Sonography-Guided Carpal Tunnel Release

[Translated article] Percutaneous ultrasound-guided section of the transverse carpal ligament vs. open surgery for the surgical treatment of carpal tunnel syndrome (CTS)

BACKGROUND AND OBJECTIVE

The gold standard of carpal tunnel syndrome (CTS) treatment is the section of the transverse carpal ligament, the most common technique being the palmar cutaneous incision. Percutaneous techniques have been developed, although their risk/benefit ratio remains controversial.

OBJECTIVE

To analyse the functional outcome of patients undergoing CTS percutaneously ultrasound-guided and compare it with those of open surgery.

MATERIAL AND METHOD

Prospective observational cohort study of 50 patients undergoing CTS (25 percutaneous with WALANT technique and 25 by open surgery with local anaesthesia and tourniquet). Open surgery was performed using a short palmar incision. The percutaneous technique was performed anterograde using the Kemis H3® scalpel (Newclip). A preoperative and postoperative assessment was performed at 2 weeks, 6 weeks and 3 months. Demographic data, presence of complications, grip strength and Levine test score (BCTQ) were collected.

RESULTS

The sample consists of 14 men and 36 women with a mean age of 51.4 years (95% CI: 48.4-54.5). Percutaneous technique was performed anterograde using the Kemis H3® scalpel (Newclip). All patients improved from their CTS clinic without obtaining statistically significant differences in BCTQ score, nor in the presence of complications (p>0.05). Patients operated on percutaneously recovered faster grip strength at 6 weeks, but it was similar in the final review.

CONCLUSIONS

In view of the results obtained, percutaneous ultrasound-guided surgery is a good alternative for the surgical treatment of CTS. Logically, this technique requires its learning curve and familiarisation with the ultrasound visualisation of the anatomical structures to be treated.

Correlation of In-situ Hand Anatomy With Point of Care Ultrasound

The effective use of point-of-care ultrasound for the diagnosis and treatment of hand conditions is dependent upon a thorough understanding of its anatomic bases. To facilitate this understanding, in-situ cadaveric hand dissections were correlated with handheld ultrasound images in the palm focusing on key areas of clinical relevance. The palms of an embalmed cadaver were dissected, minimizing the reflection of structures whenever possible to emphasize normal relationships and tissue planes. Point-of-care ultrasound images were obtained from a living hand and correlated with related anatomy in the cadaver. Juxtaposing cadaver structures, spaces, and relationships with the associated ultrasound images, surface hand orientation, and ultrasound probe positioning, a series of images were developed as a guide to correlating in-situ anatomy with point-of-care ultrasound in the hand.

Update on surgical procedures for carpal tunnel syndrome: What is the current evidence and practice? What are the future research directions?

Carpal tunnel syndrome (CTS) is a multifactorial compression neuropathy. It is reported to be very common and rising globally. CTS’s treatment varies from conservative measures to surgical treatments. Surgery has shown to be an effective method for more severe cases. However few unclear aspects and room for further research and improvements still remains. We performed a narrative literature review on the most up to date progress and innovation in terms of surgical treatments for CTS. The simple algorithm of leaving the choice of the surgical method to surgeons’ preference and experience (together with consideration of patients’ related factors) seem to be the best available option, which is supported by the most recent metanalysis and systematic reviews. We suggest that surgeons (unless in presence of precise indications towards endoscopic release) should tend to perform a minimally invasive open approach release, favoring the advantage of a better neurovascular structures visualization (and a consequent higher chance to perform a complete release with long term relief of symptoms) instead of favoring an early reduction (in the first postoperative days) of immobilization and pain. Research towards a universally accepted standardization should be aimed for by the researchers, who have failed to date to sufficiently limit bias and limitations.

Percutaneous ultrasound-guided section of the transverse carpal ligament vs open surgery for the surgical treatment of carpal tunnel syndrome (CTS)

BACKGROUND AND OBJECTIVE

The gold standard of carpal tunnel syndrome (CTS) treatment is the section of the transverse carpal ligament, the most common technique being the palmar cutaneous incision. Percutaneous techniques have been developed, although their risk/benefit ratio remains controversial.

OBJECTIVE

To analyze the functional outcome of patients undergoing CTS percutaneously ultrasound-guided and compare it with those of open surgery.

MATERIAL AND METHOD

Prospective observational cohort study of 50 patients undergoing CTS (25 percutaneous with WALANT technique and 25 by open surgery with local anesthesia and tourniquet). Open surgery was performed using a short palmar incision. The percutaneous technique was performed anterograde using the Kemis® H3 scalpel (Newclip). A preoperative and postoperative assessment was performed at 2 weeks, 6 weeks and 3 months. Demographic data, presence of complications, grip strength and Levine test score (BCTQ) were collected.

RESULTS

The sample consists of 14 men and 36 women with a mean age of 51.4 years (95% CI: 48.4-54.5). Percutaneous technique was performed anterograde using the Kemis® H3 scalpel (Newclip). All patients improved from their CTS clinic without obtaining statistically significant differences in BCTQ score, nor in the presence of complications (p> 0.05). Patients operated on percutaneously recovered faster grip strength at 6 weeks, but it was similar in the final review.

CONCLUSIONS

In view of the results obtained, percutaneous ultrasound-guided surgery is a good alternative for the surgical treatment of CTS. Logically, this technique requires its learning curve and familiarization with the ultrasound visualization of the anatomical structures to be treated.