Surgical release of the carpal tunnel

The Influence of Wound Closure Techniques after Surgical Decompression in Patients with Carpal Tunnel Syndrome on Sleep Disturbance and Life Quality: A Prospective Comparison of Surgical Techniques

BACKGROUND

The compression of the median nerve within the carpal tunnel is the cause of carpal tunnel syndrome (CTS). Surgical decompression is successful in improving sleep and quality of life, but the effect of tissue adhesives as a material for wound closure has not been investigated. The objective of the study was to evaluate sleep disorders and health-related life quality by comparing two methods for wound closure after carpal surgery in participants who were randomized to receive tissue adhesives or transcutaneous sutures.

METHODS

The subjects, aged 61.56 ± 12.03 years, were randomized to receive either tissue adhesives (n = 50) or suture-based wound closure (n = 50) using the Glubran Tiss 2® skin adhesive after subcutaneous running sutures. The outcomes were assessed during the 12-month postoperative follow-up. The Pittsburgh Sleep Quality Index (PQSI) and Insomnia Severity Scale (ISI) were used for the sleep disturbance assessment, and for the health-related quality of life assessment, the total SF-36 (36-Item Short Form Survey) was used.

RESULTS

The PQSI, ISI, and SF-36 were not statistically different between groups during the follow-up, except in the ISI score two weeks after surgery (9.40 ± 1.18 in the tissue adhesive group vs. 9.96 ± 1.09 in the suture-based group, p = 0.008). The PQSI, ISI, and SF-36 scores for all the subjects and groups were persistently improved at all the follow-up intervals after surgery. The total SF-36 score increased 12 months after surgery (49.84 ± 5.85 vs. 82.46 ± 5.68, p < 0.001).

CONCLUSIONS

Cyanoacrylate-based adhesion material can be used for wound closure after open CTS decompression as a standard transcutaneous suture, and both techniques equally lead to improved sleep and life quality. The possible advantages of tissue adhesives include a faster reduction in the ISI.

Optimizing Recovery After Carpal Tunnel Syndrome Release Surgery: The Role of Counseling in Pain Management and Perioperative Functional Enhancement

Background

Preoperative patient education is pivotal in improving patient outcomes during the perioperative phase, involving a thorough explanation of what patients can expect. This enhances adherence and reduces perioperative anxiety. In orthopedics, carpal tunnel syndrome, a common and painful hand condition, is effectively managed through surgical release under local anesthesia. Inadequate counseling before such procedures may intensify intraoperative anxiety and increase pain responses. Thus, this research aims to investigate the effects of comprehensive preoperative counseling on various parameters in carpal tunnel release surgery.

Methods

A case-control study design was adopted for this study. A retrospective analysis of patients who underwent carpal tunnel release surgery was performed. These patients were categorized into two distinct groups: one group received comprehensive counseling during their clinic visits, while the other group reported receiving less effective counseling. Evaluation encompassed patient-related factors, disease-related aspects, and perioperative variables for both groups.

Results

The study comprised 681 participants, with 526 (77.2%) being females, 421 (61.8%) undergoing surgery on the right side, and 519 (76.2%) employed in non-manual occupations. Moreover, 559 (82.1%) were non-smokers, while approximately two-thirds of the cohort had both diabetes and hypertension. The average age of participants was 52 years, and they reported a mean functional disability score of 7.2 out of 10. The comprehensive preoperative counseling group consisted of 333 patients, while the other group included 348 patients. The analysis revealed statistically significant differences between the two groups, including reduced intra-procedural anxiety (p = 0.043), decreased intraoperative pain (p = 0.005), lower rates of wound complications (p = 0.022), and improved self-reported pain relief (p = 0.3).

Conclusion

Our study emphasizes the crucial role of preoperative counseling in improving patient experiences during perioperative care, leading to reduced anxiety, milder pain responses, fewer complications, decreased reliance on postoperative pain medication, and increased self-reported pain relief.

Level of Evidence

Level III, Case-control retrospective study.

The Influence of the Tissue Adhesive Material as a Surgical Wound-Closure Technique Following Carpal Tunnel Decompression on Neurological and Functional Outcomes: A Single-Center Randomized Controlled Trial

Background Carpal tunnel syndrome (CTS) is caused by compression of the median nerve in the carpal tunnel. The effect of tissue adhesives as a material for wound closure following CTS decompression has been insufficiently investigated. This study aimed to evaluate outcomes by comparing two modalities of wound closure following carpal surgery in patients randomly assigned to either tissue adhesives or sutures. Methodology This randomized, prospective study was conducted in April 2022 at the University Hospital of Split in Croatia. Patients aged 61.56 ± 12.03 years were randomized to either tissue adhesive Glubran Tiss 2®-based (n = 50) or suture-based (n = 50) wound-closure techniques. The following outcomes were assessed before surgery and six months postoperatively: hand strength, electroneurographic characteristics of the median nerve, and the Boston Carpal Tunnel Questionnaire. Results Significant differences between glue-based and suture-based wound-closure techniques were found in the six-month postoperative hand grip strength (25.06 ± 6.69 vs. 21.41 ± 5.62 kg; p = 0.002), postoperative sensory amplitude (10.08 ± 5.50 vs. 7.54 ± 5.41 mV; p = 0.012), and postoperative sensory velocity (42.22 ± 11.04 vs. 35.23 ± 16.40 m/s; p = 0.008). In the glue-based group, significantly more patients achieved a postoperative sensory velocity greater than 45 m/s (47.9% vs. 22.0%; p= 0.006), postoperative distal sensory latency less than 3.5 ms (89.6% vs. 84.0%; p = 0.304), and postoperative motor latency of less than 4.2 ms (60.42% vs. 38.00%; p = 0.022). Conclusions This trial demonstrated that cyanoacrylate-based adhesion material for wound closure after open CTS decompression compared with sutures showed a significant six-month postoperative increment in hand grip strength and median nerve sensory conduction.

A Comparison of Tissue Adhesive Material and Suture as Wound-Closure Techniques following Carpal Tunnel Decompression: A Single-Center Randomized Control Trial

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy caused by compression of the median nerve in the carpal tunnel. The presented study aimed to evaluate clinical outcomes by comparing two techniques of wound closure following carpal tunnel surgery in subjects randomized to the application of tissue adhesive or sutures.

METHODS

From April 2022 to December 2022, a single-center randomized prospective trial was conducted at the University Hospital of Split in Croatia. The study participants consisted of 100 patients (70 females) aged 61.56 ± 12.03 years, randomly assigned to suture-based wound closure (n = 50) or tissue adhesive-based wound closure (n = 50) with two-component skin adhesive Glubran Tiss 2^®. The outcomes were assessed postoperatively during the follow-up period at intervals of 2, 6, and 12 weeks. A scar assessment was performed using the POSAS (Patient and Observer Scar Assessment Scale) and cosmetic VAS (Visual Analog Scale). The VNRS (Verbal Number Rating Scale) was used to assess pain.

RESULTS

There were significant differences between glue-based wound closure and suture-based wound closure at 2-week and 6-week intervals after the surgery on the POSAS and cosmetic-VAS scales (better aesthetic effect with glue-based wound closure technique where noticed), with less postoperative pain at the same intervals. With the 12-week interval, differences in outcomes were insignificant.

CONCLUSIONS

This trial demonstrated that cyanoacrylate-based adhesion mixtures might be possibly superior in the short term in terms of cosmetic appearance and discomfort compared to conventional skin suturing techniques for the closing of surgical wounds following open CTS decompression, but there was no difference between both procedures in the long term.

Minimally Invasive Carpal Tunnel Release Using a Hook Knife through a Small Transverse Carpal Incision: Technique and Outcome

Background

Compared to the classic open technique, limited exposure techniques have the advantages of less scar pain, more grip and pinch strength, and earlier return to daily life. We evaluated the effectiveness and safety of our novel method of minimally invasive carpal tunnel release using a hook knife through a small transverse carpal incision.

Methods

This study included 111 carpal tunnel decompressions in 78 patients who underwent carpal tunnel release from January 2017 to December 2018. We performed carpal tunnel release using a hook knife through a small transverse incision just proximal to the wrist crease under local infiltration of lidocaine with tourniquet inflation in the upper arm. All patients were tolerable during the procedure and discharged following the procedure on the same day.

Results

At an average of 29.4 months of follow-up (range, 12-51 months), all but one patient (99%) revealed complete or near complete symptomatic recovery. The average of the symptom severity score on the Boston questionnaire was 1.31 ± 0.30 and the average of the functional status score was 1.19 ± 0.26. The final mean Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) score was 8.66 (range, 2-39). There was no superficial palmar arch injury or nerve injury of the palmar cutaneous branch, recurrent motor branch, or median nerve itself as a complication of the procedure. No patient showed any wound infection or wound dehiscence.

Conclusions

Our carpal tunnel release using a hook knife through a small transverse carpal incision performed by an experienced surgeon is a safe and reliable method that is expected to have the benefits of simplicity and minimal invasiveness.

Nerve decompression surgery suppresses TNF-ɑ expression and T cell infiltration in a rat sciatic nerve chronic constriction injury model

Decompression surgery (DS) is a standard treatment for chronic nerve compression injuries; however, the mechanisms underlying its effects remain unclear. Here, we investigated the effects of DS on messenger RNA (mRNA) expression of tumor necrosis factor-α (TNF-α) and T cell recruitment in a rat sciatic nerve (SN) chronic constriction injury (CCI) model. Male Wistar rats were subjected to CCI to establish a model of SN injury (CCI group). DS, in which all ligatures were removed, was performed 3 days after CCI surgery (CCI + dec group). Mechanical sensitivity was assessed using the von Frey test 3, 7, and 14 days after the CCI surgery. Gene expression of Tnfa, Cd3, Cxcl10, and immunolocalization of TNF-α and the pan T cell marker, CD3, was evaluated using quantitative polymerase chain reaction (qPCR) and immunohistochemistry, respectively. In addition, the effects of TNF-α on Cxcl10 expression and CXCL10 protein production were evaluated using qPCR and enzyme-linked immunosorbent assay in SN cell culture. Rats that received DS had significantly higher withdrawal threshold levels than those in the CCI group. In addition, Tnfa, Cd3, and Cxcl10 mRNA expression increased following CCI. DS suppressed this elevated expression, with the CCI + dec group showing significantly reduced expression levels compared to the CCI group. Furthermore, TNF-α induced Cxcl10 expression and CXCL10 protein production in SN cell culture. Therefore, DS reduced TNF-α expression and T cell recruitment in the rat SN CCI model. These observations may partly explain the mechanism underlying the therapeutic effects of DS.

Cost Savings of Carpal Tunnel Release Performed In-Clinic Compared to an Ambulatory Surgery Center: Time-Driven Activity-Based-Costing

Purpose: The purpose of our study was to investigate carpal tunnel release (CTR) performed in the clinic versus the ambulatory surgery center (ASC) to evaluate for potential cost savings. Methods: Patients who underwent either CTR in clinic under a local anesthetic or CTR in the ASC with sedation and local anesthetic were prospectively enrolled in a registry between 2014 and 2016. All patients completed a Visual Analog Scale (VAS) pain scale for procedural and postprocedure pain. Time-Driven Activity-Based Costing (TDABC) was utilized to quantify cost of both CTR in clinic and CTR in the ASC. Statistical analysis involved parametric comparative tests between patient cohorts for both the TDABC-cost and patient pain. Results: A total of 59 participants completed the postprocedure CTR survey during the study period, 23 (38.9%) in the ASC group and 36 (61.1%) in the clinic group. Overall time for the procedure from patient arrival to discharge was significantly longer for the ASC cases, averaging 215.7 minutes (range: 201-230) compared to 78.6 minutes (range: 59-98) in the clinic group (P < .01). Both procedural and postoperative VAS pain scores were comparable between clinic and ASC cohorts, procedural pain: 1.8 vs 1.9 (P = .91) and postoperative pain: 4.8 vs 4.9 (P = .88). TDABC analysis estimated ASC CTR procedures to cost an average of $557.07 ($522.06-$592.08) and clinic procedures to cost an average of $151.92 ($142.59-$161.25) (P < .05). Conclusions: CTR in the clinic setting results in significant cost savings compared to CTR in the ASC with no difference in pain scores during the procedure or postoperative period. Level of Evidence: Therapeutic Level II.

Semivertical Incision: An Aesthetically and Electrophysiologically Effective Mini-Incision Technique for Carpal Tunnel Decompression

Background

The purpose of this study was to present the clinical results of our retrospective series of carpal tunnel release (CTR) operations. For these operations we used a unique type of incision, for the first time, for treatment of carpal tunnel syndrome (CTS) consisting of a 1-cm semi-vertical (SV) incision made into the wrist crease for macroscopic open CTR.

Material/Methods

This retrospective study included 114 patients (101 females and 13 males) with CTR who were operated upon in our neurosurgery clinic between December 2010 and June 2015. Patient ages ranged from 35 to 83 years (mean 55.05±12.04 years). In total, 127 hands (73 right and 54 left) were operated upon using the SV skin incision technique. After an average follow-up of 18 months (ranging from 6 to 30 months), clinical and electrophysiological (EP) evaluations were performed.

Results

A review of the English language literature published since 1957, when Phalen first popularised the diagnosis and treatment of this disease, determined that no previous reports of the mini-open incision technique as described in our study have been published. In our retrospective patient case review, we found that after operations using the SV incision technique, statistically significant differences were detected in electromyography (EMG) improvements (p<0.01). In addition, patients who showed improvement in EMG studies (n=90) were satisfied with the result of their surgery.

Conclusions

Our study demonstrated that 1-cm skin SV incision was a cosmetically satisfying, fast, and safe approach to CTR that was not only clinically effective but also electrophysiologically effective.

The double tunnels technique: an alternative minimally invasive approach for carpal tunnel syndrome

OBJECT

The purpose of this study was to assess the effectiveness and safety of an alternative minimally invasive technique for the treatment of carpal tunnel syndrome (CTS).

METHODS

This was designed as a prospective, randomized, open-label, blinded end point evaluation (PROBE) study. The active comparison was double tunnels technique (DTT) (Group A, 110 patients) versus standard open decompression of the median nerve (control [Group B], 110 patients). Patient recruitment started in January 2011. The primary outcomes were the functional Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) scores and visual analog scale (VAS) scores for pain (pVAS) at Weeks 2 and 4, and at Months 3, 6, and 12. The secondary outcome was the aesthetics (aVAS) score at Weeks 2 and 4, and at Months 3, 6, and 12.

RESULTS

The Student t-test and ANOVA were used, and the results were considered statistically significant if the p value was ≤ 0.05 for continuous variables. The DTT is a tissue-sparing approach that allows the surgeon to limit the length of the incision (0.6 ± 0.05 cm) and to respect the palmar fascia and the subcutaneous tissue. Recovery from wrist pain, night pain, numbness, stiffness, and weakness was achieved more effectively and quickly compared with the standard approach. Better BCTSQ, pVAS, and aVAS scores were observed in Group A.

CONCLUSIONS

The DTT is a safe and effective approach for the treatment of CTS. This technique entails faster recovery times, better aesthetic outcomes, and lower risks of complications.

Redistribution of voltage-gated sodium channels after nerve decompression contributes to relieve neuropathic pain in chronic constriction injury

Nerve decompression is an important therapeutic strategy to relieve neuropathic pain and promote the peripheral nerve regeneration. To address these issues, we investigated the effects of nerve decompression on relief of neuropathic pain behaviors, redistribution of voltage-gated sodium channels (VGSCs), and skin reinnervation with chronic constriction injury (CCI). At post-operative week (POW) 4, animals were divided into a decompression group, in which the ligatures were removed, and a CCI group, in which the ligatures remained. Thermal hyperalgesia and mechanical allodynia at POW 8 had distinct reductions in decompression group compared to CCI group. At that time in CCI group, morphological evidence of pan VGSCs (Pan Nav) and isoforms of VGSCs (Nav1.6, Nav1.9, except for Nav1.8) were shown the widely distribution along the injured sciatic nerve. All of the VGSCs in decompression group became clustering around the node of Ranvier, similar to the pattern of control sciatic nerve at POW 8. Skin reinnervation was demonstrated by epidermal nerve density (END) for protein gene product 9.5 (PGP 9.5)-immunoreactive (IR) nerve fibers and a significant difference between groups only at POW 24 (p=0.01). Growth-associated protein 43 (GAP-43) is participated in the nerve fiber growth and sprouting, a difference in END for GAP-43-IR nerve fibers at POW 24 between groups were also significant (p=0.02). These observations demonstrated that nerve decompression was accompanied with the disappearance of neuropathic pain behaviors after CCI. Morphological studies provided the evidence that redistribution of VGSCs along the injured sciatic nerve but still with an incomplete skin reinnervation. These significant findings demonstrated a role of VGSCs in the pathogenesis of neuropathic pain, and gave an approaching in pharmacological basis of therapeutics.

Open versus endoscopic carpal tunnel release

Carpal tunnel syndrome is a very common hand condition, which after a failure of conservative treatment can be treated successfully with surgical decompression in either an open or endoscopic manner. On comparing the two techniques there may be some subtle differences; however, both can provide an excellent outcome. This article provides a detailed review of each technique as well as their comparative differences in terms of technique, outcomes, and complications.

Canaletto implant in revision surgery for carpal tunnel syndrome: 21 case series

Revision carpal tunnel surgery varies from 0.3% to 19%. It involves a delayed neurolysis and prevention of perineural fibrosis. Despite numerous available procedures, the results remain mediocre. The aim of this study is to evaluate the results of the Canaletto implant in this indication. Our series includes 20 patients (1 bilateral affection) reoperated for carpal tunnel between October 2008 and December 2009. After the first operation, the symptom-free period was 112 weeks, on average. The average incision was 27 mm. After neurolysis, the Canaletto implant was placed in contact with the nerve. Immediate postoperative mobilization was commenced. Sensory (pain, DN4, and hypoesthesia), motor (Jamar, muscle wasting), and functional (disabilities of the arm, should, and hand; DASH) criteria were evaluated. Nerve conduction velocity (NCV) of the median nerve was measured. Average follow up was 12.1 months. All measurements were improved after insertion of the Canaletto implant: pain (6.45-3.68), DN4 (4.29-3.48), Quick DASH (55.30-34.96), Jamar (66.11-84.76), NCV (29.79-39.06 m/s), hypoesthesia (76.2-23.8%), wasting (42.9-23.8%). Nevertheless, four patients did not improve, and pain was the same or worse in six cases. Our results show that in recurrent carpal tunnel syndrome, Canaletto implant insertion gives results at least as good as other techniques, with the added advantage of a smaller access incision, a rapid, less invasive technique, and the eliminated morbidity of raising a flap to cover the median nerve.

Position Change of the Neurovascular Structures around the Carpal Tunnel with Dynamic Wrist Motion

OBJECTIVE

The purpose of this study was to determine the anatomic relationships between neurovascular structures and the transverse carpal ligament so as to avoid complications during endoscopic carpal tunnel surgery.

METHODS

Twenty-eight patients (age range, 35-69 years) with carpal tunnel syndrome were entered into the study. We examined through wrist magnetic resonance imaging in three different positions (neutral, radial flexion, and ulnar flexion) and determined several anatomic landmark (distance from the hamate hook to the median nerve, ulnar nerve, and ulnar vessel) based on the lateral margin of the hook of the hamate. The median nerve and ulnar neurovascular structure were studied with the wrist in the neutral, ulnar, and radial flexion positions.

RESULTS

The ulnar neurovascular structures usually passed just over or ulnar to the hook of the hamate. However, in 12 hands, a looped ulnar artery coursed 0.6-3.3 mm radial to the hook of the hamate and continued to the superficial palmar arch. The looped ulnar artery migrates on the ulnar side of Guyon's canal (-5.2-1.8 mm radial to the hook of the hamate) with the wrist in radial flexion. During ulnar flexion of the wrist, the ulnar artery shifts more radially beyond the hook of the hamate (-2.5-5.7 mm).

CONCLUSION

It is appropriate to transect the ligament greater than 4 mm apart from the lateral margin of the hook of the hamate without placing the edge of the scalpel toward the ulnar side. We would also recommend not transecting the transverse carpal ligament in the ulnar flexed wrist position to protect the ulnar neurovascular structure.

Flexor retinaculum division: does it contribute to the success of carpal tunnel release?

Yuval Krieger, Avia Moses, Eldad Silberstein, Shimon Weitzman, Naftali Liberman, Amiram Sagi

Aims: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Open decompression of the median nerve is considered the standard surgical treatment for CTS. This article describes a study to assess and compare the clinical efficacy of operative treatment performed by transverse carpal ligament release alone (limited carpel tunnel release (CTR)), to that achieved after transverse carpal ligament release with additional division of the proximal portion of the flexor retinaculum (extended CTR) which is continuous with the deep investing fascia of the forearm.

Methods: A retrospective cohort study was performed by telephone interview, using a modified Levine scale to assess symptoms and functional impairment 4–7 years post-operatively in two patient groups who were operated using two different techniques, over a two year period. One group (N = 73) had open CTR by limited transverse carpal ligament division alone, performed by one hand surgeon; the second group (N = 83) had open CTR by division of the transverse carpal ligament and the proximal portion of the flexor retinaculum, performed by another hand surgeon.

Findings: Pre-operatively the two groups were similar, both in terms of patient characteristics and of disease severity. Both groups improved significantly. No clinical difference was demonstrated in terms of symptom relief, recurrence or complication rate.

Conclusions: This study suggests that adjunctive division of the proximal portion of the flexor retinaculum, although safe, offers no advantage over division of the transverse carpal ligament alone in standard open carpal tunnel release.

Minimally invasive carpal tunnel release

We prospectively compared the safety and effectiveness of mini-incision (group A) and a limited open technique (group B) for carpal tunnel release (CTR) in 185 consecutive patients operated between November 1999 and May 2001, with a 5-year minimum follow-up. Patients in Group A had a minimally invasive approach (<2 cm incision), performed using the KnifeLight (Stryker, Kalamazoo, Michigan) instrument. Patients in Group B had a limited longitudinal incision (3-4 cm). Patient status was evaluated with an Italian modified version of the Boston Carpal Tunnel questionnaire, administered preoperatively and at 19, 30, and 60 postoperative months. Mini-incision CTR showed advantages over standard technique in early recovery, pillar pain, and recurrence rate. The recovery period after mini-incision is shorter than after standard procedure.

Functional outcomes post carpal tunnel release: a modified replication of a previous study

STUDY DESIGN

Exploratory cohort study.

INTRODUCTION

To compares the outcome of self-administered questionnaires and physical measures in assessing change in function for participants after carpal tunnel surgery.

METHODS

The self-administered questionnaires were the Carpal Tunnel Questionnaire (CTQ), the Disabilities of the Arm, Shoulder, and Hand (DASH), and Short Form-36. The physical measures were grip, pinch, range of motion, sensibility, and dexterity. Twenty-nine participants from five hand clinics were enrolled in the study.

RESULTS

The results revealed that self-administered questionnaires were sensitive to change in function and three of ten physical measures showed a change in function.

CONCLUSIONS

The authors concluded that select physical measures coupled with a disease-specific assessment, such as the CTQ and a region-specific questionnaire, such as the DASH would result in a comprehensive assessment of outcomes. This combination of assessments provides both physical measures of recovery and measures of perceived level of function.

LEVEL OF EVIDENCE

4.

A randomized controlled study of contrast baths on patients with carpal tunnel syndrome

STUDY DESIGN

Randomized clinical trial.

INTRODUCTION

Contrast baths are a treatment modality commonly used in hand clinics. Yet the benefits of contrast baths have been poorly substantiated. Contrast baths have been suggested for the purposes of reducing hand volume, alleviating pain, and decreasing stiffness in affected extremities.

PURPOSE OF THE STUDY

To determine the effects of specific contrast bath protocols on hand volume in patients diagnosed with Carpal Tunnel Syndrome.

METHODS

Study participants were randomly assigned to one of three treatment group protocols--contrast baths with exercise, contrast baths without exercise, and an exercise-only control treatment group. Study participants were evaluated with hand volumetry, before and after treatment at two different data collection periods-pre- and postoperatively.

RESULTS

Data were gathered on 58 participants before Carpal Tunnel Release surgery and on 56 participants after Carpal Tunnel Release surgery, for a total of 114 treatments. The changes in hand volume (the after treatment volume minus the before treatment volume) were analyzed using one-way and multi-way analysis of variance (ANOVA). Although all three treatments resulted in a slight increase in hand volume both pre- and postsurgery, the increase was not clinically significant with regard to hand volumes. Also no significant differences were noted among the three treatments. Specifically, the ANOVA for presurgery differences among treatments had F=0.155 (2 and 55 df), p=0.857. The ANOVA for postsurgery difference among treatments had F=0.544 (2 and 53 df), p=0.584.

CONCLUSIONS

The use of contrast bath treatment has no significant effect on increase or decrease of hand volume in Carpal Tunnel Syndrome patients, pre- and/or postoperatively.

LEVEL OF EVIDENCE

1B.

Influences of surgical decompression on the dorsal horn after chronic constriction injury: changes in peptidergic and delta-opioid receptor (+) nerve terminals

To understand plastic changes in the dorsal horn related to neuropathic pain, we developed a model of decompression in rats with chronic constriction injury (CCI) and investigated corresponding changes in the dorsal horn. At postoperative week 4 (POW 4) of CCI, rats were divided into a decompression group, in which ligatures were removed, and a CCI group, in which ligatures remained. Spinal cords were immunostained for substance P (SP), the delta-opioid receptor (DOR), and calcitonin gene-related peptide (CGRP). Areas of immunoreactive nerve terminals in the dorsal horn were quantified and expressed as the dorsal horn index (immunoreactive areas of the operated side compared with those of the contralateral side). At POW 4, dorsal horn indexes of all of these molecules were significantly reduced in both groups to similar degrees (0.36-0.43). At POW 8, neuropathic pain behaviors had completely disappeared in the decompression group with significant reversal of the dorsal horn indexes compared with the CCI group (0.81+/-0.02 vs. 0.58+/-0.09, P < 0.001 for SP and 0.75+/-0.04 vs. 0.55+/-0.03, P < 0.001 for DOR). In the CCI group, neuropathic pain behaviors became normalized at POW 12 with corresponding changes in dorsal horn indexes for both SP and DOR similar to those of the decompression group. In contrast, changes in the dorsal horn indexes of CGRP were similar in both the CCI and decompression groups throughout the experimental period. These findings suggest that CCI and decompression cause different patterns in peptidergic and DOR (+) nerve terminals in the dorsal horn.

Reversal of ERK activation in the dorsal horn after decompression in chronic constriction injury

Injury-induced neuropathic pain is related to changes in the central terminals of dorsal root ganglia neurons, i.e., dorsal horn plasticity. We investigated the influences of decompression by removing ligatures producing chronic constriction injury (CCI) in Sprague-Dawley rats at postoperative week (POW) 4, the decompression group; for comparison, all ligatures remained through the experimental period in the CCI group. The effect was evaluated with extracellular signal-regulated kinase (ERK) activation in the dorsal horn, i.e., number of phosphorylated ERK (+) cells in the dorsal horn. At POW 1, the dorsal horn indexes had increased to a similar degree in both groups (2.40+/-0.58 vs. 2.27+/-0.36, p=0.73). At POW 8, thermal hyperalgesia and mechanical allodynia had completely disappeared with a normalization of dorsal horn index (1.17+/-0.11 vs. 1.02+/-0.12 at POW 0, p=0.07) in the decompression group; in contrast, the dorsal horn index remained elevated in the CCI group (2.48+/-0.30, p<0.001) with persistent neuropathic pain behaviors at POW 8. This report suggests that ERK activation in the dorsal horn is correlated with neuropathic pain behaviors and its normalization reflects the reversal of neuropathic pain behaviors after decompression.

Effects of decompression on neuropathic pain behaviors and skin reinnervation in chronic constriction injury

Decompression is an important therapeutic strategy to relieve neuropathic pain clinically; there is, however, lack of animal models to study its temporal course of neuropathic pain behaviors and its influence on nerve regeneration to sensory targets. To address these issues, we established a model of decompression on rats with chronic constriction injury (CCI) and investigated the effect on skin reinnervation. Animals were divided into a decompression group, in which the ligatures were removed, and a CCI group, in which the ligatures remained at postoperative week 4 (POW 4). At this time point, the skin innervation indexes of protein gene product 9.5 (PGP 9.5), substance P (SP), and calcitonin gene-related peptide (CGRP) were reduced in both groups to similar degrees. Beginning from POW 6, the decompression group exhibited significant reductions of thermal hyperalgesia and mechanical allodynia compared to the CCI group (p<0.001). At POW 8, neuropathic pain behaviors had completely disappeared in the decompression group, and the decompression group had a higher skin innervation index of SP than the CCI group (0.45+/-0.05 vs. 0.16+/-0.03, p<0.001). These indexes were similar in both groups for PGP 9.5 (0.32+/-0.09 vs. 0.14+/-0.04, p=0.11) and CGRP (0.38+/-0.06 vs. 0.21+/-0.07, p=0.09). These findings demonstrate the temporal changes in the disappearance of neuropathic pain behaviors after decompression and suggest that decompression causes different patterns of skin reinnervation for different markers of skin innervation.

Mini-open blind procedure versus limited open technique for carpal tunnel release: a 30-month follow-up study

PURPOSE

To evaluate prospectively the safety and effectiveness of a mini-open blind technique for carpal tunnel release (group A) when compared with a limited open technique (group B).

METHODS

From November 1999 to May 2001 (mean follow-up period, 30 mo) we performed 222 carpal tunnel release procedures on 185 consecutive patients. All patients were affected by mild to moderate median nerve compression. Patients in group A (82 patients, 99 procedures) had a short transverse incision at the wrist (length, 2 cm). We used a manual surgical instrument that helps in blindly dividing the flexor retinaculum because it has an integrated light source. The light makes it possible to locate precisely the tool blade by transillumination. Patients in group B (103 patients, 123 procedures) had a limited longitudinal incision (length, 3-4 cm). The preoperative and postoperative patient statuses were evaluated with an Italian modified version of the Boston Carpal Tunnel questionnaire with a mean of 30 months' follow-up after surgery (range, 24-39 mo).

RESULTS

Group A patients showed better results than group B patients in all of the sections of the Italian modified version of the Boston Carpal Tunnel questionnaire at a mean follow-up period of 19 months, whereas after a mean of 30 months of follow-up evaluation the differences between groups A and B tended to decrease. Disease recurred in 7 group B patients, whereas only 1 patient in group A experienced symptom recurrence at the latest office evaluation.

CONCLUSIONS

The blind mini-invasive technique has been shown to be as safe as traditional techniques but the recovery period is significantly shortened. With the technique we described a low recurrence rate was observed. All patients in group A reported great reduction in preoperative pain and numbness.