内窥镜下治疗腕管综合征89例报告

目的 :探讨应用内窥镜技术治疗腕管综合征 (ECTR) ,从腕管内切断腕管横韧带 ,解除其对正中神经压迫的手术方法及技巧。并对其术后疗效进行分析 ,介绍内窥镜下治疗腕管综合征的经验与疗效。方法 :局部麻醉 ,皮肤 1cm切口 ,在内窥镜下切断腕管横韧带。松解受压的正中神经。据Kelly疗效评定标准 ,对其术后疗效进行分析评价。结果 :临床应用 165例 192腕 ,手术时间平均 10min ,出血少 ,术后随访 89例 98腕 ,优 73腕 ;良 2 0腕 ;一般 3例 ;差 2例 ,其中 2例发生术后正中神经粘连 ,行 2次手术。结论 :内窥镜技术治疗腕管综合征 (ECTR)皮肤切口小 ,组织创伤轻 ,手术时间短 ,术后不需石膏外固定 ,不残留手术瘢痕。注意手术适应证 ,是一种安全有效的微创手术方法。     

两点法内镜下治疗腕管综合征

腕管综合征常规手术是将皮肤与腕管横韧带之间的组织完全切断,直视下切开腕横韧带,然后行神经松解。开放性手术的缺点是手术创伤较大,术后手部功能恢复期较长,手的握力和捏力明显下降;手掌部的皮肤切开易损伤正中神经的掌皮支,形成神经瘤而产生疼痛;切口持续性疼痛,活动时加重;易发生弓弦状屈肌腱、神经与皮肤和肌腱粘连、外形不够美观等并发症。尽管开放手术的手术切口不断改良,但最终难免在手掌部残留有痛性或肥厚性瘢痕。日本Okutsu1986年首先应用内镜治疗腕管综合征,通过前臂1cm     

小双切口治疗腕管综合征15例体会

目的 介绍应用小双切口作腕管切开治疗腕管综合征的方法及临床效果。方法 在掌长肌腱尺侧，平行远侧腕横纹作1．5cm长的横切口，腕横纹以远2．5cm为中心沿鱼际肌纹作1cm长的纵切口，分别显露腕横韧带远近缘及指屈肌腱及正中神经，直视下将腕横韧带完全切开，正中神经外膜松解3例，鱼际肌支松解1例。结果 术后2周，15例症状完全消失，拇、示、中3指指腹两点辨别觉恢复正常。术后1年随访，术前大鱼际肌萎缩5例，肌萎缩明显改善，拇指对掌功能恢复正常。全部病例无1例产生腕掌部瘢痕疼痛及尺神经、掌浅弓损伤等并发症。结论 小双切口行腕管松解术，可操作窄间大，并发症少，术后美观。是治疗腕管综合征的有效方法。     

正中神经外膜显微松解术在腕管综合征中的应用

目的探讨正中神经外膜显微松解术在伴有正中神经病变的腕管综合征中的临床应用及效果。方法 2014年3月-2017年12月,采用正中神经外膜显微松解联合腕横韧带松解术治疗伴有正中神经病变的腕管综合征16例。术后定期随访,随访内容包括:麻痛、感觉异常、肌萎缩(大鱼际肌)、对掌功能、握力和瘢痕痛六个方面。结果术后16例切口均甲级愈合,无感染发生。随访3～15个月,平均8个月,采用顾玉东腕管综合征功能评定标准判断治疗效果,优2例(12.5%),良11例(68.75%),可2例(12.5%),差1例(6.25%),优良率为81.25%。结论正中神经外膜显微松解术是治疗伴有正中神经病变腕管综合征的一种有效方法,可获得较好的临床效果。     

腕管综合征的显微外科治疗

[目的]报道腕管综合征的显微外科治疗效果.[方法]术中在显微镜下神经外膜松解,彻底松解腕管部分的正中神经,并在神经周围放置醋酸泼尼松龙,术后观察其疗效.[结果]术后随访1个月～2年,147例症状完全消失,15例大部分症状缓解,拇、食、中指术后指腹两点辨别觉恢复正常,大鱼际萎缩者,肌萎缩明显改善,拇指对掌功能恢复.无1例产生腕掌部瘢痕痛及正中神经、掌浅弓、正中神经返支损伤等并发症.[结论]显微外科神经松解是治疗腕管综合征的有效方法.     

腕管综合征17例术中病变观察

腕管综合征的腕管内压力增高致正中神经受压而出现正中神经功能障碍的一组症候群，腕横韧带及滑膜的慢性炎性增生性肥厚为产生腕管综合征的主要原因，正中神经受压后常出现神经变性，与周围神经粘连，腕管减压的同时行束膜松解可有效地减轻腕综合征症状，并予彻底根治，我科近１０年来住院治疗且随访完整的１７例２３个腕，经单纯腕管减压及配合膜松解治疗后，均基本达到满意效果。     

内窥镜Chow法治疗腕管综合征

目的探讨内窥镜镜视下Chow法行钩刀或推刀切断腕横韧带,解除正中神经压迫的手术方法和疗效。方法2004年5月-2009年8月,对76例（85侧）腕管综合征患者采用Chow法在内窥镜镜视下行腕横韧带切开术。结果经2～18月随访,伤口均一期愈合,无血管神经损伤,无手掌部疼痛,无伤口感染,多数患者术后夜麻即消失,术后4周桡侧三个半指感觉恢复正常,麻木、疼痛症状明显缓解,10周左右拇对掌功能恢复。Kelly分级评定：优（症状完全消失）58侧,良（明显缓解）21侧,一般（症状轻度减轻）5侧,差（症状不变或加重）1侧,优良率92．94％。结论Chow法内窥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。     

痛风石致腕管综合征的病例分析

目的 探讨痛风石导致的腕管综合征的临床特点,以期指导其诊断和治疗.方法 回顾性分析2008年1月至2010年10月收治的6例腕管综合征患者,病程1～6个月,平均(3.0±0.6)个月.6例均为单发,除腕部外的身体其他部位均未发现痛风石.在行腕管切开减压时,发现腕管内有痛风石生长,痛风石侵犯指屈肌腱和正中神经.术中刮除痛风石,切开腕横韧带,解除周围组织对正中神经的压迫,行正中神经外膜或束膜松解术.结果 6例患者伤口均Ⅰ期愈合,手指麻木症状减轻.术后发现5例患者血尿酸升高,1例患者血尿酸正常.随访10～ 25个月,平均(17.0±5.3)个月,腕管综合征症状消失4例,缓解2例,未见新的痛风石出现.结论 痛风石导致的腕管综合征好发于男性,多伴有血尿酸升高,腕部B超、CT或MRI检查对其有诊断意义;腕横韧带切开,痛风石清除和正中神经外膜松解术是治疗痛风石导致的腕管综合征的有效方法.     

显微技术在治疗腕管综合征中的应用

目的探讨显微技术在治疗腕管综合征中的应用价值。方法随机将62例腕管综合征患者分为A、B两组，A组在腕横韧带切开的基础上，应用手术显微镜行正中神经内松解术；B组单纯行腕横韧带切开减压术。比较两组术前、术后在症状、体征、肌电图方面的改变。结果随访8～18个月，平均12个月。按自拟疗效评估标准判定，A组优良率92．5％，B组优良率70．97％。结论在腕横韧带切开的基础上，采用显微技术行正中神经内减压治疗腕管综合征可显著提高手术效果。     

国外内窥镜腕管松解术的应用进展

内窥镜松解腕横韧带治疗腕管综合征是近５年发展起来的一项新技术。Ｏｋｕｔｓｕ和Ｃｈｏｗ１９８９年首先在《关节镜杂志》上报道，以后经过很多尸体研究及不断的；伤床应用，在美国及西欧地区迅速发展，引起了世界各国同道们的广泛重视及关注。为了使我国同道们了解内窥镜松解腕管技术的进展，现经复习国外已发表的文献进行综述，供大家参考。 自从Ｕａｇｅｔ在１８５３年首先认识到腕管 综合征是由正中神经受压引起以来，早期处理都是采用保守疗法。直到１９３３年Ｌｅａｒｍｏｔｈ才采用腕管切开术对正中神经进行减压，到目前*匀谎赜…     

Median nerve excursion during endoscopic carpal tunnel release

OBJECTIVE: Restriction of the excursion of the nerve has been accepted as a pathogenetic element in carpal tunnel syndrome. The goal of this article was to evaluate the median nerve excursion in the carpal tunnel measured as a function of wrist position before and after endoscopic carpal tunnel release (ECTR) on 28 hands of 22 patients. METHODS: The position of cylindrical stainless steel markers embedded within the median nerve was measured by a direct radiographic technique. Each upper extremity was examined in three wrist positions. Then, endoscopic release with Menon's technique was performed, and the measurements were repeated. RESULTS: In this prospective clinical study, most (93%) of the patients experienced resolution of their symptoms. Before and after ECTR, median nerve excursion was linear and was affected by wrist position. Before ECTR, when the wrist was moved from the end of dorsiflexion to the end of palmar flexion, the median nerve underwent a mean total excursion of 28.8 mm at the wrist. A comparison of the before and after ECTR excursion showed no statistical differences in the amount of motion. CONCLUSION: The single-portal ECTR does not seem to influence the median nerve excursion for the wrist positions studied in patients with carpal tunnel syndrome. The results from this in vivo study showed longitudinal gliding of the median nerve twice as great as in in vitro studies.     

Safety of carpal tunnel release with a short incision. A cadaver study

The standard long incision technique for carpal tunnel release causes inevitable damage to skin sensation, the inter-thenar plexus and especially the distal branches of the palmar cutaneous branch of the median nerve (PCM), and may cause long-term disabling pain and scar tenderness. There are many variations in the distal branches of the median nerve at the wrist. Anatomic studies of this region also have important clinical implications to prevent injury to important anatomic structures. The purpose of this study was to evaluate the short-incision carpal tunnel release in cadavers. Several important anatomic structures, with possible anatomic variations, pass through the carpal tunnel, and blind percutaneous transection of the transverse ligament seems to be a high risk procedure. Sixty hands from 40 fresh cadavers were evaluated. Both the transverse ligament and the distal third of the deep forearm fascia were released using a Smillie knife. At the end of each procedure, the hand was explored for injury to tendinous and neurovascular structures of the wrist. In all cases the release of the carpal tunnel and the distal third of the forearm fascia was found to be complete. The superficial palmar arterial arch, flexor tendons, ulnar nerve and vessels, digital nerves, median nerve and its recurrent accessory branches, the flexor tendons, and even the subcutaneous tissue over the transverse ligament were damaged in no instance. Guyon's canal was entered in 6 (10%) hands without damage to its components. The distal branches from the ulnar side of the palmar cutaneous branch of the median nerve (PCM) were injured in 8 (13.6%) hands, an injury that is almost unavoidable with the classic open technique.     

内镜下两点单侧钩切法治疗腕管综合征的临床应用

目的：探讨应用内镜的两点单侧钩切法切断腕横韧带,解除正中神经压迫的手术方法和疗效。方法：临床治疗原发性11例13侧（左侧3例,右侧6例,双侧2例）43～68岁女性腕管综合征患者。全部患者均有桡侧3个半指的指端刺痛觉减退,腕部正中神经Tinel征阳性,11例大鱼际肌萎缩,同时4例存在拇指对掌功能减弱。术中局部麻醉,分别采取近侧腕横纹线处,掌长肌腱与桡侧屈腕肌腱之间1cm皮肤横切口（入口）和患者拇指最大桡侧外展位,拇指尺侧平行线与中环指间的长轴线交叉点向尺侧1cm处呈45°切口（出口）。预制隧道后入口处置入腕关节镜,由出口插入钩刀。钩刀钩住腕横韧带近段后,内镜随钩刀移动而远行,全程镜视下由近及远切断腕横韧带。结果：患者经随访4～20个月全部疗效满意,捏握功能明显改善。术后3个月时恢复至S3＋M3以上。无血管、神经或屈肌腱损伤等并发症。结论：两点单侧钩切法操作步骤简单,是一种有效的手术方法。     

小切口治疗腕管综合征14例报告

Objective　To introduce the technique of carpal tunnel release by small incision,and evaluate its outcome in the treatment of carpal tunnel syndrome.Methods　This method was applied in the operations of 14 cases of carpal tunnel syndrome.An incision 1.5 cm in length was made at the level of the proximal transverse wrist crease ulnar to the palmaris longus tendon.The proximal margin of the transverse carpal ligament was visualized and the ligament was cut subcutaneously under direct vision.The flexor digitorum tendons were retracted and the edematous synovium excised.Results　Follow - up of the patients 2 weeks postoperatively showed that the symptoms of numbess and pain disappeared in all 14 cases.Normal 2 - PD in the pulp of the thumb,index finger and long finger was ＜ 4 mm.One year after the operation,muscle atrophy in 5 patients who sustained preoperative thenar muscle atrophy was greatly improved with recovery of normal opponens function of the thumb.No pillar pain and injury of the ulnar nerve and superficial palmar arch was found.Conclusion　Carpal tunnel release under direct vision through a small incision is a new and effective surgical procedure.     

腕管综合征内窥镜手术预防正中神经损伤的临床研究

目的 介绍腕管综合征内窥镜手术(endoscopic carpal tunnel release,ECTR)预防正中神经损伤并发症的方法.方法 利用彩色多普勒超声仪(B超)对37例74手患者术前进行检测.结果 71例正中神经走行在桡侧腕屈肌腱与掌长肌腱之间,3例走行在掌长肌腱与尺侧腕屈肌腱之间,并术中确认.结论 正中神经变异走行在掌长肌腱与尺侧腕屈肌腱之间是ECTR的禁忌证,B超能准确定位正中神经与掌长肌腱关系,避免内窥镜手术损伤正中神经,更具有简单、经济、方便可靠等优点.

Abstract：

Objective To introduce a method of preventing median never injury during endoscopic carpal tunnel release (ECTR). Methods Ultrasonography of both wrists was done to 37 patients of carpal tunnel syndrome who were going to undergo open release of the transverse carpal ligament. Structures in the carpal tunnel were visualized to guide surgical decision-making. Results Ultrasonography showed that median never lies between the tendon of flexor carpi radialis and palmaris longus in 71 patients and lies between the tendon of palmaris longus and flexor carpi ulnaris in 3 patients. These findings were confirmed during the surgeries. Conclusion It is a contraindication of ECTR if median never lies between palmaris longus and flexor carpi ulnaris. Ultrasonography can accurately reveal the relative position of median never to the palmaris longus tendon. Pre-operative ultrasonography of the wrist is a simple, inexpensive and convenient method to exclude these contraindications and thus prevent median never injuries in ECTR.     

Surgical outcome of endoscopic carpal tunnel release in 100 patients with carpal tunnel syndrome.

The purpose of this study is to present the surgical outcome of endoscopic carpal tunnel release (ECTR) for the treatment of carpal tunnel syndrome (CTS). One hundred and thirty-one procedures (36 right hands, 33 left hands and 31 bilateral hands) of single portal ECTR were performed upon 100 patients (age range: 36-77 years, mean age: 52.9 years; 98 women and 2 men) with electrodiagnostically proven CTS for 2.5 years from 2001. Preoperative clinical severity and results of electrodiagnostic studies were compared with surgical outcomes at the minimal 3-month postoperative period. Among 131 cases 125 (95.4 %) with complete or significant relief of symptoms were satisfied and 6 (4.6 %) with partial or no relief of symptoms were dissatisfied. There were 2 cases of major complications (one with ulnar nerve injury and the other with ulnar artery injury) that developed in our early experience of ECTR and 1 case of recurrence. The grade of electrodiagnostic abnormalities was associated with surgical outcome but there was no statistical significance between them. The severity of clinical findings, age at onset and symptom duration were not correlated with surgical outcome. In conclusion, ECTR surgery was effective in relieving the symptoms of CTS with a low complication rate after the learning curve period. Thus, ECTR can be an alternative to the traditional open surgery and can be the first procedure for CTS with several advantages over open methods.     

Practical anatomy of the carpal tunnel

The carpal tunnel is most narrow at the level of the hook of the hamate. The median nerve is the most superficial structure. It has specific relationships to surrounding structures within the carpal tunnel to the ulnar bursa, flexor tendons, and endoscopic devices placed inside the canal. The importance of the ring finger axis is stressed. Knowledge of topographical landmarks that mark the borders of the carpal tunnel, the hook of the hamate, superficial arch, and thenar branch of the median nerve ensure appropriate incision placement for endoscopic as well as open carpal tunnel release surgery. Anatomy of the transverse carpal ligament, its layers and relationships to adjacent structures including the fad pad, Guyon's canal, palmar fascia, and thenar muscles has been discussed. Fibers derived primarily from thenar muscle fascia with connections to the hypothenar muscle fascia and dorsal fascia of the palmaris brevis form a separate fascial layer directly palmar to the TCL and can be retained. This helps to preserve postoperative pinch strength. The fat pad in line with the ring finger axis overlaps the deep surface of the distal edge of the TCL and must be retracted in order to visualize the distal end of the ligament. Whereas the ulnar artery within Guyon's canal is frequently located radial to the hook of the hamate, injury to this structure has not been a problem during ECTR surgery. Variations of the median nerve and its branches, as well as the palmar cutaneous nerve distribution, have been reviewed. A rare ulnar-sided thenar branch from the median nerve, interconnecting branches between the ulnar and median nerves located just distal to the end of the TCL, and transverse ulnar-based cutaneous nerves can be injured during open or ECTR surgery. Anomalous muscles, tendons or interconnections, and the lumbricals during finger flexion may be seen within the carpal tunnel. These structures can be the cause of compression of the median nerve. The anatomy of the carpal tunnel and surrounding structures have been reviewed with emphasis on clinical applications to endoscopic and open carpal tunnel surgery. A thorough knowledge of the anatomy of the carpal tunnel is essential in order to avoid complications and to ensure optimal patient outcome. An understanding of the contents and their positions and relationships to each other allows the surgeon to perform a correct approach and accurately identify structures during procedures at or near the carpal tunnel.     

Bilateral carpal tunnel syndrome with anomalous palmaris profundus tendons

Abstract

This report presents the case of a 44-year-old man who presented with elective bilateral carpal tunnel decompression. At the operation, he was found to have bilateral palmaris profundus tendons within the carpal tunnel, impinging on the median nerve. In releasing both carpal tunnels, the patient's symptoms were alleviated and there was regain of full function. There have been very few documented cases of these anomalous tendons implicated in carpal tunnel syndrome and this case highlights how such anatomical variations are important in the surgical approach to carpal tunnel decompression.     

内窥镜治疗腕管综合征的疗效观察

目的：观察内窥镜治疗腕管综合征的临床疗效。方法2009年至今,利用内窥镜单切口入路,通过切开腕管、松解正中神经,治疗腕管综合征18例（30侧）。术前及术后3个月进行神经电生理测试,测定正中神经掌腕段感觉及运动传导速度。结果本组患者术后随访6个月,术后3个月正中神经感觉、运动神经传导速度明显较术前加快（P〈0.05）,患者肢体感觉基本恢复正常,未见复发。结论内窥镜治疗腕管综合征疗效确切,术后正中神经功能恢复明显。