CARPAL TUNNEL RELEASE WITH A LIMITED PALMAR INCISION: CLINICAL RESULTS AND PILLAR PAIN AT 18 MONTHS FOLLOW-UP

State of the art review. Complications after carpal tunnel release

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

Evaluation of Dynamic Carpal Arch Stability following Carpal Tunnel Release Using Four-Dimensional Computed Tomography

Introduction  This study aimed to assess the carpal arch dynamics during active finger and wrist motion following carpal tunnel release using four-dimensional computed tomography (4D-CT). Materials and Methods  Four patients who diagnosed with bilateral carpal tunnel syndrome and underwent unilateral carpal tunnel release were prospectively included. 4D-CT of the bilateral wrists during active finger and wrist motion was performed for 10 seconds at five frames per second. The distances between the tip of tuberosity of the scaphoid and the volar ridge of the pisiform (S-P distance) and volar ridge of trapezium and the tip of hook of hamate (T-H distance) were measured at each position and the values of S-P and T-H distances were compared between the postoperative and contralateral wrists. Results  During finger motion, the S-P and T-H distances were not different at any position between the postoperative side and contralateral side. Conversely, S-P and T-H distances gradually increased in the postoperative wrists. The differences between the sides of S-P distance were significant, with >0 degrees of wrist extension, and differences of T-H distance were significant with >15 degrees of wrist extension. Conclusion  This study demonstrated the carpal arch dynamics using 4D-CT and revealed that the carpal arch was widened with the wrist in extension after carpal tunnel release. This study suggests that the transverse carpal ligament plays an important role in maintaining carpal arch stability.

Efficacy of extracorporeal shock wave therapy for pillar pain after open carpal tunnel release: a double-blind, randomized, sham-controlled study

Background

Pillar pain may develop after carpal tunnel release surgery (CTRS). This prospective double-blinded randomized trial investigated the effectiveness of extracorporeal shock wave therapy (ESWT) in pillar pain relief and hand function improvement.

Methods

The sample consisted of 60 patients with post-CTRS pillar pain, randomized into two groups. The ESWT group (experimental) received three sessions of ESWT, while the control group received three sessions of sham ESWT, one session per week. Participants were evaluated before treatment, and three weeks, three months, and six months after treatment. The pain was assessed using the visual analogue scale (VAS). Hand functions were assessed using the Michigan hand outcomes questionnaire (MHQ).

Results

The ESWT group showed significant improvement in VAS and MHQ scores after treatment at all time points compared to the control group (P < 0.001). Before treatment, the ESWT and control groups had a VAS score of 6.8 ± 1.3 and 6.7 ± 1.0, respectively. Three weeks after treatment, they had a VAS score of 2.8 ± 1.1 and 6.1 ± 1.0, respectively. Six months after treatment, the VAS score was reduced to 1.9 ± 0.9 and 5.1 ± 1.0, respectively. The ESWT group had a MHQ score of 54.4 ± 7.7 before treatment and 73.3 ± 6.8 six months after. The control group had a MHQ score of 54.2 ± 7.1 before treatment and 57.8 ± 4.4 six months after.

Conclusions

ESWT is an effective and a safe non-invasive treatment option for pain management and hand functionality in pillar pain.

Endoscopic Carpal Tunnel Release Without Invading the Tunnel: A New Transretinacular Technique

Established endoscopic carpal tunnel release (ECTR) techniques carry a not entirely eludible risk of iatrogenic complications, mainly because of incomplete view of the cutting blade and intraoperative pressure increase inside the carpal tunnel (CT). We describe a novel single-portal ECTR method, conceived to reduce these risks, by optimizing visual control and avoiding dilatation of the CT. After incising the well exposed proximal third of the transverse carpal ligament (TCL), transection of the remainder is completed using a pediatric urethrotome. This small caliber instrument is moved in the plane of the TCL, without invading the tunnel, and provides detailed view of the TCL and any crossing anatomical structures at any given moment. We present the technique and the results of a retrospective case series of 33 patients with CT syndrome who underwent the procedure, after failing to respond to conservative treatment. Because of improved view and the avoidance of intraoperative pressure trauma to structures passing through the CT, the described approach may contribute to prevent iatrogenic complications and represent a valid improvement over conventional ECTR procedures.

A mini-incision carpal tunnel release technique to prevent pillar pain: A technical note

Pillar pain represents one of the most common complications of classic open carpal tunnel release (CTR). This complication causes a sense of discomfort worse than the compression syndrome itself. We, herein, introduce a new treatment method for CTR through a mini-incision, which allows subcutaneously cutting the transverse carpal ligament (TCL) and releasing the median nerve without neurovascular complications. This mini-incision approach can allow the direct visualization and preservation of the thenar motor branch in those rare cases where it has an aberrant origin. For the past 10 years, we have consecutively performed this technique in the surgical treatment of 318 patients with the diagnosis of primary CTS, without developing any neurovascular and tendon injuries as well as pillar pain.

Effectiveness of Surgical Treatment in Carpal Tunnel Syndrome Mini-Incision Using MIS-CTS Kits: A Cadaveric Study

Introduction. Carpal tunnel syndrome (CTS) is caused by the compression of the median nerves in the wrist. Patients have pain and numbness in the hands. According to the records of Songklanagarind Hospital from 2015 to 2018, of 800 patients, 196 or 24.5% were treated with surgery. The novel tool of minimally invasive surgery for carpal tunnel syndrome (MIS-CTS) was developed to improve effectiveness and safety.

'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.

Carpal tunnel release with a new mini-incision approach versus a conventional approach, a retrospective cohort study

PURPOSE

We have make use of a new method to perform carpal tunnel release (CTR) through a 1.5-2.0 cm long incision The aim of this study is to introduce this method and to compare the effectiveness and safety of this approach to the conventional one.

METHODS

We included consecutive patients diagnosed with primary carpal tunnel syndrome (CTS) who had CTR from January 2015 to September 2016. A total of 85 patients were included in our study. Among them, 42 patients with mini-incision approach were enrolled in group A, and the other 43 patients with conventional approach were enrolled in group B. Objective tests and subjective evaluations were performed to compare the outcomes of mini-incision approach with the conventional approach. Postoperative complications after the two approaches were also compared.

RESULTS

At the 12-months follow-up, all patients in both groups got recovery. We found no significant differences between the two groups in postoperative pinch strength, grip strength, 2-point discrimination (2-PD), visual analogue scale (VAS) score, Levine score and the Disabilities of the Arm, Shoulder and Hand (DASH) score (P > 0.05). However, at the one-month follow-up, the percentage of patients with wound pain in group A was significantly lower than that in group B (0.05% vs. 0.23%, P = 0.03). At the 12 months follow-up, the number of patients with persistent wound pain and pillar pain in group B were 2 (4.7%) and 3 (7.0%) respectively, while no patients showed wound pain and pillar pain in group A.

CONCLUSION

Patients with mini-incision approach have satisfactory surgical outcomes, low postoperative complications, and good appearance.

The Effect of Carpal Tunnel Release on Neuropathic Pain in Carpal Tunnel Syndrome

Purpose

The aim of this study was to determine the risk factors of neuropathic pain (NP) in the patient with carpal tunnel syndrome (CTS) before and after the carpal tunnel release.

Materials and Methods

One hundred and two CTS patients were enrolled in the study. The pain score was measured by the visual analogue score. NP was determined by the painDETECT (PD) questionnaire. All subjects were divided into 3 groups at 12 weeks after surgery: an Improved, Unchanged, and Worsened group. The risk factors of worsening NP after surgery were evaluated.

Results

We found that 36% and 18% of patients with CTS had neuropathic pain before and 12 weeks after surgery, respectively, and pain was significantly stronger than in those without NP. The PD score of eight hands worsened after surgery. In the “Improved group,” the average age at the surgery was younger and the pain score was lower than in the “Unchanged group.” Conclusions. The surgery was very effective on NP of CTS; however, the PD in 7% of hands worsened after surgery. Risk factors before surgery that predicted worse NP after surgery were found to be a younger age, weaker pain, and the absence of night pain.

Effect of preoperative gabapentin on pain intensity and development of chronic pain after carpal tunnel syndrome surgical treatment in women: randomized, double-blind, placebo-controlled study

CONTEXT AND OBJECTIVES

Effective postoperative analgesia is important for reducing the incidence of chronic pain. This study evaluated the effect of preoperative gabapentin on postoperative analgesia and the incidence of chronic pain among patients undergoing carpal tunnel syndrome surgical treatment.

DESIGN AND SETTINGS

Randomized, double-blind controlled trial, Federal University of São Paulo Pain Clinic.

METHODS

Forty patients aged 18 years or over were randomized into two groups: Gabapentin Group received 600 mg of gabapentin preoperatively, one hour prior to surgery, and Control Group received placebo. All the patients received intravenous regional anesthesia comprising 1% lidocaine. Midazolam was used for sedation if needed. Paracetamol was administered for postoperative analgesia as needed. Codeine was used additionally if the paracetamol was insufficient. The following were evaluated: postoperative pain intensity (over a six-month period), incidence of postoperative neuropathic pain (over a six-month period), need for intraoperative sedation, and use of postoperative paracetamol and codeine. The presence of neuropathic pain was established using the DN4 (Douleur Neuropathique 4) questionnaire. Complex regional pain syndrome was diagnosed using the Budapest questionnaire.

RESULTS

No differences in the need for sedation, control over postoperative pain or incidence of chronic pain syndromes (neuropathic or complex regional pain syndrome) were observed. No differences in postoperative paracetamol and codeine consumption were observed.

CONCLUSIONS

Preoperative gabapentin (600 mg) did not improve postoperative pain control, and did not reduce the incidence of chronic pain among patients undergoing carpal tunnel syndrome surgery.

Splinting after Carpal Tunnel Release: Does it really Matter?

Splinting of the wrist after carpal tunnel release (CTR) has been practised by many surgeons especially in North America. The main reason was to prevent possible adverse events of bowstringing of flexor tendons and the median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect of splinting after standard CTR have had dismal results. The duration of splinting in standard CTR has been either too long (for 2-4 weeks) or too short (48 hours only). The aim of our study was to compare the effects of post-operative splinting for a duration of one week with no splinting.

Methods: All 30 of our patients underwent a standardized limited open CTR by a designated surgeon. Post operatively, they were randomized into a splinted (n=16) and a nonsplinted (n=14) group. The splint was kept for a week. Patients were reviewed at regular intervals of one week, two months and six months. At each follow up, these patients were clinically assessed for the following outcome measures: VAS (visual analogue score), 2PD (two-point discrimination), pinch grip, grip, Abductor Pollicis Brevis (APB)) power and completion of the Boston questionnaire. Results: All patients presented with significant improvement in the postoperative evaluation in the analyzed parameters within each group. However, there was no significant difference between the two groups for any of the outcome measurements at sequential and at final follow-up.

Conclusion: We conclude that wrist splinting in the immediate post-operative period has no advantage when compared with the unsplinted wrist after a limited open carpal tunnel release.

Extracorporeal shock wave therapy in pillar pain after carpal tunnel release: a preliminary study

"Pillar pain" is a relatively frequent complication after surgical release of the median nerve at the wrist. Its etiology still remains unknown although several studies highlight a neurogenic inflammation as a possible cause. Pillar pain treatment usually includes rest, bracing and physiotherapy, although a significant number of patients still complain of painful symptoms two or even three years after surgery. The aim of this study was to investigate the efficacy of low-energy, flux density-focused extracorporeal shock wave therapy (ESWT) in the treatment of pillar pain. We treated 40 consecutive patients with ESWT who had pillar pain for at least six months after carpal tunnel release surgery, and to our knowledge, this is the first study that describes the use of ESWT for treating this condition. Our results show that in all of the treated patients, there was a marked improvement: the mean visual analogue scale (VAS) score decreased from 6.18 (±1.02) to 0.44 (±0.63) 120 d after treatment, and redness and swelling of the surgical scar had also decreased significantly.

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.

Functional sensibility assessment. Part II: Effects of sensory improvement on precise pinch force modulation after transverse carpal tunnel release

Patients with median nerve compression at the carpal tunnel often have poor sensory afferents. Without adequate sensory modulation control, these patients frequently exhibit clumsy performance and excessive force output in the affected hand. We analyzed precision grip function after the sensory recovery of patients with carpal tunnel syndrome (CTS) who underwent carpal tunnel release (CTR). Thirteen CTS patients were evaluated using a custom-designed pinch device and conventional sensory tools before and after CTR to measure sensibility, maximum pinch strength, and anticipated pinch force adjustments to movement-induced load fluctuations in a pinch-holding-up activity. Based on these tests, five force-related parameters and sensory measurements were used to determine improvements in pinch performance after sensory recovery. The force ratio between the exerted pinch force and maximum load force of the lifting object was used to determine pinch force coordination and to prove that CTR enabled precision motor output. The magnitude of peak pinch force indicated an economic force output during manipulations following CTR. The peak pinch force, force ratio, and percentage of maximum pinch force also demonstrated a moderate correlation with the Semmes-Weinstein test. Analysis of these tests revealed that improved sensory function helped restore patients' performance in precise pinch force control evaluations. These results suggest that sensory information plays an important role in adjusting balanced force output in dexterous manipulation.

Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-up with matched controls

PURPOSE

To compare the clinical outcome after carpal tunnel release in diabetic and nondiabetic patients.

METHODS

We evaluated a prospective, consecutive series of 35 diabetic patients (median age, 54 years; 15 with type 1 and 20 with type 2 diabetes) with carpal tunnel syndrome, who were age- and gender-matched with 31 nondiabetic patients (median age, 51 years) having idiopathic carpal tunnel syndrome. Exclusion criteria were other focal nerve entrapments, cervical radiculopathy, inflammatory joint disease, renal failure, thyroid disorders, previous wrist fracture, and long-term exposure to vibrating tools. Participants were examined independently at baseline (preoperatively) and 6, 12, and 52 weeks after surgery, including evaluating sensory function (Semmes-Weinstein), motor function (abductor pollicis brevis muscle strength and grip strength), pillar pain, cold intolerance, and patient satisfaction.

RESULTS

The number of patients with normal sensory function (pulp of index finger) increased notably in both patient groups from baseline (diabetic patients, 7 of 35; nondiabetic patients, 10 of 31) compared with the 52-week follow-up (diabetic patients, 25 of 35; nondiabetic patients, 24 of 31). Grip strength decreased temporarily at 6 weeks but recovered completely after 12 weeks. At the 52-week follow-up, mean grip strength (95% confidence interval) had improved significantly in both patient groups (diabetic patients: 3.0 kg [-0.3 to 6.2], nondiabetic patients: 3.4 kg [0.2 to 6.6]). Pillar pain correlated significantly with grip strength at the 6-week follow-up (r(s) = -0.41 to -0.54 [p < .05]). The number of patients reporting cold intolerance decreased over time (diabetic patients, 22 of 35 to 19 of 35; nondiabetic patients, 18 of 31 to 8 of 31), but decreased markedly less for the diabetic patients. Level of patient satisfaction was equal between groups. Comparing type 1 and type 2 diabetic patients, no important difference was noted on any test variables.

CONCLUSIONS

Patients with diabetes have the same beneficial outcome after carpal tunnel release as nondiabetic patients. Only cold intolerance demonstrated a lesser extent of relief for diabetic patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.