Reducing neurologic and vascular complications of endoscopic carpal tunnel release using a modified chow technique

Case report: Ultrasound-guided needle knife technique for carpal ligament release in carpal tunnel syndrome treatment

Carpal tunnel syndrome (CTS) is a common peripheral neuropathy of the hand, mainly manifesting as sensory disturbances, motor dysfunctions, and pain in the fingers and hand. The pathogenesis of the disease is associated with fibrosis of the transverse carpal ligament in the carpal tunnel, which compresses median nerve. In our case, we demonstrate an ultrasound-guided needle knife technique to treat CTS. We guided the patient to a supine position on the examination table. The skin of the wrist area was sterilized for the procedure. After the skin was dry, we positioned sterile drapes, located the median nerve and compression, and marked the compression point. Local anesthesia was administered. An ultrasound-guided needle knife was inserted. The needle knife was advanced under ultrasound guidance. The carpal ligament was incised. A gradual release of pressure on the median nerve was observed on the ultrasound monitor. After treatment, the patient's finger sensation and motor function can significantly improve, and pain symptoms are markedly reduced, this case demonstrates that small needle-knife treatment can serve as a safe and effective minimally invasive therapeutic method.

Comparison of clinical outcomes between open and modified endoscopic release for carpal tunnel syndrome

The aim of the present study was to investigate a novel technology, requiring only a single portal and no special equipment, to perform endoscopic treatment of carpal tunnel (CT) syndrome (CTS). This novel technique involves a surgical approach and standard operating procedures and is designed to minimize the potential for complications. Patients with CTS were randomly assigned using a computer-generated random allocation and stratified by site to either the modified endoscopic CT release (MECTR) group (n=48) or open CT release (OCTR) group (n=46). Various medical indexes were compared between the two groups, including operative time, hospitalization time, the time required to resume a normal life or work, intraoperative complications, incision infection rate, the amelioration of symptoms (Kelly grading), post-operative scar pain score, recovery of grip strength and pinch strength, two-point discrimination and the presence of sympathetic dystrophy. The results revealed that all patients had grade A wound healing and the symptoms were completely relieved. No significant differences were observed between the two groups with regards to the incision infection rate, intraoperative complications, grip strength, pinch strength, two-point discrimination, presence of sympathetic dystrophy and clinical symptom amelioration. In addition, compared with the OCTR group, the MECTR group had a decreased operative and hospitalization time, post-operative scar pain score and time required to resume a normal lifestyle. Post-operative electromyographic examination also revealed that the median nerve sensory conduction speed increased compared with that prior to surgery in both groups. In conclusion, the use of MECTR for the treatment of CTS achieved higher patient satisfaction, a shorter operative time and hospitalization time, an earlier return to work time or resumption of a normal life, as well as less post-operative scar pain compared with OCTR. Thus, these results suggested that MECTR may be an effective method for the treatment of idiopathic CTS. Trial registration no. ChiCTR2000041165, retrospectively registered 20th December 2020.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions

PURPOSE

To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.

METHODS

A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.

RESULTS

Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.

CONCLUSIONS

Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

The effect of patient involvement in surgical decision making for carpal tunnel release on patient-reported outcome

PURPOSE

To investigate whether patient-reported outcomes are different according to patients' preference or experience in surgical decision making for carpal tunnel release.

METHODS

We preoperatively surveyed 85 patients who underwent carpal tunnel release regarding their preferred role in the process of surgical decision making and assessed their experienced role in the actual decision making 6 months after surgery using a Control Preference Scale. For patient-reported surgical outcomes, we used the Disabilities of the Arm, Shoulder, and Hand questionnaire. We compared these outcomes with those of patients having different preferences or experiences in surgical decision making and also compared the outcomes according to whether the preferred roles match the experienced roles.

RESULTS

The Disabilities of the Arm, Shoulder, and Hand scores were not significantly different between patients with different preferences for involvement in decision making for surgery or between those with different experiences in the actual decision making. However, those who experienced the same level of involvement as they had preferred were found to have better Disabilities of the Arm, Shoulder, and Hand scores than those who experienced a more active role or a more passive role than they had preferred.

CONCLUSIONS

This study demonstrates that patient-reported outcomes were not different between those with different preferences or experiences in surgical decision making for carpal tunnel release. However, this study suggests that patients whose experience in decision making matched with their preference may have better subjective outcomes after carpal tunnel release. This suggests that patients with carpal tunnel syndrome may benefit from physicians' efforts of identifying patients' preferences for involvement in decision making and matching the identified preferences to the decision-making process.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Evaluation of female hormone-related symptoms in women undergoing carpal tunnel release

As carpal tunnel syndrome is more common in women, particularly around the menopause, female-related risk factors are suspected to play a role in its pathogenesis. We have assessed whether female hormone-related symptoms are associated with upper extremity disabilities in women undergoing carpal tunnel release. A total of 92 women with a mean age of 53 years scheduled for surgery for carpal tunnel syndrome were assessed preoperatively for female hormone-related symptoms using the menopausal rating scale and other female-related factors such as menopausal status, pregnancy number and serum female hormone levels. Upper extremity disability was evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. DASH scores had a moderate correlation with total menopausal rating scale scores, but not with other female-related factors assessed. This study suggests that female hormone-related symptoms are associated with subjective upper extremity disabilities in women with carpal tunnel syndrome. This information may be helpful in addressing patients' complex symptoms or interpretation of outcomes in women with carpal tunnel syndrome.

Technical difficulties and their prediction in 2-portal endoscopic carpal tunnel release for idiopathic carpal tunnel syndrome

PURPOSE

This study aimed to identify technical difficulties encountered during 2-portal endoscopic carpal tunnel release (ECTR) and to determine their incidence. Furthermore, we assessed the possibility of preoperatively predicting such technical difficulties.

METHODS

We retrospectively reviewed the records of 311 hands of 311 patients with idiopathic carpal tunnel syndrome who underwent ECTR with our modified Chow 2-portal technique. Any technical difficulties during the procedure were reviewed and correlated with preoperative physical findings, nerve conduction studies, and magnetic resonance imaging findings, by use of the t test, χ(2) test, and binary regression analysis.

RESULTS

One or more difficulties were encountered in 139 of 311 hands (44.7%), whereas surgery in the remaining 172 hands (55.3%) was performed without any difficulties. Technical difficulties encountered were as follows: tight access in 61 hands, difficulty in identifying the distal part of the transverse carpal ligament through the exit portal in 35 hands, synovial tissue being caught at the cannula tip when pulling it out of the carpal tunnel in 39 hands, steep angle of the cannula assembly with difficulty in emerging from the exit portal in 29 hands, and other difficulties. Postoperative worsening of symptoms was observed in 8 hands (2.6%), in all of which technical difficulties were encountered. Tight access was noted in younger patients and those with a small cross-sectional area at the hook-of-hamate level. The entire ECTR procedure for older female patients was more likely to be easily performed.

CONCLUSIONS

The surgeon may face a variety of technical difficulties during ECTR. Technical difficulties were most often encountered during introduction of the cannula assembly into the carpal tunnel and pulling it out of the exit portal. Older female patients may be the best candidates for 2-portal ECTR.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Carpal tunnel pressure measurement during two-portal endoscopic carpal tunnel release

BACKGROUND

Although there remain concerns of median nerve damage during endoscopic carpal tunnel release for carpal tunnel syndrome, carpal tunnel pressure variations during Chow's two-portal technique have not been well investigated.

METHODS

We performed a modified two-portal endoscopic carpal tunnel release on 30 patients by inserting a catheter pressure transducer into the carpal tunnel for continuous pressure measurement during the procedure. Grip and pinch strengths, Semmes-Weinstein monofilament test, and nerve conduction studies were examined preoperatively and at postoperative 1, 3, and 6 months. Numbness and the Disabilities of the Arm, Shoulder and Hand score were also evaluated pre and postoperatively.

FINDINGS

Subjective symptoms and nerve conduction study findings improved uneventfully. The pressure was always observed to be maximum pressure immediately before the cannula was withdrawn from the exit portal, and carpal tunnel pressure >300 mm Hg was recorded in most of the patients.

INTERPRETATION

A transient increase in the carpal tunnel pressure occurred in all the patients; however, it did not correlate with their clinical outcome or with increased risk of peri-operative complications. Since time-pressure threshold of the median nerve during endoscopic carpal tunnel release is still unknown, our results did not guarantee its safety.

Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation

The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.