LONG-TERM FOLLOW-UP OF DUAL-PORTAL ENDOSCOPIC RELEASE OF THE TRANSVERSE LIGAMENT IN CARPAL TUNNEL SYNDROME

Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance in Over 100 Patients at Two to Six Years

Purpose

The purpose of this study was to determine the clinical results of carpal tunnel release using ultrasound guidance (CTR-US) at a minimum of 2 years postprocedure.

Methods

The study consisted of 102 patients (162 hands) treated with CTR-US by the same physician between June 2017 and October 2020 for whom minimum 2-year follow-up data were available. Questionnaires were sent to gather long-term information, with additional phone calls for clarification if needed. Outcomes included Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores; global satisfaction scores; and subsequent surgeries.

Results

The 102 patients included 68 females and 34 males with a mean age of 56.9 years at the time of surgery. Fifty-five (53.9%) patients had simultaneous bilateral procedures, 42 (41.2%) had unilateral procedures, and 5 (4.9%) had staged bilateral procedures. Significant improvements in BCTQ-SSS, BCTQ-FSS, and QuickDASH scores persisted at a mean final follow-up of 46 months (range 2-6 years). At final follow-up, 91.2% of patients reported satisfaction with the procedure. No outcomes were significantly different between those treated with simultaneous bilateral versus unilateral procedures. No revision surgeries were reported.

Conclusions

CTR-US is a safe and effective procedure that results in significant improvements that persist up to 6 years postprocedure. Long-term results of simultaneous bilateral and unilateral procedures are similar.

Type of study/level of evidence

Therapeutic IV.

Long-term Outcome of Local Steroid Injections Versus Surgery in Carpal Tunnel Syndrome: Observational Extension of a Randomized Clinical Trial

Background: In a previous paper, we have demonstrated that: (1) local injection of corticosteroids for carpal tunnel syndrome (CTS) is as effective as decompressive surgery, at 1-year follow-up; and (2) surgery has an additional benefit in the 2-year follow-up. In this study, we assess the long-term outcomes of both therapies in an observational extension of the patients originally enrolled in our randomized clinical trial. Methods: Patients were included in an open, randomized clinical trial, comparing injections versus surgery in CTS. After the end of the clinical trial, patients received the treatment prescribed by their general practitioner or specialist. Therapeutic failure was defined as the need of any new therapeutic intervention on the involved wrist. Comparison between groups was made using Cox multiple regression analysis. Estimation of the accumulated incidence of new therapeutic failure was made considering the withdrawal as a competitive risk (Gooley's test). Results: Of 163 randomized wrists at the beginning of the study, only 148 were available at the final follow-up. The mean follow-up was 6.3 and the median was 5.9 years. In the long-term follow-up, the accumulated incidence of therapeutic failure in the surgery group was 11.6% versus 41.8% in the injection group. The Cox multiple regression analysis showed a risk of failure associated with injection group of 4.5 (95% confidence interval [CI], 2.1-9.8; P < .0001). Conclusions: In long-term follow-up, surgery seems more effective than local corticosteroid injections in primary CTS. Nonetheless, about 58% of the patients in the injection group will not need further therapeutic interventions during the follow-up.

Imaging of Microhemodynamics in Peripheral Nerves by Contact Endoscope

BACKGROUND

Entrapment neuropathies include a wide field of locations. In most cases, the microsurgical decompression is still the therapy of choice. However, the role of venous stasis and ischemia is still discussed controversially. Here the authors evaluated the visualization of microvessels and the microperfusion at peripheral nerves with a contact endoscope during the surgical decompression for the first time.

METHODS

Eight patients were subjected to endoscopic or endoscopically assisted peripheral nerve decompression. In 3 patients with nerve tumors, the tumor carrying nerve was inspected endoscopically proximal and distal to the tumor site before and after resection. Microcirculation was assessed by a contact endoscope, allowing a 150-fold magnification, at superficial areas proximal and distal to the compression site. The electronically stored records were analyzed retrospectively using image processing software. Vessel diameter, red blood cell velocity, and blood flow, before and after decompression, were extracted.

RESULTS

The contact endoscope was easy to handle intraoperatively without problems. All minimally invasive procedures were performed without complications. In the offline computer-assisted analysis, single arterioles and veins were visualized showing decreased red blood cell velocity prior to decompression. After surgical treatment, a statistically significant increase of blood flow was observed.

CONCLUSIONS

Basically, the application of a contact endoscope for visualization of peripheral nerves' microcirculation is feasible. The observed effect of increased blood flow after decompression should be compared with the clinical outcome in a further prospective randomized study.

Long-term outcomes following single-portal endoscopic carpal tunnel release

BACKGROUND

There is limited published information about long-term outcomes and recurrence rates following single-portal endoscopic carpal tunnel release.

METHODS

We reviewed symptom and function outcomes from a prospectively collected database of patients who underwent single-portal endoscopic carpal tunnel release at a minimum of 8 years follow-up. Out of 207 patients in the original database, we were able to confirm correct current contact information for 106 patients. Of these, 91 patients with 115 single-portal endoscopic carpal tunnel releases agreed to participate. All of these patients were eligible for this long-term follow-up study based on documented preoperative and 6-month postoperative Levine-Katz questionnaire scores. Patients then completed a current update of the Levine-Katz questionnaires to assess function and symptom outcomes at latest follow-up.

RESULTS

The average 6-month postoperative scores were significantly lower compared with the average preoperative scores and were maintained at long-term follow-up. There were no significant differences in average change in scores at long-term follow-up compared to 6-months postoperative.

CONCLUSIONS

Single-portal endoscopic carpal tunnel release is an effective surgical treatment for carpal tunnel syndrome. Low recurrence rates and maintenance of low symptom and function scores can be expected at 8 to 10 years following this technique.

Retrospective analysis of five-year and longer clinical and electrophysiological results of the world's first endoscopic management for carpal tunnel syndrome

We have analyzed postoperative long-term follow-up results of five years or more from idiopathic carpal tunnel syndrome patients that underwent our complete carpal canal release and decompression procedure that uses the Universal Subcutaneous Endoscope system. In this series, 203 hands were followed up both clinically and electrophysiologically. Final follow-up times were determined by the most recent electrophysiological measurements. Mean follow-up period was nine years. Tingling, pain (using a 3 gm needle) and touch (using a 2 gm von Frey hair) at all median nerve distribution areas recovered to normal in 92.9, 98.2, 95.2%, respectively. Abductor pollicis brevis muscle power improved from preoperative manual muscle testing of 0, 1, 2 to post-operative 4 or 5 in 82.6%. Mean detectable distal sensory latency improved from 4.3 (n = 130) to 3.1 msec (n = 200). Mean detectable distal motor latency improved from 6.2 (n = 189) to 4.1 msec (n = 200). Complication and recurrence rates were 0% and 0.5% respectively.

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.

Early versus delayed endoscopic surgery for carpal tunnel syndrome: prospective randomized study

OBJECTIVE

To compare the effects of early versus delayed endoscopic surgery in patients with moderately severe carpal tunnel syndrome (CTS).

METHODS

The study included 100 patients with CTS. Investigations performed before surgery excluded secondary causes. Patients with moderately severe CTS (grade 3-4) were randomly assigned. Bland's neurophysiologic grading scale for CTS was used to assess the patients. Patients underwent an endoscopic carpal tunnel release using an indigenously designed instrument.

RESULTS

Following a course of conservative treatment, surgical treatment was offered in two groups: early surgery (n = 51; <1 week after diagnosis) and delayed surgery as per the usual waiting list (n = 49; >6 months after diagnosis). Improvement in both groups was significant (P < 0.001). When both groups were compared, improvement was better for the early surgery group (P < 0.001; confidence interval 6.35-9.12).

CONCLUSIONS

On the basis of this study, early endoscopic surgery is proposed in patients with moderately severe CTS.

Carpal tunnel syndrome caused by supernumerous lumbrical muscle in hemihyperplasia of the upper extremity

INTRODUCTION

Hemihyperplasia of the upper extremity is a rare pathology that occurs in 1/86,000 births. Carpal tunnel syndrome may be associated with this disease.

CLINICAL PRESENTATION

We describe the case of a 74-year-old male who has hemihyperplasia of both upper extremities since birth. At the age of 73, he started experiencing continuous, progressive and high intensity pain that occurred more frequently at night and was localized in the right hand. It was associated with paresthesia and hypoesthesia predominantly of the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to diagnosis of carpal tunnel syndrome.

RESULTS

The patient underwent surgical carpal tunnel release to treat the disease. The enlarged nerve was compressed by a supernumerous lumbrical muscle, which was resected intraoperatively. After six months of follow-up the patient has normal sensitivity and grip strength in the right hand.

CONCLUSION

Hemihyperplasia should be clearly distinguished from other complex pathologies that may also entail CTS. Since significant variation in the anatomy of the hemihyperplasic extremities is the rule rather than the exception, a conventional open approach should be taken to localize and treat the compression.

Anterior interosseous nerve compression syndrome: is there a role for endoscopy?

BACKGROUND

Anterior interosseous nerve syndrome is characterized by paralysis of the flexor digitorum profundus, the flexor pollicis longus and the pronator quadratus muscles without sensory loss. Extended exploration of the anterior interosseous nerve is the surgical treatment of choice. The present study evaluates the feasibility of an endoscopic approach for nerve decompression.

METHODS

Preparation of the anterior interosseous nerve was performed in ten human cadaver arms. Subsequently, one female patient suffering from anterior interosseous nerve syndrome was endoscopically operated on.

FINDINGS

A skin incision of 3-4 cm in the proximal direction was made at the forearm, and the median nerve was visualized between the pronator teres muscle and the flexor digitorum superficialis. Subsequently, the anterior interosseus nerve branch was identified, followed distally and decompressed under endoscopic view. The procedure could be accomplished in all cases under endoscopic view. Due to the very steep surgical angle, a branch of the anterior interosseus nerve was injured in one cadaver case. In all other cases, no adverse effects were observed. In the clinical case, the anterior interosseus nerve was endoscopically identified and decompressed, but a skin incision of 5 cm was required.

CONCLUSIONS

The results demonstrate that an endoscopic decompression of the anterior interosseus nerve is possible. Several difficulties occurred: Due to the depth of the surgical approach, especially in case of bulky muscles and very small skin incisions, the view is limited, harboring a higher risk of nerve injury. With more experience and specially designed endoscopes, application of this technique in anterior interosseus nerve compression syndrome might become more feasible.

Simple Endoscopic Decompression of Cubital Tunnel Syndrome With the Agee System

BACKGROUND

Simple decompression in ulnar nerve compression syndromes offers options for endoscopic applications.

OBJECTIVE

The authors present their initial experience with the Agee device.

PATIENTS AND METHODS

The monoportal endoscopic technique (Agee system) was evaluated on 10 cadaveric arms. Subsequently, 32 arms of 29 patients were operated on between January 2006 and March 2009. All patients presented with typical clinical signs and neurophysiologic studies. Long-term follow-up examinations were obtained in 27 of 32 arms.

RESULTS

In the cadaver study, the ulnar nerve was always correctly identified. No nerve damage occurred, and sufficient decompression of the ulnar nerve was always achieved. In the clinical series, no intraoperative complications were observed. A change to open technique was not required, and no worsening of the cubital tunnel syndrome occurred. Two wound infections required surgical wound cleaning. Wound hematomas treated conservatively were found in 5 cases. On long-term follow-up, an improvement in the McGowan-Classification was achieved in 22 of 27 cases. One patient was operated on by open surgery after endoscopic surgery.

CONCLUSION

The endoscopic technique for ulnar nerve entrapment syndrome using an Agee device appears to be safe and efficient. The results are comparable to those achieved with simple open decompression. A randomized prospective study should be performed to further evaluate the value of new technique in ulnar nerve entrapment syndrome.

Single portal endoscopic carpal tunnel release: modification of Menon's technique and data from 65 cases

The purpose of our study is to make a follow-up evaluation of endoscopic carpal tunnel release under focal anesthesia using the Wolf single portal system. A total of 65 patients with a mean age of 50 years undergoing 79 procedures were retrospectively studied. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were recorded. Follow-up was conducted at 1, 5, 12, and 24 weeks and at 1 year postoperatively. Wound pain, analysis of satisfaction, Levine functional status scales, and surgical complications were included. No patients sustained iatrogenic neurovascular injury or hematoma formation. The average Levine functional severity score decreased from 2.82 points preoperatively to 1.2 points at the most recent survey. One case recurred at 1 year after the surgery and subsequently underwent open release. Surgery using the Wolf single portal system under focal anesthesia is a safe and efficacious option for endoscopic carpal tunnel release.

Endoscopic Decompression of the Ulnar Nerve at the Elbow

OBJECTIVE

Recently, several studies suggested that simple decompression is as effective as anterior transposition in ulnar nerve entrapment syndrome. Simple decompression might be performed with minimally invasive techniques. The authors present their technique and results with endoscopic decompression in ulnar nerve entrapment syndrome.

MATERIAL AND METHODS

Between January 2005 and March 2008, 24 patients (mean age, 45.5 years; range, 26–67 years) underwent surgery for 26 ulnar nerve entrapment syndromes (2 bilateral). All patients presented with typical clinical signs and neurophysiologic studies.

RESULTS

Intraoperatively, the ulnar nerve was localized directly at the sulcus, and subsequently under endoscopic view, the decompression was completed approximately 10 cm proximal as well as distal. In 26 cases, a significant compression of the nerve was found directly at and distal to the sulcus. In 1 case, a subluxation of the nerve was observed, the endoscopic technique was abandoned, and open anterior submuscular transposition followed. The procedure was successful in 19 of 22 cases (86%). Neither intraoperative nor postoperative complications were observed. Nevertheless, the identification of the nerve directly at the sulcus, where severe nerve compression was often found, seemed to be difficult and potentially risky, particularly in obese patients.

CONCLUSION

The endoscopic technique for ulnar nerve entrapment syndrome seems to be safe and effective. However, particularly in patients with a thick subcutaneous fat layer, identification of the nerve at the sulcus is difficult and possible more risky than in open simple decompression. A randomized prospective study should be performed to further evaluate the value of this new technique in the treatment of ulnar nerve entrapment syndrome.