Current Approaches for Carpal Tunnel Syndrome

With advancement in biomechanical and biological research on idiopathic carpal tunnel syndrome, the insight on the pathophysiology of carpal tunnel syndrome has gained much clinical relevance. Open carpal tunnel release is still a gold standard procedure for carpal tunnel syndrome, which has evolved into mini-open procedure with development of new devices. Endoscopic carpal tunnel release has become popular in recent practice of hand surgery with an advantage of early recovery of hand function with minimal morbidity. However, endoscopic carpal tunnel release has its own limitation such as long learning curve with obvious surgical risk reported in the literature. In this review article, various treatment protocols for idiopathic carpal tunnel syndrome are presented with special highlight on endoscopic carpal tunnel release, which is gaining popularity in current practice.     

Endoscopic Carpal Tunnel Release

On the basis of clinical outcome measures, endoscopic carpal tunnel release is an effective operation for treating idiopathic carpal tunnel syndrome. Patients who have undergone bilateral carpal tunnel operations have routinely preferred endoscopic release over the open release. An endoscopic release allows many patients to return to work sooner. However, the benefits of more rapid functional recovery and return to work are tempered by the increased cost and higher complication rate of the procedure. Endoscopic carpal tunnel release is a technically demanding procedure with low tolerances for error. Despite its widespread use, its role is not yet clearly defined.     

Endoscopic carpal tunnel release for recurrent carpal tunnel syndrome after previous open release.

Recurrent carpal tunnel syndrome from various causes has been shown to occur in up to 19% of patients. Endoscopic carpal tunnel release has been used to decompress the median nerve in carpal tunnel syndrome for many years. However, endoscopic release for recurrent carpal tunnel syndrome after previous surgical release has not been reported. Nine hands in six patients had recurrent carpal tunnel syndrome five to 20 years after previous open carpal tunnel release. All the cases were successfully treated with endoscopic release.     

Endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome. A prospective,randomised, blinded assessment

The advantages and disadvantages of endoscopic compared with open carpal tunnel release are controversial. We have performed a prospective, randomised, blinded assessment in a district general hospital in order to determine if there was any demonstrable advantage in undertaking either technique. Twenty-five patients with confirmed bilateral idiopathic carpal tunnel syndrome were randomised to undergo endoscopic release by the single portal Agee technique to one hand and open release to the other. Independent preoperative and postoperative assessment was undertaken by a hand therapist who was blinded to the type of treatment. Follow-up was for 12 months. The operating time was two minutes shorter for the open technique (p < 0.005). At all stages of postoperative assessment, the endoscopic technique had no significant advantages in terms of return of muscle strength and assessment of hand function, grip strength, manual dexterity or sensation. In comparison with open release, single-portal endoscopic carpal tunnel release has a similar incidence of complications and a similar return of hand function, but is a slightly slower technique to undertake.     

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.     

Early recovery after endoscopic vs. short-incision open carpal tunnel release

Endoscopic carpal tunnel release has been claimed to offer improvement in recovery time and postoperative discomfort over open carpal tunnel release. Short-incision open carpal tunnel release has been claimed to offer recoveries comparable with endoscopic techniques. Patients receiving carpal tunnel surgery were randomized to short-incision open release or single-portal endoscopic release. Preoperative and postoperative evaluation included grip and pinch strength measurements and patient completion of a questionnaire regarding symptoms and function. Thirty-six operated hands completed evaluation, including 22 endoscopic and 14 open releases. Early grip and pinch strength after endoscopic carpal tunnel release were improved significantly over short-incision open release (p < 0.05). Subjective evaluation indicated a trend toward improved symptoms and function with endoscopic over short-incision open carpal tunnel release. Endoscopic carpal tunnel release provides faster recovery of strength than short-incision open carpal tunnel release and improves early postoperative comfort and function to a small degree.     

Endoscopic carpal tunnel release using the subligamentous two-portal technique

The surgical treatment for entrapment neuropathy of the median nerve in the carpal tunnel is varied. Recent publications have demonstrated a closed, endoscopic method for release of the carpal tunnel using a two-portal technique. In this report, a surgical technique for performing a subligamentous modification of this two-portal procedure is discussed, and the special tools used in this approach are demonstrated. In the early portion of this series of 75 symptomatic hands in 65 patients, 8% (6/75 hands) developed transient postoperative ulnar nerve neuropraxia. One patient experienced an iatrogenic laceration of the median nerve. Following the institution of the subligamentous approach, no postoperative nerve complications occurred. The majority of the patients experienced a significant decrease in their median nerve symptoms. This procedure has been found to be safe and is equally as effective as open surgical treatment of patients with carpal tunnel syndrome.     

Retrospective analysis of 242 patients whose carpal tunnels were released using a one-port endoscopic procedure: superior results of early intervention

Various approaches to endoscopic carpal tunnel release have been described, including the advantages of the open compared with the endoscopic technique. However recent results suggest that both are equal in terms of outcome and morbidity. The misconception about the potential morbidity and the hope of successful conservative treatment can sometimes delay operative release of the carpal tunnel. The aim of this study was to evaluate whether the preoperative duration of symptoms influences outcome and recovery. Patients who had endoscopic release of the carpal tunnel using a modified one-port method were included in this retrospective study. Patients' satisfaction and general outcome were analysed with a questionnaire. A total of 242 patients were included in the study, and the data of 170 endoscopic decompression operations were analysed (70%). There were no major operative complications, except the conversion to open release in one case. There was a significant association between the preoperative interval of symptoms and the return to everyday activities and normal function (p < 0.001). Patients with longer-lasting symptoms also had reduced recovery of postoperative strength, which was negatively associated with the duration of preoperative symptoms (p < 0.001). Operative decompression by the endoscopic one-port method is a low risk procedure with a low morbidity. The decision for operative decompression should be made as early as possible to avoid complications seen in patients with long-lasting symptoms and permanent nerve damage.     

Retrospective analysis of 242 patients whose carpal tunnels were released using a one-port endoscopic procedure: Superior results of early intervention

Abstract

Various approaches to endoscopic carpal tunnel release have been described, including the advantages of the open compared with the endoscopic technique. However recent results suggest that both are equal in terms of outcome and morbidity. The misconception about the potential morbidity and the hope of successful conservative treatment can sometimes delay operative release of the carpal tunnel. The aim of this study was to evaluate whether the preoperative duration of symptoms influences outcome and recovery. Patients who had endoscopic release of the carpal tunnel using a modified one-port method were included in this retrospective study. Patients' satisfaction and general outcome were analysed with a questionnaire. A total of 242 patients were included in the study, and the data of 170 endoscopic decompression operations were analysed (70%). There were no major operative complications, except the conversion to open release in one case. There was a significant association between the preoperative interval of symptoms and the return to everyday activities and normal function (p < 0.001). Patients with longer-lasting symptoms also had reduced recovery of postoperative strength, which was negatively associated with the duration of preoperative symptoms (p < 0.001). Operative decompression by the endoscopic one-port method is a low risk procedure with a low morbidity. The decision for operative decompression should be made as early as possible to avoid complications seen in patients with long-lasting symptoms and permanent nerve damage.     

Carpal tunnel syndrome: Unusual contraindications to endoscopic release

Endoscopic carpal tunnel release has become an increasingly popular method of surgical treatment of carpal tunnel syndrome. Consequently, the contraindications to this technically challenging procedure continue to evolve. We describe two patients with carpal tunnel syndrome and unusual anomalies and pathology of the hook of the hamate that we believe represent relative or absolute contraindications to endoscopic carpal tunnel release.     

Carpal tunnel release. A prospective,randomised study of endoscopic versus limited-open methods

Endoscopic carpal tunnel release has the advantage over open release of reduced tissue trauma and postoperative morbidity. Limited open carpal tunnel release has also been shown to have comparable results, but is easier to perform and is safer. We have compared the results of both techniques in a prospective, randomised trial. Thirty patients with bilateral carpal tunnel syndrome had simultaneous bilateral release. The technique of release was randomly allocated to either two-portal endoscopic release (ECTR) or limited open release using the Strickland instrumentation (LOCTR). The results showed that the outcome was similar at follow-up of one year using both techniques. However, the LOCTR group had significantly less tenderness of the scar at the second and fourth postoperative week (p < 0.01). There was also less thenar and hypothenar (pillar) pain after LOCTR. Subjective evaluation showed a preference for LOCTR.     

Carpal tunnel syndrome associated with long-term hemodialysis: case report

Since Warren and Otieno reported carpal tunnel syndrome in patients on intermittent hemodialysis in 1975, a number of related reports have been published. However, there are few reports associated with neurosurgery about carpal tunnel syndrome in patients on long term hemodialysis. We reviewed this disease and reported our case. We treated a patient who complained of bilateral hand numbness and atrophy of the right thenar muscle. He had been suffering from chronic renal failure and had been treated with hemodialysis for ten years. We diagnosed carpal tunnel syndrome based on the findings concerning Tinel's sign, Phalen test, and the conduction velocity of the median nerve. We performed decompression surgery of the median nerve. However, although there was no recovery from thenar muscle atrophy, there was improvement of hand numbness. Histologically, amyloid deposits within the hypertrophic transverse carpal ligament on the right side, could be found but on the left side where the internal shunt had been made amyloid deposits were absent. The reason why patients receiving long term hemodialysis develop carpal tunnel syndrome is controversial, but it seems that beta 2 microglobulin may play an important role in developing carpal tunnel syndrome in hemodialysis patients. This was reported by Gejyo in 1985. There may be uremic and/or diabetic neuropathy in these patients, and these neuropathies may be responsible for the more rapid deterioration and poorer surgical results in carpal tunnel syndrome associated with hemodialysis than in idiopathic cases. It is most important that carpal tunnel syndrome has to be diagnosed early and that surgical decompression is performed while the disease is in its early stage.     

Endoscopic release of the carpal ligament for carpal tunnel syndrome: long-term results using the Chow technique.

This report presents the author's experience with the Chow method for endoscopic release of the carpal ligament for carpal tunnel syndrome, with a minimum follow-up of 5 years. The report includes 116 cases (wrists) of 84 patients. The success rate for these cases is 93.3% and the recurrence rate is 0.96%. One temporary ulnar neuropraxia was reported in this group with spontaneous recovery. There were no permanent nerve injuries. Results of 5-year follow-up nerve conduction velocity tests are also included. This report shows that endoscopic release of the carpal ligament for carpal tunnel syndrome, using the Chow method, is a reliable alternative to the open procedure and has produced good, long-term, results.     

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.     

Preissler endoscopic carpal ligament release. Experiences from 1,000 operations

To reduce the postoperative morbidity different methods of endoscopic carpal tunnel release have been developed since 1989. We report our results and experiences with the method described by Preissler. Since its introduction in our clinic 1995, 1,000 patients have been operated until now. Out of 477 with an electrophysiological examination, 396 patients (83%) showed no symptoms. In three cases it was necessary to change to an open approach during operation, there were no other intraoperative complications. To evaluate our results we sent a questionnaire to 32 of our patients that were operated on one hand with an open technique and on the other hand with the endoscopic technique of Preissler. The results demonstrated that the endoscopic method was significantly better. From our experience endoscopic technique for carpal tunnel release Preissler's is a safe, well accepted, easy for learning and cheap alternative to the open procedure.     

Morphologic Analysis of the Carpal Tunnel and Median Nerve Following Open and Endoscopic Carpal Tunnel Release

Background: Endoscopic carpal tunnel release (ECTR) has purported advantages over open release such as reduced intraoperative dissection and trauma and more rapid recovery. Endoscopic carpal tunnel release has been shown to have comparable outcomes to open release, but open release is considered easier and safer to perform. Previous studies have demonstrated an increase in carpal tunnel volume, regardless of the technique used. However, the mechanism by which this volumetric increase occurs has been debated. Our study will determine through magnetic resonance imaging (MRI) analysis the morphologic changes that occur in both open carpal tunnel release (OCTR) and ECTR, thereby clarifying any morphologic differences that occur as a result of the 2 operative techniques. We hypothesize that there will be no morphologic differences between the 2 techniques. Methods: This was a prospective study to compare the postoperative anatomy of both techniques with MRI. Nineteen patients with clinical and nerve conduction study–confirmed carpal tunnel syndrome underwent either open or endoscopic release. Magnetic resonance imaging was performed preoperatively and 6 months postoperatively in all patients to examine the volume of the carpal tunnel, transverse distance, anteroposterior (AP) distance, divergence of tendons, and Guyon’s canal transverse and AP distance. Results: There was no significant difference in the postoperative morphology of the carpal tunnel and median nerve between OCTR and ECTR at 6-month follow-up on MRI. Conclusion: We conclude that there are no morphologic differences in OCTR and ECTR. It is an increase in the AP dimension that appears to be responsible for the increase in the volume of the carpal tunnel.     

Uniportal endoscopic surgery of carpal tunnel syndrome: technique and clinical results.

The endoscopic carpal tunnel release is a new minimally invasive method which has been used to decompress the median nerve in the carpal tunnel for the past decade. Advantages of this method should be a decreased postoperative morbidity and earlier return to work. Preoperative complaints, postoperative results and complications of the therapy for a total of 60 patients are presented. All endoscopic releases were performed using the Agee uniportal technique. The overall success rate in our study was 56/60 (93.3 %). 47/54 (87.0 %) patients were completely free of pain after endoscopic surgery. An improvement in preoperative pain was noted in 4/54 (7.4 %) patients. Hypesthesia and dysesthesia disappeared totally in 39/46 (84.8 %) patients. An improvement of the sensible disturbances was observed in 4/46 (8.7 %) cases. 10/13 (76.9 %) preoperative pareses recovered completely, 3/13 (23.1 %) remained unchanged. The complication rate in total in our series was 4/60 (6.7 %), thereof 3 cases of post-operative infection (5 %) and one serious median nerve injury (1.7 %). The mean time for return to work was 29 days. Summing up, it may be said that monoportal endoscopic carpal tunnel release appears to be an effective and safe minimally invasive method for the treatment of carpal tunnel syndrome.     

Long-term outcomes following single-portal endoscopic carpal tunnel release

Background

There is limited published information about long-term outcomes and recurrence rates following single-portal endoscopic carpal tunnel release.

Methods

We reviewed symptom and function outcomes from a prospectively collected database of patients who underwent single-portal endoscopic carpal tunnel release at a minimum of 8 years follow-up. Out of 207 patients in the original database, we were able to confirm correct current contact information for 106 patients. Of these, 91 patients with 115 single-portal endoscopic carpal tunnel releases agreed to participate. All of these patients were eligible for this long-term follow-up study based on documented preoperative and 6-month postoperative Levine-Katz questionnaire scores. Patients then completed a current update of the Levine-Katz questionnaires to assess function and symptom outcomes at latest follow-up.

Results

The average 6-month postoperative scores were significantly lower compared with the average preoperative scores and were maintained at long-term follow-up. There were no significant differences in average change in scores at long-term follow-up compared to 6-months postoperative.

Conclusions

Single-portal endoscopic carpal tunnel release is an effective surgical treatment for carpal tunnel syndrome. Low recurrence rates and maintenance of low symptom and function scores can be expected at 8 to 10 years following this technique.     

Carpal tunnel syndrome caused by a fibrolipomatous hamartoma of the median nerve treated by endoscopic release of the carpal tunnel

Fibrolipomatous hamartoma has up to now been considered a rare anomaly that most commonly affects the median nerve. Its pathogenesis is controversial. The magnetic resonance (MR) appearance is pathognomonic and precludes the necessity for a diagnostic biopsy. Its reported incidence is likely to increase as a result of the increased use of MRI. There is no definitive treatment, although carpal tunnel syndrome caused by fibrolipomatous hamartoma has been noted to respond to open release of the carpal tunnel. We describe a case of carpal tunnel syndrome caused by fibrolipomatous hamartoma of the median nerve that responded to a two-port endoscopic technique of release. Provided that a safe, distinct surgical plane can be established between the median nerve and the flexor retinaculum, the two-port technique of endoscopic release of the carpal tunnel is both safe and effective.     

Two cases of endoscopic management of carpal tunnel syndrome in macrodactyly patients.

Some cases of carpal tunnel syndrome in macrodactyly patients have been reported. We performed endoscopic carpal canal release on two unilateral macrodactyly patients suffering from bilateral carpal tunnel syndrome. We measured carpal canal pressure before performing endoscopic surgery using the Universal Subcutaneous Endoscope system to confirm median nerve compression. We diagnosed median nerve compression in each patient due to the high preoperative carpal canal pressure. Carpal canal pressure immediately decreased to within normal range following release of both the flexor retinaculum and the distal holdfast fibres of the flexor retinaculum. One patient recovered to within normal in terms of sensory disturbances and abductor pollicis brevis muscle strength. The other patient showed improvement in terms of sensory disturbance, however, muscle power did not recover because this patient had suffered from carpal tunnel syndrome for ten years. Endoscopic carpal canal release and decompression surgery was effective for carpal tunnel syndrome in both macrodactyly patients.