression of the median nerve in the carpal tunnel. Apropos of 1,400 cases]

We report the results of endoscopic carpal tunnel release in 1,400 patients over a two year period (minimum 6-month follow-up). All patients were operated on using a technique derived from that of Chow. Complications were limited to two partial lesions of the superficial palmar arch and one interdigital nerve lesion. The technique is described. Analysis of the results indicates the advantages of this method. Though immediate post-operative comfort was greater and restoration of the grip quicker, the results were roughly similar to those of the classic method in the 6 months following surgery. Sympathetic dysfunction represented only 0.28% of cases. Patients generally returned to work earlier than with the classic technique. This method does not replace the conventional technique for certain indications. The authors emphasize the difficulties involved and recommend that this method be used only by experienced surgeons and aware of intra-operative risks.