An open twin incision technique of carpal tunnel decompression with reduced incidence of scar tenderness

Pillar Pain After Minimally Invasive and Standard Open Carpal Tunnel Release: A Systematic Review and Meta-analysis

Purpose

Pillar pain is a recognized postoperative complication of carpal tunnel release (CTR). Minimally invasive and alternative surgical techniques can theoretically prevent pillar pain, and the aim of this review was to compare the incidence of pillar pain after standard open CTR and alternative surgical techniques.

Methods

MEDLINE, Embase, and Scopus databases were thoroughly searched. Randomized controlled trials comparing minimally invasive surgical techniques to standard open CTR were identified. Data, including surgical technique, number of hands, incidence of pillar pain, and follow-up intervals, were extracted. Odds ratios (OR) were expressed as pillar pain incidence in the intervention group relative to standard open CTR.

Results

There were 12 studies included. No statistically significant differences were noted among endoscopic (OR = 0.53, P = .20), flexor retinaculum lengthening (OR = 1.00, P = 1.00), short incision (OR = 0.41, P = .07) or illuminated knife techniques (OR = 0.18, P = .16). There was a statistically significant decrease in pillar pain after minimally invasive CTR (OR = 0.41, 95% confidence interval 0.20-0.86, I2 = 0%, P = .02) between 3- and 6-months follow-up; however, analyses at all other follow-up periods failed to reach statistical significance.

Conclusions

Although our findings suggest that standard open CTR may be associated with an increased duration of pillar pain between 3 and 6 months postoperatively, our results suggest that minimally invasive CTR techniques do not affect either the initial development or persistence of pillar pain.

Clinical relevance

Our results illustrate the natural history of pillar pain with the majority of cases resolving after 6 months, highlighting the utility of symptomatic and conservative treatments and patient education in the management of pillar pain.

[Differential therapeutic Approaches in Treatment of Carpal Tunnel Syndrome]

Carpal tunnel syndrome (CTS) is one of the most common compression neuropathies. The therapeutic concept should be tailored to each patient individually, with initial non-surgical treatment being the standard of care for early CTS. Primary surgical intervention should be considered in more advanced diseases stages, in case of concomitant pathologies (including space-occupying lesions, complex regional pain syndrome or diabetic neuropathy), if non-surgical strategies have failed or in pregnancy-related CTS. This work aims to discuss common surgical approaches, their clinical application as well as benefits and disadvantages in a pragmatic style. Further, we highlight surgical strategies to address recurrent CTS following failed primary surgery. In view of the recently updated S3 guidelines "Diagnosis and Therapy of Carpal Tunnel Syndrome", this topic is timely and relevant for hand and nerve surgeons.

Revision of Carpal Tunnel Surgery

Carpal tunnel release is one of the most commonly performed upper extremity procedures. The majority of patients experience significant improvement or resolution of their symptoms. However, a small but important subset of patients will experience the failure of their initial surgery. These patients can be grouped into persistent, recurrent, and new symptom categories. The approach to these patients starts with a thorough clinical examination and is supplemented with electrodiagnostic studies. The step-wise surgical management of revision carpal tunnel surgery consists of the proximal exploration of the median nerve, Guyon’s release with neurolysis, the rerelease of the transverse retinaculum, evaluation of the nerve injury, treatment of secondary sites of compression, and potential ancillary procedures. The approach and management of failed carpal tunnel release are reviewed in this article.

Three-dimensional analysis of thumb motion recovery after carpal tunnel release

This study quantified recovery of thumb motion in patients with carpal tunnel syndrome after carpal tunnel release using three-dimensional motion analysis with a retroreflective surface-based marker method. Eighteen hands from 14 patients who underwent carpal tunnel release for idiopathic carpal tunnel syndrome were included. The angular movements of the three joints of the thumb, the path length of the thumb tip and the area enclosed by the perimeter path of the thumb tip were measured during circumduction. The range of joint movement, including abduction/adduction of the trapeziometacarpal joint, and flexion/extension of the interphalangeal and metacarpophalangeal joints and the path length of the thumb tips, improved significantly 1 year after surgery. The quantification of thumb kinematics helps to better understand motor dysfunction in carpal tunnel syndrome, assess the severity of the condition and decide on treatment.Level of evidence: IV.

Open carpal release using local anesthesia without a tourniquet: Does bleeding tendency affect the outcome?

Background

The aim of this study was to analyze the clinical results of minimal single palmar-incision carpal tunnel release without a tourniquet.

Methods

We reviewed the medical records of 75 patients (90 cases of carpal tunnel syndrome) who underwent minimal single-palmar incision carpal tunnel release without a tourniquet from June 2010 to January 2018. Ten patients had a bleeding tendency. We compared the preoperative and postoperative Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) scores. We also analyzed outcomes and complications according to the presence of a bleeding tendency.

Results

In all cases, there was a complete disappearance or marked improvement in symptoms within 6 months, with no recurrence. The postoperative BCTQ score showed a significant improvement compared to the preoperative score, and no statistically significant difference in BCTQ scores was detected according to the presence of a bleeding tendency.

Conclusions

Carpal tunnel release without a tourniquet using a minimal single palmar incision is effective and reliable. This technique prevents unnecessary pain associated with the tourniquet and is especially helpful in patients with a bleeding tendency or those treated with hemodialysis.

Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice

Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

'INSIGHT-PRECISION': a new, mini-invasive technique for the surgical treatment of carpal tunnel syndrome

Objective

To describe a new mini-invasive surgical technique for carpal tunnel release and to present clinical findings associated with using this technique.

Methods

Patients with idiopathic carpal tunnel syndrome without prior surgical treatment, who underwent a new minimally-invasive surgical technique using a specific surgical tool-kit developed by the author, were included. Prospective data were collected, including preoperative electrodiagnostic testing. The subjective condition of all patients was evaluated pre- and postoperatively with a five-level Likert-type scale (LS) and muscular strength was tested using a JAMAR dynamometer and pinch gauge.

Results

A total of 116 patients (157 hands/cases) underwent surgery performed by the author, and were followed for a mean of 40 months (range, 6 months–7 years). Of these, preoperative electrodiagnostic testing was performed in 112 patients (96.6%). No significant complications were reported. By three months, patients reported that they were satisfied or very satisfied in 147/149 cases (98.7%; LS grade I and II). Strength recovery at three months, based on the average of four measures, was 99.17% (range, 97.43–100.97%).

Conclusions

The described technique is minimally invasive, safe and simple to perform, and provides good results.

Comparison between single portal endoscopic and 1-cm open carpal tunnel release

Given the controversy about the best surgical technique for carpal tunnel release, this study tested the hypothesis that no significant differences would be observed between single-portal endoscopic release and a short, 1-cm incision open release in a large sample of patients. Consecutive patients were assigned to one of the two techniques. Preoperative and postoperative measurements included grip and pinch strength, a visual analog scale for pain and a satisfaction questionnaire. Eighty-seven patients completed the study: 35 with an endoscopic release and 52 with an open release. Both techniques were effective and safe: grip and pinch strength decreased 1 month after surgery in both techniques but improved significantly at 6 and 12 months (P < 0.05) while the complication rate was low. Subjective results were judged to be "excellent or good" by more than 90% of patients in both groups. No significant between-technique differences in outcomes were observed thus, surgical decisions may be based on criteria other than effectiveness. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Recurrent carpal tunnel syndrome: Evaluation and treatment of the possible causes

AIM

To investigate the causes of the recurrent carpal tunnel syndrome (CTS) and implemented surgical interventions.

METHODS

Four hundred and eighty-seven patients, who were diagnosed with CTS and underwent surgical intervention between October 2016 and September 2007, were evaluated in this retrospective study. The age, gender, physical evaluation findings, electrophysiological examination reports and implemented surgical treatment methods were analyzed.

RESULTS

Thirty-nine of the cases were operated due to recurrent CTS. Further examination of the patients with recurrent CTS revealed that ten cases had diabetic polyneuropathy, three cases had hypothyroidism, two cases had rheumatoid arthritis and one case had systemic amyloidosis. Postoperative electromyography confirmed the neuropathy was due to systemic diseases. The remaining 23 patients with recurrent CTS did not have any systemic disease and all of them had applied previously to another health center.

CONCLUSION

We concluded that the recurrence rates in CTS might be decreased with exploration and incision of the entire transverse ligament. Damage to the motor and sensory branches of the median nerve could be avoided with an incision on the ulnar side.

A Clinical Study of the Modified Thread Carpal Tunnel Release

BACKGROUND

Previous studies have indicated that the thread carpal tunnel release (TCTR) is a safe and effective technique. Through a study on 11 cadaveric wrists, the TCTR procedure was modified and the needle control accuracy was improved to 0.15 to 0.2 mm, which is precise enough to preserve superficial palmar aponeurosis (SupPA), Berrettini branch, and common digital nerves. The aim of the present study was to verify the modified TCTR clinically.

METHODS

The modified TCTR was performed on 159 hands of 116 patients. The Boston Carpal Tunnel Syndrome Questionnaire was used for assessing the outcomes. Statistical analyses were used to compare the outcomes with the available data from the literature for the open and endoscopic techniques.

RESULTS

TCTR led to significant improvement in the short-term results, and the outcomes were better in long-term results compared with the open or endoscopic release. The SupPA, Berrettini branch, and common digital nerves were protected. There was no neurovascular complication for any case. Significant relief of symptoms was observed 3 to 5 hours post procedure. Most patients used their hands on the day of the procedure for simple daily activity. Patients reported their sleep quality was improved on the surgical day. Most patients with office jobs were able to return to work on postoperative day 1, and those with repetitive jobs returned to work in about 2 weeks. The statistical evidence proves that the modified TCTR procedure results in improved clinical outcomes as compared with open carpal tunnel release (CTR) and endoscopic CTR.

CONCLUSIONS

The TCTR procedure has been shown to be a safe and effective technique for CTR. The modified TCTR procedure minimizes postoperative complications, such as pillar pain, scar tenderness, or functional weakness, by avoiding unnecessary injuries to the surrounding structures around the transverse carpal ligament during the procedure.

The Potential Benefit of Intracarpal Pressure Measurement in Endoscopic Carpal Tunnel Syndrome Surgery – An Analysis of EMG Findings and Pressure Values

Endoscopic carpal tunnel syndrome surgery is a modern minimally invasive method of carpal tunnel decompression. However, the method does also have its critics, who emphasize that there is an increased rate of complications in comparison to open procedures. To further improve and optimize results of endoscopic surgery we used an intracarpal pressure sensor to verify the effect of carpal tunnel decompression. The endoscopic single portal approach was used in all cases. Median nerve conduction studies were performed prior to and 3 months after surgery. Two groups, those with pressure studies and those without, were then compared according to several EMG parameters such as: median nerve distal motor latency, amplitude of motor response, sensory nerve conduction velocity to the index finger, and amplitude of sensory nerve action potential. In both groups, we observed similarly significant improvements in all conduction parameters, except the amplitude of motor response, which did not change in either group, i.e. no difference in postoperative EMG between the two groups was observed. Despite this fact, intracarpal pressure measurement is still useful in localising the point in which the median nerve is compressed and provides valuable functional information on the level decompression achieved.

A Comparison of Two Limited Open Techniques for Carpal Tunnel Release

Review of the literature shows the effectiveness of limited open carpal tunnel release to be comparable to that of endoscopic carpal tunnel release in respect of recovery of grip strength, time of return to work and complication rate. A randomised, controlled study was designed to compare the effectiveness of a single versus a double limited open technique of carpal tunnel release. Sixty-five patients (73 hands) with a mean age of 48 years were operated on, 40 hands by the single incision and 33 by the double incision method. Grip and pinch strengths, digital sensibility (Filament and 2PD tests) and Levine scores were evaluated throughout 12 months of follow-up. We found that the single incision method offers better results in respect of grip and pinch strengths: less weakness at 1 month after surgery and a faster improvement relative to pre-operative values which is statistically significant. This, however, did not translate directly into Levine functional and symptom scores which, at each assessment, did not differ significantly between the two methods.

Ultra-Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to compare the outcomes of 1-mm ultra-minimally invasive ultrasound-guided carpal tunnel release and 2-cm blind mini-open carpal tunnel release.

METHODS

We conducted a single-center individual parallel-group controlled-superiority randomized control trial in an ambulatory office-based setting at a third-level referral hospital. Eligible participants had clinical signs of primary carpal tunnel syndrome and positive electrodiagnostic test results and were followed for 12 months. Independent outcome assessors were blinded. Patients were randomized by concealed allocation (1:1) by an independent blocked computer-generated list. The postoperative score on the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire was the primary variable. Grip strength and time for discontinuation of oral analgesics, complete wrist flexion-extension, relief of paresthesia, and return to normal daily activities (including work) were assessed.

RESULTS

Ninety-two of 128 eligible patients were randomly allocated and analyzed. QuickDASH scores were 2.2 to 3.3 times significantly lower in the ultra-minimally invasive group for the first 6 months: 23.6 [95% confidence interval (CI), 20.5, 27.4] versus 52.6 [95% CI, 49.4, 57.0] at the first week and 4.09 [95% CI, 1.5, 7.1] versus 13.0 [95% CI, 9.4, 18.9] at 6 months. Return to normal daily activities occurred significantly sooner in the ultra-minimally invasive group: 4.9 [95% CI, 3.2, 6.5] versus 25.4 [95% CI, 18.2, 32.6] days.

CONCLUSIONS

Ultra-minimally invasive carpal tunnel release provides earlier functional return and less postoperative morbidity with the same neurologic recovery as mini-open carpal tunnel release for patients with symptomatic primary carpal tunnel syndrome.

Comparison of short wrist transverse open and limited open techniques for carpal tunnel release: a randomized controlled trial of two incisions

The purpose of this randomized controlled trial was to compare outcomes of limited open and short wrist transverse techniques in patients with carpal tunnel syndrome. In a single centre randomized controlled trial, 84 patients with idiopathic carpal tunnel syndrome were randomized before surgery to limited open or short wrist transverse open carpal tunnel release. The patients were evaluated at 6 weeks, 3 months, 6 months, and 1 and 2 years after surgery. At every follow-up, the Brigham and Women's Carpal Tunnel Questionnaire scores, scar discomfort, and subjective patient satisfaction were evaluated. Two years after surgery, five patients were lost to follow-up. The groups had similar Brigham and Women's Carpal Tunnel Questionnaire Symptom Severity and Functional Status scores and subjective satisfaction scores. The incidence of scar discomfort was not significantly different between the two groups on serial postoperative follow-up. Short wrist transverse open release surgery showed similar early postoperative symptoms and subjective and functional outcomes to limited open release.

LEVEL OF EVIDENCE

II.

Carpal tunnel release using the radial sided approach compared with the two-incision approach

We compared carpal tunnel release using a radial sided approach (RCTR) with a two-incision approach with regards to complications, grip strength, and functional outcomes. Retrospective chart review was done and data was collected pre-operatively, and post-operatively at six weeks and three months. A total of 32 and 26 patients were included in the two-incision and RCTR groups respectively. At six weeks, the RCTR group showed an increased grip strength (+32.24%) while the two-incision group was weaker (-6.75%). Both groups showed an increased strength at three months, RCTR at 98.4% while the two-incision group was significantly lower at 38.6% increase. Both techniques provided improvement in outcome scores, with no statistical difference. RCTR was associated with a significantly earlier return of grip strength and had better grip strength at six weeks and three months post-operatively. Both techniques provided symptom relief and good functional outcome.

Ultra minimally invasive sonographically guided carpal tunnel release: an external pilot study

BACKGROUND

Authors have reported better outcomes, by reducing surgical dissection for carpal tunnel syndromes requiring surgery. Recently, a new sonographically guided technique for ultra minimally invasive (Ultra-MIS) carpal tunnel release (CTR) through 1mm incision has been described.

HYPOTHESIS

We hypothesized that a clinical trial for comparing Ultra-MIS versus Mini-open Carpal Tunnel Release (Mini-OCTR) was feasible.

MATERIALS AND METHODS

To test our hypothesis, we conducted a pilot study for studying Ultra-MIS versus Mini-OCTR respectively performed through a 1mm or a 2 cm incision. We defined success if primary feasibility objectives (safety and efficacy) as well as secondary feasibility objectives (recruitment rates, compliance, completion, treatment blinding, personnel resources and sample size calculation for the clinical trial) could be matched. Score for Quick-DASH questionnaire at final follow-up was studied as the primary variable for the clinical trial. Turnover times were studied for assessing learning curve stability.

RESULTS

Forty patients were allotted. Primary and secondary feasibility objectives were matched with the following occurrences: 70.2% of eligible patients finally recruited; 4.2% of randomization refusals; 26.6 patients/month recruited; 100% patients receiving a blinded treatment; 97.5% compliance and 100% completion. A sample size of 91 patients was calculated for clinical trial validation. At final follow-up, preliminary results for Quick-Dash substantially favored Ultra-MIS over Mini-OCTR (average 14.54 versus 7.39) and complication rates were lower for Ultra-MIS (5% versus 20%). A stable learning curve was observed for both groups.

CONCLUSIONS

The clinical trial is feasible. There is currently no evidence to contraindicate nor withhold the use of Ultra-MIS for CTR.

LEVEL OF EVIDENCE

III.

Prospective randomized comparison of single-incision and two-incision carpal tunnel release outcomes

BACKGROUND

This study analyzes both the subjective and objective symptom and functional outcomes of patients who underwent either traditional single-incision or two-incision carpal tunnel release (CTR).

METHODS

From 2008 to 2009, patients with isolated carpal tunnel syndrome were randomized to undergo either single-incision or two-incision CTR by a single surgeon at a university medical center. Pre-operatively, participants completed a Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, Brigham and Women's Carpal Tunnel Questionnaire (BWCTQ), as well as grip and pinch strength and Semmes-Weinstein monofilament sensation testing. At 2 weeks, 6 weeks and at least 6 months post-operatively, these measurements were repeated along with assessment of scar tenderness and pillar pain. Data were analyzed using SPSS version 20 software to perform non-parametric tests and Pearson's correlations. Significance was set at p = 0.05.

RESULTS

There was no statistically significant difference between the single- and two-incision CTR groups with respect to pre- and post-operative DASH scores, BWCTQ scores, grip strength, pinch strength, scar tenderness, or pillar pain. The only statistically significant difference was improved sensation by Semmes-Weinstein in the single-incision group in the second finger at 6 weeks post-operatively and in the third finger at 6 months post-operatively.

CONCLUSIONS

The preservation of the superficial nerves and subcutaneous tissue between the thenar and hypothenar eminences may account for reports of less scar tenderness and pillar pain among recipients of two-incision CTR compared to single-incision CTR in the early post-operative period. However, there is similar post-operative recovery and improvement in grip and pinch strength and sensation after 6+ months post-operatively.

Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes

PURPOSE

To evaluate intraoperative findings and outcomes of revision carpal tunnel release (CTR) and to identify predictors of pain outcomes.

METHODS

We performed a retrospective cohort study of all adult patients undergoing revision CTR between 2001 and 2012. Patients were classified according to whether they presented with persistent, recurrent, or new symptoms. We compared study groups by baseline characteristics, intraoperative findings, and outcomes (strength and pain). Within each group, we analyzed changes in postoperative pinch strength, grip strength, and pain from baseline. Predictors of postoperative average pain were examined using both multivariable linear regression analyses and univariable logistic regression to calculate odds ratios of worsened or no change in pain.

RESULTS

We performed revision CTR in 97 extremities (87 patients). Symptoms were classified as persistent in 42 hands, recurrent in 19, and new in 36. The recurrent group demonstrated more diabetes and a longer interval from primary CTR, and was less likely to present with pain. Incomplete release of the flexor retinaculum and scarring of the median nerve were common intraoperative findings over all. Nerve injury was more common in the new group. Postoperative pinch strength, grip strength, and pain significantly improved from baseline in all groups, apart from strength measures in the recurrent group. Persistent symptoms and more than 1 prior CTR had higher odds of not changing or worsening postoperative pain. Higher preoperative pain, use of pain medication, and workers' compensation were significant predictors of higher postoperative average pain.

CONCLUSIONS

Carpal tunnel release may not always be entirely successful. Most patients improve after revision CTR, but a methodical approach to diagnosis and adherence to safe surgical principles are likely to improve outcomes. Symptom classification, number of prior CTRs, baseline pain, pain medications, and workers' compensation status are important predictors of pain outcomes in this population.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Ultra-minimally invasive sonographically guided carpal tunnel release: anatomic study of a new technique

OBJECTIVES

The purposes of this study were to measure a safe zone and a path for ultra-minimally invasive sonographically guided carpal tunnel release with a 1-mm incision in healthy volunteers and then test the procedure in cadavers.

METHODS

First, a previously reported sonographic zone was defined as the space between the median nerve and the closest ulnar vascular structure. Axially, the safest theoretical cutting point for carpal tunnel release was set by bisecting this zone. Magnetic resonance imaging was used for axially determining the limits of the sectors (origin at the cutting point) that did not enclose structures at risk (arteries and nerves) and coronally for determining whether our release path could require directions that could potentially compromise safety (origin at the pisiform's proximal pole). Second, in cadavers, we performed ultra-minimally invasive sonographically guided carpal tunnel release from an intracarpal position through a 1-mm antebrachial approach. Efficacy (deepest fibrous layer release rate), safety (absence of neurovascular or tendon injury), and damage to any anatomy superficial to transverse carpal ligament were assessed by dissection.

RESULTS

All 11 of our volunteers (22 wrists) had safe axial sectors located volar and radially of at least 80.4º (considered safe). Release path directions were theoretically safe (almost parallel to the longitudinal axis of the forearm). In 10 cadaver wrists, ultra-minimally invasive sonographically guided carpal tunnel release was effective (100% release rate) and safe without signs of intrusion into the superficial anatomy.

CONCLUSIONS

Ultra-minimally invasive sonographically guided carpal tunnel release in a safe sonographic zone may be feasible The technique preserves the superficial anatomy and diminishes the damage of a surgical approach.

Comparison of longitudinal open incision and two-incision techniques for carpal tunnel release

PURPOSE

This study analyzes the long-term postoperative symptoms and functional outcomes of patients who underwent either traditional open (single-incision) or 2-incision carpal tunnel release (CTR). Because 2-incision CTR preserves the superficial nerves and subcutaneous tissue between the thenar and hypothenar eminences, it may account for fewer postoperative symptoms and improved functional recovery.

METHODS

A retrospective chart review identified patients who underwent either open or 2-incision CTR for isolated carpal tunnel syndrome between 2005 and 2008 by a single surgeon. Patients with a history of hand trauma or confounding comorbidities were excluded. We mailed a Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire and a Brigham and Women's Carpal Tunnel Questionnaire (BWCTQ) to all eligible participants. Data from the completed questionnaires were analyzed using independent t-tests and Pearson's correlation. Significance was set at p = .05.

RESULTS

A total of 82 patients (106 hands; 27 men and 55 women; mean age, 60.5 y) were eligible to participate. Of these, 51 patients (63 hands; 20 men and 31 women; mean age, 61.1 y) responded (62% response rate). The mean duration of follow-up was 22 months (range, 12-37 mo; SD 7.3 mo). The 2-incision group mean BWCTQ Symptom Severity Scale score (1.13, SD 0.25) was significantly lower than the open group mean Symptom Severity Scale score (1.54, SD 0.70, p = .001). The 2-incision group mean BWCTQ Functional Status Scale score (1.24, SD 0.51) was significantly lower than the open group mean Functional Status Scale score (1.71, SD 0.76, p = .008). The 2-incision group mean DASH score (5.10, SD 12.03) was significantly lower than the open group mean DASH score (16.28, SD 19.98, p = .01).

CONCLUSIONS

Patients treated with 2-incision CTR reported statistically significantly less severe long-term postoperative symptoms and improved functional status compared with patients treated with traditional open CTR. Future prospective studies with objective measures are needed to further investigate the difference in outcomes found between these 2 CTR techniques.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Double- versus single-incision technique for open carpal tunnel release

A prospective, randomized, controlled trial was performed comparing the double incision technique to the conventional open method used in carpal tunnel decompression surgery, with pillar pain, scar sensitivity, and recovery of grip strength each assessed independently. Forty patients (40 hands) were operated on, 21 hands with the standard single-incision technique and 19 hands with the double-incision technique. Patients were assessed throughout 6 months of follow-up. The results showed that the double-incision technique caused less pillar pain and scar sensitivity compared to the single-incision technique. No difference in recovery of grip strength was noted between the 2 techniques. The limited open technique using the double incision in carpal tunnel decompression surgery is advantageous over the standard technique in tackling scar-related morbidities.

A Systematic Review of Reviews Comparing the Effectiveness of Endoscopic and Open Carpal Tunnel Decompression

Controversy persists regarding the benefit of endoscopic carpal tunnel release compared with open carpal tunnel release for pain, numbness, strength, return to work and function, scar tenderness, and complications. For surgeons, a recommended first source of information on treatment effectiveness is a review of high-methodologic-quality articles. This review of reviews was undertaken to answer this clinical question regarding these outcomes. Cochrane, MEDLINE, EMBASE, CINAHL, and HealthSTAR databases were searched using the key words "endoscopic carpal tunnel," with limits "review or overview" and dates from 1989 to present. Five key journals were hand-searched. Any review with a reference to at least one randomized controlled trial that compared endoscopic carpal tunnel release to open carpal tunnel release was to be included. Two reviewers independently scanned titles and abstracts for potential relevance. Selection as relevant was confirmed through a review of full texts. Disagreements were resolved through discussion and consensus. The selected reviews were assessed for methodologic quality on the basis of the scale of Hoving et al. Of 48 articles initially identified, seven pertinent reviews were selected. Of these seven, three reviews of high methodologic quality concurred that there is no difference between the two techniques in symptom relief and that the evidence is conflicting for return to work and function. The risk of permanent median nerve injury does not differ between the techniques. The reviews indicated that the endoscopic carpal tunnel release technique is worse in terms of reversible nerve injury but superior in terms of grip strength and scar tenderness, at least in short-term follow-up. Several trials have not been incorporated in these reviews and statistical pooling has not been conducted. Further systematic review with meta-analysis may permit more definitive conclusions about the relative effectiveness of these two techniques, particularly with regard to return to work and function.

Open Median Nerve Release Using Double Mini Skin Incision in Patients With Carpal Tunnel Syndrome: Technique and Clinical Results

Patients who undergo open carpal tunnel surgery frequently complain of the postoperative cosmetic appearance at the site of the incision on the palm. This problem occurs as a result of excessive scar formation, and the long incision. A double mini skin incision, each 1 cm long, was used in the surgical treatment of carpal tunnel syndrome. The transverse carpal ligament was easily sectioned. Postoperatively healing was good with no excessive scar formation.

Surgical technique to reduce scar discomfort after carpal tunnel surgery

A total of 379 patients (416 hands) with clinically diagnosed and electromyographically confirmed carpal tunnel syndrome were enrolled in a prospective study to determine the influence of a modified open decompression technique on postoperative scar discomfort. The new technique used in 184 patients (200 hands) is presented. Special attention was focused on identification and preservation of macroscopically detectable subcutaneous nerves. After using this method, which permits complete visualization of the entire transverse carpal ligament, the incidence of postoperative scar discomfort was 2.5%. This was significantly lower compared with the group of 195 patients (216 hands) treated by standard open decompression technique, without preservation of subcutaneous nerves. Primary results regarding relieving symptoms were comparable in both groups. Five anatomic variations of subcutaneous innervation, at the site of the incision in the line with the radial border of the ring finger, are described. The etiology of scar discomfort is discussed.

Identification and preservation of Palmar cutaneous nerves during open carpal tunnel release

We looked for crossing cutaneous nerve branches during standard open carpal tunnel release and attempted to preserve them. Open carpal tunnel release was performed on 34 hands in 29 patients. Crossing cutaneous nerves were identified in 47% of hands and successfully preserved in each case. No patient experienced postoperative pillar pain or scar hypersensitivity.

The detailed anatomy of the palmar cutaneous nerves and its clinical implications

The forearms and hands of 40 fresh-frozen cadavers were dissected under the microscope to study the palmar cutaneous branch of the median nerve (PCBm) and the palmar cutaneous branch of the ulnar nerve (PCBu). Branches of the PCBm innervating the scaphoid were typically found, but in no specimen did we find a 'typical' cutaneous branch of the ulnar nerve. According to our findings, standard incisions for open carpal tunnel release carry a significant risk of damaging branches of the PCBm or PCBu. The chance of injury to these sensory nerves can be minimized by using a short incision in the proximal palm or a twin incision approach, which we describe. Because the PCBm is closely associated with the ulnar side of the flexor carpi radialis (FCR) sheath, this sheath should be opened on the radial side during harvest of the FCR tendon for transfer. When transferring the palmaris longus tendon, it should be cut proximal to the distal wrist crease to avoid possible damage to the PCBm.

Two-portal endoscopic carpal tunnel release surgery: report of early experience

Endoscopic carpal tunnel release is increasingly performed to treat median nerve entrapment neuropathy at the transverse carpal ligament. Proponents of these procedures claim that there are early postoperative advantages to be gained by the patient in the form of decreased pain and weakness, thus facilitating an earlier return to function. However, serious complications associated with the use of these techniques have been reported, especially during the surgeon's purported initial steep learning curve. A prospective analysis of the authors' first 51 cases using a two-portal endoscopic technique was conducted to determine whether these learning curve complications occurred. The authors did experience a learning curve; however, it was not significant. They encountered no serious complications and patient satisfaction was very high. It is concluded that the procedure is relatively easy to learn and safe to perform.

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.

Distribution of nerve fibers in the standard incision for carpal tunnel decompression

Twenty-two paired biopsy specimens of skin and subcutaneous tissue from the proximal and distal halves of the conventional curvilinear incision or carpal tunnel decompression were histologically examined. The specimens were immunohistochemically stained with S100 antibody to highlight the nerve fibers. The mean count of free nerve endings in the proximal biopsy site was 4.42/mm2 (SD, 2.97; range, 1.23-12.27), compared to 4.2/mm2 (SD, 2.71; range, 1.01-10.50) in the distal biopsy specimens. This difference was not statistically significant (p = .20, Wilcoxon's signed ranks [matched pairs] test). The proximal incision site for carpal tunnel decompression did not appear to be more neuroreceptive than the distal incision site, providing no support for the implication of proximal incision sites in proximal scar tenderness.