Release of the transverse carpal ligament alone is associated with elevated pressure beneath the distal volar forearm fascia in a cadaver model of carpal tunnel syndrome

Open surgery for carpal tunnel syndrome: is it necessary to release the antebrachial fascia? A randomized clinical trial study

Background

Open surgery for carpal tunnel syndrome (CTS) has historically involved release of the antebrachial fascia. The benefit of antebrachial fascia release in CTS surgery is still controversial. So, this study was designed to evaluate this hypothesis.

Methods

The study was designed as a two-arm randomized clinical trial study. Patients diagnosed with bilateral carpal tunnel syndrome were enrolled in the study, while those under 18 years of age and those with a history of carpal tunnel release, trauma to the spine, shoulder, or elbow, rheumatologic disease, inflammatory arthropathy, and CTS onset during pregnancy were excluded. The hands of the eligible patients were randomly assigned to two surgical groups. In the first group, the antebrachial fascia was opened to the proximal part, while in the second group, the fascia was opened from the central part of the deep layer to the distal volar part of the wrist. Pain severity, grip and pinch strength, symptom severity, and functional status were evaluated by the visual analog scale, the SAEHAN® hydraulic handgrip and pinch dynamometer, and the Boston Carpal Tunnel Questionnaire (BCTQ), respectively, at the baseline and 1, 3, and 6 months after surgery.

Results

Finally, 230 patients (220 women and 10 men, 460 hands) completed the study. The mean age of the patients was 50.4 ± 8.4 years. In both open surgery groups with and without antebrachial fascia release, the grip and pinch strength, BCTQ scores, and pain severity significantly improved at the end of the study (P < 0.01), but there was no statistically significant difference between the two groups (P > 0.05). Patient satisfaction improved in both groups; again, no significant difference was observed between the two groups (P > 0.05).

Conclusion

Both open CTS surgery with and without antebrachial fascia release show the same clinical and functional outcomes. Therefore, avoiding the release of the antebrachial fascia preserves proprioception and prevents iatrogenic injury to the median nerve and its branches. Conversely, a blunt release of the antebrachial fascia does not adversely affect the outcome.

Clinical Trial Registration

https://irct.behdasht.gov.ir/search/result?query=@irct_id:IRCT2012103111341N1, Identifier: IRCTID: IRCT2012103111341N1.

Comparison of clinical outcomes between open and modified endoscopic release for carpal tunnel syndrome

The aim of the present study was to investigate a novel technology, requiring only a single portal and no special equipment, to perform endoscopic treatment of carpal tunnel (CT) syndrome (CTS). This novel technique involves a surgical approach and standard operating procedures and is designed to minimize the potential for complications. Patients with CTS were randomly assigned using a computer-generated random allocation and stratified by site to either the modified endoscopic CT release (MECTR) group (n=48) or open CT release (OCTR) group (n=46). Various medical indexes were compared between the two groups, including operative time, hospitalization time, the time required to resume a normal life or work, intraoperative complications, incision infection rate, the amelioration of symptoms (Kelly grading), post-operative scar pain score, recovery of grip strength and pinch strength, two-point discrimination and the presence of sympathetic dystrophy. The results revealed that all patients had grade A wound healing and the symptoms were completely relieved. No significant differences were observed between the two groups with regards to the incision infection rate, intraoperative complications, grip strength, pinch strength, two-point discrimination, presence of sympathetic dystrophy and clinical symptom amelioration. In addition, compared with the OCTR group, the MECTR group had a decreased operative and hospitalization time, post-operative scar pain score and time required to resume a normal lifestyle. Post-operative electromyographic examination also revealed that the median nerve sensory conduction speed increased compared with that prior to surgery in both groups. In conclusion, the use of MECTR for the treatment of CTS achieved higher patient satisfaction, a shorter operative time and hospitalization time, an earlier return to work time or resumption of a normal life, as well as less post-operative scar pain compared with OCTR. Thus, these results suggested that MECTR may be an effective method for the treatment of idiopathic CTS. Trial registration no. ChiCTR2000041165, retrospectively registered 20th December 2020.

Modification of intra-carpal tunnel pressure after Z-lengthening of the transverse carpal ligament

Background Flexor retinaculum reconstruction techniques or simply Flexor Retinaculum Z-lengthening have been proposed to preserve Flexor Retinaculum continuity after carpal tunnel release. Their effectiveness is based solely on symptom relief. There has been no analysis of the effects on intra-carpal tunnel pressure of Flexor Retinaculum-lengthening techniques. Objective was to compare intra-carpal tunnel pressure outcomes between complete division and Z-lengthening of the Retinaculum in a cadaveric model of carpal tunnel release. Methods Experimental study of carpal tunnel pressure after surgical Flexor Retinaculum modification in 10 fresh-frozen forearm and hand cadaveric specimens. The Kyphon™ Balloon Kyphoplasty system was used to measure the pressure before and after infusing 1, 2, 3, 4 and 5 ml of saline solution when untreated (Flexor Retinaculum continuity stage I), when Z-lengthened (Flexor Retinaculum continuity stage II), and after complete Flexor Retinaculum division (Flexor Retinaculum continuity stage III). Finding Intra-carpal tunnel pressure increased with larger volume of infused saline solution, although mean pressures were lower after Z lengthening or complete division of the Retinaculum than at baseline. Analysis of linear regression coefficients indicated significant differences as a function of FR continuity stage (F(2,18) = 18.38, p < 0.001), while the Bonferroni test revealed significant differences in slopes between stages I and III (p = 0.003), between stages I and II (p < 0.02), but not between stages II and III (p > 0.05). Interpretation The effectiveness of carpal tunnel release and the reduction in intra-carpal tunnel pressures obtained by Z-lengthening of the FR were similar to those observed after its complete division, while preserving FR continuity.

Mini-open versus extended open release for severe carpal tunnel syndrome

BACKGROUND

This study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release.

METHODS

The method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ).

RESULTS

Patients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months ± 5.0), while patients in group 2 had a 59.3 % increase (10.0 months ± 6.9). BCTQ surveys from group 1 (n = 46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9 ± 10.6 months. Group 2 (n = 42) surveys demonstrated averages of 12.88 and 9.10 at 43.1 ± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision.

CONCLUSION

No significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.

Single-incision extensile volar approach to the distal radius and concurrent carpal tunnel release: cadaveric study

PURPOSE

To determine whether a single-incision extensile approach to the distal radius used for open reduction internal fixation and a concomitant radial sided carpal tunnel (CT) release safely and effectively decompresses the carpal tunnel.

METHODS

Five pairs of cadaveric forearms were mounted to a tabletop with a cable pulley system attached to the long finger. Each paired specimen was randomized to volar plating via either the flexor carpi radialis approach (control group) or the extensile volar exposure (combined flexor carpi radialis and radial-sided carpal tunnel release). Before and after the respective exposure and plating, increased CT pressures were created with 2.27, 4.54, and 6.81 kg of distraction. We used a paired t-test to compare the change in CT pressure at each level of distraction before and after intervention for the 2 groups, with significance set at p </= .05. A dissection of each exposure was performed with attention given to the radial aspect of the transverse carpal ligament (TCL) and any possible iatrogenic injuries.

RESULTS

Carpal tunnel pressure increased with increasing distraction. We noted a statistically significant reduction in CT pressure after the extensile exposure and plating with 4.54 (p = .023) and 6.81 (p < .001) kg of distraction, respectively. No significant reduction in mean CT pressure for the control group specimens occurred at any level of distraction force. The average length of the radial TCL was 22 mm (range, 18-31 mm); the average distance between the recurrent motor branch and distal TCL was 11 mm (range, 8-15 mm). No iatrogenic tendon or nerve injury occurred with the extensile volar exposure.

CONCLUSIONS

Carpal tunnel pressure is safely reduced and the distal radius is adequately exposed for fixation with the extensile volar approach.