Sonographic Changes After Ultrasound-Guided Release of the Transverse Carpal Ligament: A Case Report

Carpal Tunnel Release With Ultrasound Guidance: Intermediate-Term Clinical Outcomes and Magnetic Resonance Imaging Findings

Purpose

The purpose of this study was to report intermediate-term outcomes following carpal tunnel release using ultrasound guidance and wide-awake local anesthesia no tourniquet, including a subset of patients with preoperative and postoperative magnetic resonance imaging (MRI).

Methods

In this observational study, patients with carpal tunnel syndrome were treated with carpal tunnel release using ultrasound guidance and wide-awake local anesthesia no tourniquet in a procedure room at a single center. Main outcomes were complications; return to activity and work at 2 weeks; Quick Disabilities of the Arm, Shoulder, and Hand and Boston Carpal Tunnel Questionnaire scores through 6 months; and postoperative morphological changes of the transverse carpal ligament, median nerve, and carpal tunnel evaluated using MRI.

Results

No complications were reported among 65 patients (68% women, 96 wrists). By 2 weeks, 97% of patients returned to normal activity and 100% returned to work. Statistically significant improvements in Boston Carpal Tunnel Questionnaire symptom severity scale, Boston Carpal Tunnel Questionnaire functional status scale, and Quick Disabilities of the Arm, Shoulder, and Hand scores occurred by the 2-week follow-up interval and persisted at 6 months (all P < .001). Pre- and postoperative MRI scans were available for 13 patients (17 wrists) at the 3-month mean follow-up. Complete transverse carpal ligament transection was documented in all wrists. Key MRI findings included a 22% increase in carpal tunnel cross-sectional area at the hamate (P < .001), a 52% increase in median nerve cross-sectional area at the hamate (P < .001), an 18% reduction in median nerve signal intensity (P = .002), a 38% reduction in the flattening ratio of the median nerve at the hamate (P < .001), a 33% reduction in the flattening ratio of the median nerve at the pisiform (P < .001), a 20% reduction in the flattening ratio of the carpal tunnel at the hamate (P < .001), and a palmar shift of the median nerve relative to the hamate in all cases.

Conclusions

Carpal tunnel release using ultrasound guidance using wide-awake local anesthesia no tourniquet in a procedure room setting was safe, effective, and resulted in morphological changes that were consistent with carpal tunnel decompression as demonstrated by MRI.

Type of study/level of evidence

Therapeutic IV.

Long-term Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance

BACKGROUND

The purpose of this study was to determine the long-term safety and efficacy of carpal tunnel release (CTR) using ultrasound guidance in a group of patients treated by a single physician.

METHODS

The study group consisted of 76 consecutive CTRs performed on 47 patients between June 2017 and April 2019 for whom 1-year follow-up was available. All procedures were performed by the same operator using a single CTR technique. Outcomes included complications; Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores; Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) scores; and a 5-point global satisfaction score (4 = satisfied, 5 = very satisfied).

RESULTS

The 47 patients included 27 females and 20 males (ages 31-91 years). Twenty-five patients (50 hands) had simultaneous bilateral CTRs, 4 patients (8 hands) had staged bilateral CTRs, and 18 patients had unilateral CTRs. No complications occurred. Statistically and clinically significant reductions in BCTQ-SSS, BCTQ-FSS, and QDASH scores occurred by 1 to 2 weeks post-CTR and persisted at 1-year (mean 1-year changes vs. pre-CTR -2.11, -1.70, and -44.99, respectively; P < .001 for all). The mean global satisfaction score at 1-year was 4.63.

CONCLUSIONS

CTR using ultrasound (US) guidance is a safe and effective procedure that produces statistically and clinically significant improvements within 1 to 2 weeks postprocedure that persist to 1 year. Furthermore, simultaneous bilateral CTRs using US guidance are feasible and may be advantageous for patients who are candidates for bilateral CTR.

Ultrasound (US) Changes in the Median Nerve Cross-Sectional Area After Microinvasive US-Guided Carpal Tunnel Release

OBJECTIVE

To document changes in the median nerve cross-sectional area (CSA) in the proximal carpal tunnel region after ultrasound (US)-guided carpal tunnel release (CTR).

METHODS

Prospective data were collected on 23 consecutive patients (37 wrists) treated with US-guided CTR by the primary author using the same office-based microinvasive technique. Ultrasound was used to measure the largest CSA of the median nerve in the proximal carpal tunnel region both preoperatively and postoperatively. The primary outcome measure was the change in the preoperative versus 6- to 10-week postoperative median nerve CSA.

RESULTS

The mean CSA of the median nerve decreased from 16.08 to 12.75 mm² at 6 to 10 weeks after US-guided CTR (P < .001). During the same period, the mean Boston Carpal Tunnel Questionnaire (BCTQ) symptom score decreased from 3.23 to 1.67 (P < .001), and mean BCTQ functional score decreased from 2.49 to 1.47 (P < .001), both exceeding minimal clinically important differences. Although the primary end point was the median nerve CSA at 6 to 10 weeks, statistically significant reductions in the median nerve CSA, as well as BCTQ scores, were also observed as early as 2 to 4 weeks after US-guided CTR (median nerve CSA, 12.40 mm² ; BCTQ symptom score, 2.00; BCTQ functional score, 1.75; all P ≤ .03).

CONCLUSIONS

To our knowledge, this investigation was the largest to date examining changes in the proximal median nerve CSA after US-guided CTR. Statistically significant reductions in the proximal median nerve CSA were observed within 6 to 10 weeks after ultrasound-guided CTR. These reductions were similar to those previously reported for open and endoscopic CTR and validate the ability of US-guided CTR to relieve median nerve compression.

Clinical Results of Ultrasound-Guided Carpal Tunnel Release Performed by a Primary Care Sports Medicine Physician

OBJECTIVES

The purpose of this study was to determine the safety and efficacy of ultrasound-guided carpal tunnel release (USCTR) in a consecutive group of patients treated by a single primary care sports medicine physician.

METHODS

The study group consisted of 35 USCTRs performed on 22 consecutive patients for whom clinical outcomes were available before USCTR and at 1 to 2 weeks, 1 month, and 3 months after USCTR. All procedures were performed by the same operator using a single USCTR technique. Outcomes included complications, Quick Disabilities of the Arm, Shoulder, and Hand scores, Boston Carpal Tunnel Questionnaire symptom severity and functional status scores, and a 5-point global satisfaction score.

RESULTS

The 22 patients included 13 female and 9 male patients (ages 31-82 years). Eleven patients (22 wrists) had bilateral simultaneous USCTRs; 2 patients (4 wrists) had staged bilateral USCTRs; and 9 patients had unilateral USCTRs. No complications occurred in any patient. Statistically and clinically significant reductions in Quick Disabilities of the Arm, Shoulder, and Hand scores and Boston Carpal Tunnel Questionnaire symptom severity and functional status scores occurred by 1 to 2 weeks after USCTR (mean 1- to 2-week changes, -29.23, -1.74, and -1.18, respectively), and further improvements occurred during the 3-month follow-up period (mean 3-month changes, -51.11, -2.29, and -1.91; P < .0001 for all values versus before USCTR). Mean global satisfaction scores at 1 to 2 weeks and 3 months were 4.63 and 4.66.

CONCLUSIONS

Ultrasound-guided CTR is a safe and effective procedure that can be performed by an experienced primary care sports medicine physician and typically results in significant improvements within the first 2 weeks after the procedure. Furthermore, bilateral simultaneous USCTRs are feasible and may provide significant advantages for patients who are candidates for bilateral CTRs.