Endoscopic Carpal Tunnel Release

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.

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.

Special operative considerations in musicians

Musicians are a unique group, requiring digital control and skills at the highest levels. Each instrument has its own special needs and the musician must be seen in the context of the instrument played. Surgery also must be seen in this context. The special areas of modification of technique and some of the more commonsurgical situations encountered in musicians are considered in this article.

Contribution of magnetic resonance imaging for the diagnosis of median nerve lesion after endoscopic carpal tunnel release

Deterioration of pre-existing signs or appearance of a nerve deficit raise difficult problems during the complicated course following endoscopic carpal tunnel release. One possible explanation is transient aggravation of nerve compression by passage of the endoscopy material, but these signs may also be due to incomplete section of the flexor retinaculum or an iatrogenic nerve lesion. Each case raises the problem of surgical revision. The authors report three cases of open revision in which MRI allowed a very precise preoperative diagnosis of the lesions and all of the MR findings were confirmed during surgical revision. In the first case, MRI showed section of the most radial branches of the median nerve (collateral nerves of the thumb, index finger and radial collateral nerve of the middle finger). The proximal origin of the nerve of the 3rd web space, above the retinaculum, an anatomical variant, was also identified. Section of 2/3 of the nerve of the 3rd web space, proximal to the superficial palmar arch, was observed in the second case. Simple thickening of the nerve of the 3rd web space, without disruption after opening of the perineurium, was observed in the third case. MRI therefore appears to be an examination allowing early and precise definition of indications for surgical revision in this new iatrogenic disease.