Carpal tunnel syndrome: morphologic changes after release of the transverse carpal ligament

We describe the morphologic changes that follow division of the transverse carpal ligament in patients with carpal tunnel syndrome. Fifteen hands in 12 patients with carpal tunnel syndrome were studied with magnetic resonance imaging before operation and for 6 weeks after operation. Eight hands were studied at 8 months after operation. Carpal arch width, anterior displacement of the carpal canal contents, and carpal canal volume were measured by use of multiplanar reformation and three-dimensional reconstruction of magnetic resonance images. There was a 24.2 +/- 11.6% increase in carpal canal volume 6 weeks after carpal tunnel release (p less than 0.001). This difference persisted at 8-month follow-up. There was an anterior displacement of carpal canal contents 3.5 +/- 1.9 mm from its original position 6 weeks after operation (p less than 0.001). This palmar displacement persisted at the 8-month follow-up. There was no statistically significant increase in carpal arch width 8 months after carpal tunnel release. We believe that division of the transverse carpal ligament restores median nerve function by increasing the volume of the carpal canal. This volumetric increase results from an anterior displacement of the newly formed transverse carpal ligament and not from a widening of the bony carpal arch.     

Internal neurolysis or ligament division only in carpal tunnel syndrome—Results of a randomized study

Summary In a series of patients with clinically and neurophysiologically well defined carpal tunnel syndrome a randomization has been made into two groups, one for operation with internal neurolysis and a microscopical technique, and the other group for cutting of the carpal ligament (flexor retinaculum) alone. The two groups have been compared postoperatively regarding clinical and neurophysiological parameters. All patients improved, 89% in both groups considered themselves totally free of symptoms at follow-up examinations but there was no significant difference in any parameter between the two groups. As a conclusion the use of internal neurolysis cannot be recommended as a routine procedure in carpal tunnel syndrome.     

Results of internal neurolysis of the median nerve for severe carpal-tunnel syndrome

Thirty-six hands in thirty-two patients had internal neurolysis of the median nerve and carpal tunnel release for severe carpal-tunnel syndrome. Median-nerve function was evaluated in all hands using Weber two-point discrimination and electromyography. Thenar-muscle strength or bulk, or both, were recorded in thirty hands. Ten hands also had Semmes-Weinstein monofilament pressure-testing. The indication for neurolysis in these selected patients was the presence of any one of the following: an increase in two-point-discrimination values, thenar-muscle atrophy, or denervation potentials in the thenar muscles. Twenty-two (76 per cent) of the twenty-nine hands that had had diminished two-point discrimination preoperatively regained normal sensibility. Seven (70 per cent) of ten hands that had had thenar-muscle weakness (grade 3 or less) preoperatively regained grade-4 or 5 strength. Nine (50 per cent) of eighteen hands that had had thenar-muscle atrophy regained normal muscle bulk. Seventy-six per cent of the patients in this series recovered sensation and 70 per cent recovered muscle strength, and the procedure was well tolerated. Although no studies comparing the results of treatment of severe carpal-tunnel syndrome with and without internal neurolysis have been reported, we think that neurolysis, if it is done by a surgeon who is skilled in microsurgery, is a safe and effective procedure for severe carpal-tunnel syndrome.     

Intraoperative assessment of median nerve blood flow during carpal tunnel release with laser Doppler flowmetry

Eleven consecutive median nerves in patients with clinical carpal tunnel syndrome were examined prospectively with laser Doppler flowmetry. All procedures were done without a tourniquet with the patient under local or general anesthesia. Multiple measurements of median nerve blood flow were obtained during carpal tunnel release. Flow characteristics proximal to the transverse carpal ligament did not change after release of the ligament. Beneath the transverse carpal ligament, initial flow was random in 10 of 11 nerves. Within 1 minute after release of the transverse carpal ligament, flow became pulsatile and synchronized with the patient's pulse in nine nerves. Although preliminary, these data suggest that in carpal tunnel syndrome the segment of median nerve beneath the carpal ligament is relatively ischemic and this ischemia may be a factor in the development of symptomatic median nerve entrapment. The rapid return of a pulsatile signal within the nerve after release is positively correlated with relief or improvement of median nerve dysesthesias.     

Carpal tunnel pressure in patients with carpal tunnel syndrome due to long-term hemodialysis

We studied carpal tunnel pressure and outcome of endoscopic carpal tunnel release in 42 patients (53 hands) with carpal tunnel syndrome (CTS) and receiving long-term hemodialysis. We compared these results with those of 41 patients (49 hands) with idiopathic CTS. Pressure was measured peroperatively: first, before dilation of the carpal tunnel; second, after dilation but before release of the transverse carpal ligament; and third, after completion of the release. In patients receiving long-term hemodialysis, the highest pressures were 76.9, 56.0, and 7.8 mmHg respectively. In patients with idiopathic CTS, pressures were 68.8, 44.1, and 4.0 mmHg respectively. The clinical outcome was inferior in patients receiving long-term hemodialysis.     

Endoscopic release in carpal tunnel syndrome: analysis of clinical results in 200 cases.

Carpal tunnel syndrome is the most common peripheral neuropathy. Conventional carpal tunnel surgery has been performed as a primary procedure for the decompression of the median nerve at the wrist in patients who have idiopathic carpal tunnel syndrome. While the results have been excellent, this surgical procedure has been reported to be related to high postoperative morbidity and extended length of recovery time. Over the past decade, endoscopic release of the transverse carpal ligament has been developed as a new, alternative method to the open procedures. Endoscopic carpal tunnel release has been reported to ensure less postoperative morbidity, more rapid recovery of strength, with earlier return to work, reduced disability time and a better cosmetic result. The authors present a surgical series of 200 hands in 164 patients (36 bilaterals) with idiopathic carpal tunnel syndrome, who underwent a single-portal endoscopic carpal tunnel release (Agee technique), with regards to the clinical outcome and complications occurred after 4-months follow-up.     

Endoscopic carpal tunnel release: Development of a new device

The carpal tunnel syndrome is traditionally treated through an open incision. To reduce scar formation and postoperative recovery time, endoscopic methods were developed. These methods have one major problem in common, as cadaver studies show, which is the incomplete release of the transverse carpal ligament. To avoid this severe complication, we started to develop an instrument which allows to perform complete releases. Therefore we worked from the very beginning with a pair of basket forceps, which divides ligament tissue safely, completely and additionally performs partial resection of the ligament during the procedure. The new device is based on a standard 4.0 mm, 30° angled scope. Subligamental, dorsal tissue is bluntly dissected from the transverse carpal ligament by an 80 mm cannula that has a longitudinal notch. Λ 2.5 mm basket forceps is introduced and securely guided within this notch. Using the basket forceps endoscopic carpal tunnel release was performed in a uni-portal approach on 7 cadaver hands followed by a duo-portal approach on 7 additional cadaver hands. Succeeding endoscopic carpal tunnel release, the transverse carpal ligament and adjoining structures were exposed and scrutinized for unintended injuries. In the duo-portal approach all ligaments were completely divided. There were no complications (laceration of nerves, vessels, tendons) found after endoscopic carpal tunnel release in all cadaveric hands. Conclusion: The developed device seems in its technique and potential for prevention of iatrogenic injuries superior to other endoscopic systems, since it not only permits endoscopic carpal tunnel release under direct visualization but also results in the partial resection of the ligament during the procedure, thus reducing the risk of later recurrencies.     

Role of ancillary procedures in surgical management of carpal tunnel syndrome: epineurotomy,internal neurolysis,tenosynovectomy, and tendon transfers

The role of ancillary procedures in the treatment of carpal tunnel syndrome is controversial, especially with regard to internal neurolysis and epineurotomy. At present, there are little to no data to support their routine use in the treatment of primary carpal tunnel syndrome. Similarly, the use of tenosynovectomy in carpal tunnel surgery should be limited to those patients with clear underlying rheumatologic or inflammatory risk factors, or with gross synovitis incidentally noted at surgery. The Camitz transfer is uniquely suited to treating the thenar wasting seen in advanced carpal tunnel syndrome. It can be performed concurrently with open carpal tunnel release with minimal additional dissection and morbidity.     

Intraoperative changes in motor nerve conduction latency in carpal tunnel syndrome

A prospective study of 47 patients with 51 hands treated for carpal tunnel syndrome by surgical release of the deep transverse carpal ligament was performed using intraoperative motor nerve conduction latency measured over a standard distance across the carpal tunnel both before and after release of the ligament. The results of intraoperative conduction latencies indicated a dramatic and immediate reduction in the conduction latency across the carpal canal in all but seven patients, two of whom had diabetes. When the results were subjected to statistical analysis, they were significant (P is equal to 0.00001). Although further studies are indicated, these data suggest that a rapidly reversible mechanical or metabolic block, such as ischemia in the segment of the median nerve, may be responsible for the symptoms of carpal tunnel syndrome.     

腕横韧带切除预防桡骨下端骨折迟发性腕管综合征的病例对照研究

目的：探讨桡骨下端骨折采用掌侧切口切开复位＂T＂形钢板内固定并Ⅰ期行腕横韧带切除对术后发生迟发性腕管综合征的预防作用。方法：自2000年3月至2007年3月,桡骨下端骨折患者采用两种方法治疗。采用切开复位＂T＂形钢板内固定并Ⅰ期行腕横韧带切除治疗32例,男8例,女24例;年龄46～66岁;B3型骨折21例,C1型骨折6例,C2型骨折4例,C3型骨折1例。采用单纯骨折切开复位＂T＂形钢板内固定治疗30例,男7例,女23例;年龄45～65岁;B3型骨折13例,C1型骨折9例,C2型骨折6例,C3型骨折2例。对两组术后迟发性腕管综合征发生率进行比较。结果：骨折切开复位＂T＂形钢板内固定并Ⅰ期行腕横韧带切除组32例,其中3例发生迟发性腕管综合征,而单纯骨折切开复位＂T＂形钢板内固定组30例,其中10例发生迟发性腕管综合征,两组差异有统计学意义（P〈0.05）。结论：Ⅰ期行腕横韧带切除能较好地预防桡骨下端骨折掌侧切口术后迟发性腕管综合征。     

Internal neurolysis or ligament division only in carpal tunnel syndrome II a 3 year follow-up with an evaluation of various neurophysiological parameters for diagnosis

48 patients with clinical and neurophysiological signs of carpal tunnel syndrome were randomized to any of two operative methods: Internal neurolysis of the median nerve with a microsurgical technique, or simple division of the carpal ligament (flexor retinaculum). After a minimum follow-up period of 3 years 81% of the patients did not report any complaints at all, and all patients considered themselves improved after operation. There was no difference between the operation groups. Therefore there seems to be no justification to perform the more difficult procedure of internal microsurgical neurolysis for treatment of the carpal tunnel syndrome. A study of the neurophysiological parameters before and after restitution showed the highest sensitivity (91%) for the sensory conduction velocity, and the highest specificity for motor distal latency and sensory distal latency (83 and 75% resp.).     

Measurement of median nerve blood flow during carpal tunnel release with laser Doppler flowmetry.

Eight consecutive median nerves in eight patients with clinical carpal tunnel syndrome were prospectively examined by non-contact laser Doppler flowmetry before and after undergoing carpal tunnel release. Before performing carpal tunnel release, the difference in the median nerve blood flow between the values at the distal and proximal portions to the transverse carpal ligament was statistically significant (p = 0.021). After carpal tunnel release, the median nerve blood flow both distal and proximal to the transverse carpal ligament increased by 1.5 and 1.3 times, respectively, compared to the flow prior to carpal tunnel release, however, only the difference at the distal portion to the transverse carpal ligament was statistically significant (p = 0.015). In this study, we directly measured the median nerve blood flow using non-contact laser Doppler flowmetry and thus demonstrated a significant difference in the median nerve blood flow between the values at the distal and proximal portions to the transverse carpal ligament before carpal tunnel release and a significant increase in the nerve blood flow only at the distal portion to the transverse carpal ligament after surgery. This technique is thus considered to be an easy and reproducible way to intraoperatively evaluate the nerve blood flow in real time during the release of entrapment neuropathies.     

Can simple release relieve symptoms of carpal tunnel syndrome caused by a persistent median artery?

Introduction Compression of the median nerve at the wrist by a persistent median artery is one of the uncommon reasons for carpal tunnel syndrome. Most of the studies in the literature deal with thrombosed persistent median artery.Materials and method In this study, we present surgical treatment of four carpal tunnel syndromes, which had persistent median arteries. The mean age of the patients was 51 years. All four median arteries were patent and only transverse carpal ligament releases were performed using a standard anterior open approach for decompression of the carpal tunnel. Neither ligation nor transposition of the arteries was done.Results All patients became symptom free after a few weeks. Only one patient had a slight recurrence 13 months postoperatively. Splint use and modification of her activities reduced her disturbance, and no further treatment was applied.Conclusion If the patient has no additional anomaly, our clinical experiences lead us not to advise resection or transposition because simple release of the transverse carpal ligament can relieve symptoms.     

Transverse carpal ligament reconstruction in surgery for carpal tunnel syndrome: a new technique

We present a two-year follow-up of a technique to reconstruct the transverse carpal ligament in surgery for carpal tunnel syndrome. The transverse carpal ligament is exposed through a four to five centimeter palmar incision in line with the axis of the ring finger. The ligament is divided in step-wise fashion, creating a distal radially-based flap and a proximal ulnarly-based flap. The apices of these flaps are approximated, lengthening the ligament six to ten millimeters. All seventy-three patients (one hundred-four hands) reported substantial improvement with 93% having complete resolution of symptoms. Ninety-seven percent returned to work (average disability, two months). There were no recurrences or significant operative complications. In those with unilateral reconstruction (60%), there was no diminution in grip strength (p less than 0.05). This technique of transverse carpal ligament reconstruction stabilizes the transverse carpal arch, provides protection to the median nerve, prevents bowstringing of the flexor tendons, and maximizes postoperative grip strength.     

Use of the palmaris brevis flap for preventing recurrent median nerve compression in mucolipidosis.

In a patient with severe, recurrent bilateral carpal tunnel syndrome secondary to mucolipidosis, the 'turnover' palmaris brevis flap was used in conjunction with internal neurolysis. The procedure was effective in alleviating symptoms of recurrent carpal tunnel compression in both hands.     

Unusual causes of carpal tunnel syndrome: space occupying lesions

Space occupying lesions found at surgery caused or contributed to carpal tunnel syndrome in 23 of 779 patients operated for carpal tunnel syndrome from January 1999 to December 2008. The mean age of these 23 patients was 52.9 years, and in patients who had a local swelling or palpable mass, ultrasonography or magnetic resonance imaging (MRI) was done. All had open release of the transverse carpal ligament and lesions were removed. Histopathology showed tophaceous gout in 10 men, tenosynovitis in seven patients and tumors in eight. The tumors included ganglion cysts in two, lipoma in three and fibroma of the tendon sheath in one. The neurological symptoms subsided after surgery in all. In patients with gout, one had an infected wound and another had recurrence of symptoms 1 year after later. Carpal tunnel syndrome caused by a space occupying lesion is rare and more complicated than idiopathic carpal tunnel syndrome.     

关节镜镜视下行腕横韧带切开术

目的 介绍在关节镜镜视下行腕横韧带切开术治疗腕管综合的方法。方法 1999年3月以来，对15例（18侧）腕管综合征采用Chow两点法在关节镜镜视下行腕横韧带切开术。腕管入口位于腕横纹近端2－3cm，掌长肌腱尺侧缘。腕关节背伸位时，将带槽套管自腕管入口处对准第3指蹼方向插入，从腕管远端穿出。在关节镜监控下用钩刀切开腕横韧带。结果 术后随访2－16上月，平均7个月。术后桡侧3指半的感觉已恢复正常。3例有拇指对掌功能和大鱼际肌萎缩者，术后3－6个月均恢复正常。无血管神经损伤和感染等并发症发生。结论 关节镜镜视下切开腕横韧带治疗腕管综合征是安全有效的微创手术。     

Endoscopic management of carpal tunnel syndrome

This article describes a subcutaneous endoscopic operative procedure for carpal tunnel syndrome and analyzes its effectiveness using electrophysiological data. Subcutaneous transverse carpal ligament release under universal subcutaneous endoscope (USE) was performed using local anesthesia without pneumotourniquet in 54 hands of 45 patients since June 1986. The mean follow-up period was 13.8 months. Sensory disturbances began to subside immediately after the operation and disappeared within 2 months in all cases. After the disappearance of sensory disturbances, we performed postoperative electrophysiological studies in 27 patients (33 hands). Postoperative electrophysiological data were significantly improved in all cases. Patients did not suffer from any serious complications such as motor branch injuries of the median nerve, hypesthesia of the palm, or injuries of the superficial palmar arch. From these results, we conclude that the transverse carpal ligament can be safely incised by this procedure.     

Median nerve injury from local steroid injection in carpal tunnel syndrome

Local steroid injections for symptomatic relief of carpal tunnel syndrome have become common in the evaluation and treatment of this disorder; yet reports of median nerve injection injury from this practice are rare. We present a case of nerve injury from a steroid injection in a 24-year-old man with carpal tunnel syndrome that was successfully treated by division of the transverse carpal ligament and neurolysis. The histopathological characteristics of the lesion are presented, and the pathogenesis and treatment of this injury are discussed. Means of avoiding this complication include careful attention to anatomic landmarks as well as to the patient's subjective response during injection and avoidance of the use of local anesthetics.     

Endoscopic carpal tunnel release in patients receiving long-term hemodialysis

This study evaluated the clinical results of endoscopic carpal tunnel release in carpal tunnel syndrome caused by long-term hemodialysis and compared the results with that of idiopathic carpal tunnel syndrome. Operations were done in 32 patients (60 hands) with idiopathic carpal tunnel syndrome and in eight patients (15 hands) with carpal tunnel syndrome resulting from long-term hemodialysis. There was no significant difference in findings of preoperative evaluations and postoperative clinical results between the two groups, except for a difference with the patient satisfaction score with surgery on a visual analogue scale. The mean satisfaction score was 9.0 at 6 months, 9.3 at 1 year, and 9.5 at the 2-year followup in the group of patients with idiopathic carpal tunnel syndrome. However, in the group of patients with carpal tunnel syndrome resulting from long-term hemodialysis, the mean satisfaction score was 8.5 at 6 months, 8.2 at 1 year, and 6.5 at the 2-year followup. The score began to decrease at an average of 17.2 months after surgery. Long-term hemodialysis related carpal tunnel syndrome showed satisfactory short-term clinical results until approximately 1.5 years after the operation. After that time, the symptoms tended to deteriorate in 50% of the patients who received hemodialysis continuously.