Palmar uniportal extrabursal endoscopic carpal tunnel release

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.

A Clinical Study of the Modified Thread Carpal Tunnel Release

BACKGROUND

Previous studies have indicated that the thread carpal tunnel release (TCTR) is a safe and effective technique. Through a study on 11 cadaveric wrists, the TCTR procedure was modified and the needle control accuracy was improved to 0.15 to 0.2 mm, which is precise enough to preserve superficial palmar aponeurosis (SupPA), Berrettini branch, and common digital nerves. The aim of the present study was to verify the modified TCTR clinically.

METHODS

The modified TCTR was performed on 159 hands of 116 patients. The Boston Carpal Tunnel Syndrome Questionnaire was used for assessing the outcomes. Statistical analyses were used to compare the outcomes with the available data from the literature for the open and endoscopic techniques.

RESULTS

TCTR led to significant improvement in the short-term results, and the outcomes were better in long-term results compared with the open or endoscopic release. The SupPA, Berrettini branch, and common digital nerves were protected. There was no neurovascular complication for any case. Significant relief of symptoms was observed 3 to 5 hours post procedure. Most patients used their hands on the day of the procedure for simple daily activity. Patients reported their sleep quality was improved on the surgical day. Most patients with office jobs were able to return to work on postoperative day 1, and those with repetitive jobs returned to work in about 2 weeks. The statistical evidence proves that the modified TCTR procedure results in improved clinical outcomes as compared with open carpal tunnel release (CTR) and endoscopic CTR.

CONCLUSIONS

The TCTR procedure has been shown to be a safe and effective technique for CTR. The modified TCTR procedure minimizes postoperative complications, such as pillar pain, scar tenderness, or functional weakness, by avoiding unnecessary injuries to the surrounding structures around the transverse carpal ligament during the procedure.

Superficial plane endoscopy for carpal tunnel release

In this publication we describe three techniques for endoscopic carpal tunnel release which use the palmar portal approach and the superficial plane to enable a view from above the transverse carpal ligament. These techniques prevent any iatrogenic compression of the median nerve inside the already narrow tunnel. Although the necessary instruments are inexpensive and recommended in instrumentation catalogues, their use has rarely been reported. These techniques are safe and easy to learn for surgeons familiar with arthroscopy. We believe that they constitute an important alternative to the already well-established methods of interior tunnel access, and believe that their use should become more widespread.

Outcomes of open and endoscopic carpal tunnel release: a meta-analysis

BACKGROUND

Currently, there are two genres of surgical treatment of carpal tunnel syndrome, open versus endoscopic. The goal of our study is to analyze published data by comparing outcomes of surgical treatment for carpal tunnel syndrome and determine if one approach is superior to the other (open versus endoscopic).

METHODS

A meta-analysis of retrospective series of Carpal tunnel release including >20 patients, with results measuring outcomes based on at least six of the following nine parameters (paresthesia relief, scar tenderness, two-point discrimination, thenar muscle weakness, Semmes-Weinstein/SW monofilament testing, return to work time, grip and pinch strength, and complications).

RESULTS

Endoscopic carpal tunnel approach showed statistically superior outcomes in eight of the nine categories investigated. Only in the category of complications (mean occurrence of 1.2 % in the open release versus 2.2 % in the endoscopic release group) was the endoscopic group inferior.

CONCLUSION

This suggests that the endoscopic release is superior to the open release, particularly in experienced hands.

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

Limited open carpal tunnel release was performed in 58 hands (44 patients) using a single 1.5 cm palmar incision according to the technique described by Lee and Strickland.1The patients were assessed at regular intervals after surgery for hand functions and subjective symptoms, in particular pillar pain. There was rapid wound recovery with minimal post-operative pain and scarring, and return to functional activities within four weeks. At an average follow-up of 18 months (range 14–24 months), 91% of patients had complete or significant resolution of hand paraesthesia. No patient required further surgery. However, pillar pain was found in 48% of hands at four weeks, 21% at 12 weeks, 12% at six months, 9% at 12 months and 7% at the last follow-up. The significance of the incidence of pillar pain is discussed.

Scope-assisted release of the cubital tunnel

We report on a technique of endoscopic release of the cubital tunnel, which is a modification of Bruno and Tsai's technique. This article covers the history, complications, indications, and postoperative management of ulnar nerve entrapments treated endoscopically, with a special focus on our technique. This minimally invasive alternative to transposition requires no mobilization of the ulnar nerve, which could potentially reduce iatrogenic trauma to the nerve and its vascularity.

Endoscopic release of the carpal tunnel: a 2-portal-modified technique

Endoscopic carpal tunnel release has been popularized since 1989 when Okutsu described it for the first time. Several surgeons have followed his principles and described their own techniques. These were developed in an attempt to decrease the well-known complications related to the open technique. Single and 2-portal techniques have been described. Indications include patients with moderate Carpal tunnel syndrome (CTS) and failed conservative treatment. A modified Tsai 2-portal technique is used creating a "fixed surgical tunnel" for decompression and a custom made plastic tube is used to check the quality of release. A specific instrumentation is needed (A.M. Surgical, Smithtown, NY). Few complications are associated, finding it a reliable technique for the decompression of the carpal tunnel.

Minimally invasive carpal tunnel decompression using the KnifeLight

OBJECTIVES

Carpal tunnel syndrome is a common condition causing hand pain, dysfunction, and paresthesia. Endoscopic carpal tunnel decompression offers many advantages compared with conventional open surgical decompression. However, it is equipment intensive and requires familiarity with endoscopic surgery. We review a minimally invasive technique to divide the flexor retinaculum by using a new instrument, the KnifeLight (Stryker, Kalamazoo, Michigan), which combines the advantages of the open and endoscopic methods, without the need for endoscopic set-up.

METHODS

Between July 2003 and April 2005, 44 consecutive patients (26 women [59%] and 18 men [36%]), with clinical signs and symptoms, as well as electrodiagnostic findings consistent with carpal tunnel syndrome, who did not respond to non-surgical treatment, underwent the new procedure. All patients were asked about scar hypertrophy, scar tenderness, and pillar pain. The Michigan Hand Outcomes Questionnaire (MHQ) was used to determine overall hand function, activities of daily living, work performance, pain, aesthetics, and satisfaction with hand function. Other preoperative testing included grip strength and lateral pinch strength. Grip strength was measured using the Jamar hand dynamometer (Asimov Engineering Co., Los Angeles, CA); lateral key pinch was measured using the Jamar hydraulic pinch gauge. Postoperative evaluations were scheduled at 2 weeks, 3 months, and 6 months after the procedure. A small 10-mm incision was made in the wrist crease and a small opening was made at the transverse carpal ligament. The KnifeLight tool was inserted, and the ligament was incised completely. Follow-up evaluations with use of quantitative measurements of grip strength, pinch strength, and hand dexterity were performed at 2 weeks, 3 months, and 6 months after surgery.

RESULTS

Fifty procedures were performed on 22 left hands (44%) and 28 right hands (56%). There were no complications related to the approach. All patients were able to use their hands immediately after the surgery. Scar tenderness and incisional pain were mild-to-moderate in the first 2 weeks, and these symptoms disappeared completely 6 months after surgery. Significant postoperative improvements in pain relief, patient satisfaction, hand function, daily activities, and work performance as assessed with the MHQ were noted at 3 and 6 months after surgery. Furthermore, significant improvement in patients' hand grip and pinch strength were observed 6 months after surgery. From a literature review, we found that the mean operation time of KnifeLight carpal tunnel release was the shortest compared with the conventional and endoscopic carpal tunnel release techniques. The median time needed for our patients to return to work was also the shortest among the different techniques.

CONCLUSION

Excellent functional outcomes and satisfaction were achieved using the KnifeLight for carpal tunnel decompression. Our minimally invasive method offers a quick, easy, and effective alternative to conventional or endoscopic carpal tunnel decompression.

Complications of endoscopic and open carpal tunnel release

PURPOSE

To compile the major complications of carpal tunnel surgery and compare reported complications for open and endoscopic techniques.

METHODS

A literature assessment was performed for published complications of open and endoscopic carpal tunnel release procedures; 80 publications, representing a period from 1966 through 2001, were reviewed. Complications were identified as neurapraxia; nerve, tendon, or artery injury; and wound infection or dehiscence that required antibiotics or additional operative care. Differences in the proportions of complications between carpal tunnel release procedures were explored with the use of Fisher exact tests.

RESULTS

The literature review yielded 22,327 cases of endoscopic carpal tunnel release and 5,669 cases of open carpal tunnel release. For structural damage to nerves, arteries, or tendons, the incidence for open carpal tunnel release is 0.49% and for endoscopic methods (transbursal and extra-bursal), 0.19%. This difference is statistically significant (P < .005; 2-tailed Fisher exact test) and suggests that the overall proportion of structural complications for open carpal tunnel release according to our complication selection criteria is greater than the overall proportion of complications for endoscopic carpal tunnel release.

CONCLUSIONS

The proportion of complications for carpal tunnel release, performed through an endoscopic or open approach, is very low. Selection of an open versus an endoscopic approach on the basis of structural complications for nerve, arteries, or tendons is not supported by statistical analysis of published complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic study.

Biomechanical and anatomical consequences of carpal tunnel release

Carpal tunnel syndrome is an exceedingly common orthopaedic problem in the United States. When conservative management is unsuccessful, most surgeons proceed to surgical treatment. Though the carpal tunnel release procedure is usually curative, many patients experience postoperative complications, such as scar sensitivity, pillar pain, recurrent symptoms, and grip weakness, regardless of whether the release was done through an open, mini-open, or endoscopic approach. The exact causes of these and other complications of carpal tunnel release remain unclear. Release of the carpal tunnel has an effect on carpal anatomy and biomechanics, including an increase in carpal arch width, carpal tunnel volume, and changes in muscle and tendon mechanics. We set out to review the morphological and biomechanical changes caused by carpal tunnel release with the goal of better understanding the root causes of postoperative complications. This article first reviews normal carpal tunnel anatomy and anatomic variations, then available surgical techniques for carpal tunnel release, and finally the literature on morphologic, physiologic and biomechanical alterations in the wrist after carpal tunnel release.

Endoscopic carpal tunnel release

Endoscopic carpal tunnel release is not a procedure to be taken lightly. Like many surgical procedures, it is a demanding exercise that requires exacting knowledge of the anatomy of the hand, attention to detail, and the ability to manipulate three-dimensional objects while observing them in two dimensions on a video screen. In the hands of well trained surgeons, ECTR provides patients with a safe, predictable solution to their carpal tunnel sydrome that will allow them a rapid return to normal activities with minimal postoperative discomfort.

Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? An analysis of published series

The purpose of this study was to evaluate the reported rate of complications after endoscopic carpal tunnel release by means of an analysis of 54 publications, reporting a total of 9516 endoscopic and 1203 open releases. Endoscopic release was comparable to open release in the rate of irreversible nerve damage (0.3% and 0.2% respectively) but case reports may indicate a small risk of unacceptable complications with endoscopy, such as transection of the median nerve. Reversible nerve problems were more common after endoscopic release. Tendon lesions were extremely rare (0.03%) and the rate of other complications (reflex sympathetic dystrophy, haematoma, wound problems, etc.) was about the same with endoscopic as with open release.

Safe carpal tunnel release via a limited palmar incision

Despite its demonstrated advantages in postoperative recovery, endoscopic carpal tunnel release has not been adopted by most surgeons because of the associated complications of neurovascular injury. A technique of carpal tunnel release is presented that utilizes a 1.0 to 1.5-cm palmar incision and a specially designed carpal tunnel "tome." Any aberrant anatomy of adjacent neurovascular structures may be identified under direct vision. Anatomic dissection in 28 cadaveric specimens following the procedure showed complete decompression of carpal tunnel and preservation with safe margins of the palmar cutaneous branch and thenar motor branch of median nerve, ulnar artery and nerve, and superficial palmar arch. Clinical experience with the technique in two centers consisted of 525 patients and 694 hands over a 29-month period. The great majority of patients derived complete (72.6 percent) or near-complete (19.6 percent) symptomatic relief from the procedure, and two complications (0.29 percent) of median nerve lacerations occurred. Postoperative incisional and pillar tenderness and grip, key pinch, and three-point pinch strengths were comparable with those in published series of endoscopic carpal tunnel release. We conclude that this technique of carpal tunnel release combines the simplicity and safety of traditional open release and the reduced tissue trauma and improved postoperative recovery of the endoscopic modality.

Pillar pain as a postoperative complication of carpal tunnel release: a review of the literature

Carpal Tunnel Syndrome (CTS) has been referred to as the most common peripheral entrapment neuropathy. As Mirza and colleagues note, its incidence continues to increase. Einhorn and Leddy cite Palmer's estimated incidence of 1% in the general population and 5% or more of workers in certain industries which require repetitive use of the hands and wrists. Conservative treatment of CTS includes splinting and modification of activities. However, surgical release of the transverse carpal ligament or the flexor retinaculum is an extremely common procedure. The open surgical technique has been used since 1924 and is still considered by many to be the gold standard. In 1989 Oksuto introduced the endoscopic carpal tunnel release (ECTR) with the rationale of potentially decreasing the prevalence of complications. In the ensuing years, endoscopic results have generated a tremendous amount of study and controversy. Berger reported that many "passionate arguments both for and against the use of ECTR" exist. This paper briefly reviews the literature generated by this debate, focusing on one potential postoperative complication: pillar pain. Various definitions of pillar pain are noted, and suggested etiologies are grouped into four categories. This is followed by a brief discussion of the treatment approaches and issues.

Ultrasonographically assisted carpal tunnel release

An operative technique of carpal tunnel release using intraoperative ultrasonography is described. In this technique, "safe line" is defined in the transverse carpal ligament and the adjacent deep forearm fascia midway between the ulnar margin of the median nerve and the radial margin of the ulnar artery. After ultrasonographic design of a 1.0 to 1.5-cm skin incision along the safe line at the distal carpal tunnel, the distal ligament is released under direct vision. Proximal release is performed along this line under ultrasonographic monitoring using a device that consists of a basket punch and an outer metal tube. In a prospective randomized study, the outcomes were compared for carpal tunnel release using either this technique in 50 hands of 50 patients or conventional open release in 53 hands of 53 patients. Follow-up assessment at 3, 6, 13, 26, 52, and 104 weeks showed no significant difference with respect to numbness and paresthesias, static two-point discrimination, findings on Semmes-Weinstein monofilament testing, findings on manual muscle testing of the abductor pollicis brevis, and electrophysiologic findings. The ultrasonographic-release group had better outcomes regarding pain, tenderness of the scar, and key-pinch strength at 3, 6, and 13 weeks, and grip strength at 3 and 6 weeks after surgery. The scar was more aesthetic in this group. There were no complications with either technique.