Can the outcome of carpal tunnel release be predicted?

Between 1994 and 1996 we performed a prospective study on the effect of carpal tunnel release on the health status of 96 patients. The Nottingham Health Profile, a validated global scoring system, was used to assess quality of life before, and at 4 months after surgery. Carpal tunnel syndrome had a significant impact on the health status of our patients. There were significant improvements in the scores for pain, energy and sleep. Patients who were dissatisfied following surgery had significantly higher pre-operative scores, indicating poor perceived health status. Our findings show that outcome assessment tools have predictive value in identifying patients who may not benefit from surgery, or in whom a poor result might be anticipated.     

Does the severity of bilateral carpal tunnel syndrome influence the timing of staged bilateral release?

A retrospective chart analysis was performed of 66 patients with bilateral carpal tunnel syndrome (CTS) who underwent either single endoscopic carpal tunnel release (ECTR) or staged bilateral ECTR to determine the frequency and timing of contralateral surgery. Bilateral CTS patients with contralateral severe CTS underwent bilateral staged ECTR 86% of the time and the second operation was performed 6 ± 5 weeks after the initial ECTR. Patients with contralateral moderate CTS underwent bilateral staged ECTR 74% of the time with a mean of 11 ± 3 months between operations. Patients with contralateral mild CTS underwent bilateral staged ECTR 20% of the time and averaged 7 ± 3 years between procedures. For patients with bilateral CTS, the severity of CTS on the contralateral side to the initial release affects both the frequency and timing of the contralateral surgery. This information may be used to establish guidelines for treatment with bilateral simultaneous CTR.     

Thickening of the synovium of the digital flexor tendons: cause or consequence of the carpal tunnel syndrome?

Using a monofilament wire suture, the radial and ulnar edges of the flexor retinaculum were approximated in 14 white New Zealand rabbits. As a result, the volume of the carpal tunnel was diminished, and "carpal tunnel syndrome" was produced. At various intervals after this procedure the animals were sacrificed. The median nerve and all the digital flexor tendons passing through the carpal tunnel were excised "en bloc", and sent for histological examination. Vascular proliferation with perivascular round cell infiltration and oedema, and large areas of fibroblastic activity were observed around the digital flexor tendons. This was probably due to increased vascular permeability secondary to ischaemic endothelial damage. These findings are similar to those observed in the synovium of patients operated on for carpal tunnel syndrome.     

Prophylactic carpal tunnel decompression during buttress plating of the distal radius--is it justified?

Our objective was to evaluate the role of carpal tunnel decompression in preventing median nerve dysfunction after buttress plating of the distal radius. We studied 69 consecutive patients with distal radial fractures managed by volar plating over a 4-year period. (1995-1998). Patients' clinical notes were assessed for symptoms of median nerve dysfunction and all the patients were followed up for a minimum period of 6 months. Twenty-four patients had prophylactic carpal tunnel decompression and 45 patients did not. Forty-two patients (61%) were women and 27 patients (39%) men. The average age of the patients was 56 years, (range 24-81 years). Overall 17 patients (25%) developed median nerve dysfunction post-operatively of which nine patients had and eight patients did not have formal prophylactic tunnel decompression, respectively; this was not statistically significant (P=0.08). In addition prophylactic decompressed patients had more than twice the relative odds=2.7 (confidence interval: CI=0.94-4.76) of developing median nerve dysfunction. All cases resolved spontaneously except for three cases that required carpal tunnel decompression. We conclude that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may increase post-operative morbidity.     

Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? An analysis of published series

The purpose of this study was to evaluate the reported rate of complications after endoscopic carpal tunnel release by means of an analysis of 54 publications, reporting a total of 9516 endoscopic and 1203 open releases. Endoscopic release was comparable to open release in the rate of irreversible nerve damage (0.3% and 0.2% respectively) but case reports may indicate a small risk of unacceptable complications with endoscopy, such as transection of the median nerve. Reversible nerve problems were more common after endoscopic release. Tendon lesions were extremely rare (0.03%) and the rate of other complications (reflex sympathetic dystrophy, haematoma, wound problems, etc.) was about the same with endoscopic as with open release.     

Should we stop oral anticoagulants in the surgical treatment of carpal tunnel syndrome?

Introduction

It is usual to stop the intake of oral anticoagulants (anti-vitamin K) before surgery. Some authors have shown that during minimal surgery, the relay with low molecular weight heparin (LMWH) may lead to more thromboembolic complications. We present a prospective comparative study while evaluating the results of stopping or continuing anticoagulants in the surgery for carpal tunnel syndrome.

Material and methods

Our series included 21 patients (24 hands) taking anticoagulants on a long-term basis. For the first nine patients (group I), treatment with anticoagulants was stopped before the surgery. For the following 12 patients (group II), treatment with anticoagulants was not interrupted. The evaluation was based on the measurement of pain (VAS), functional score of the Quick D.A.S.H. and grip strength (Jamar®) and search for a haematoma or thromboembolism).

Results

The pain decreased by 3.5 points in both groups. The Quick D.A.S.H. decreased by 19.9 and 27.7 points in groups I and II, respectively. The average grip strength decreased by 2.5 kg in group I and increased by 3.8 kg in group II. A subcutaneous haematoma that got healed by itself was observed in group II. We did not observe any thromboembolic complications.

Discussion

In conclusion, it seems pointless to stop anticoagulants before surgical treatment of carpal tunnel. The first reason is that continuing anticoagulants does not result in a bleeding risk. The second reason is that this approach removes the theoretical risk of thromboembolic complications during a poorly monitored relay.     

Dash and Boston questionnaire assessment of carpal tunnel syndrome outcome: what is the responsiveness of an outcome questionnaire?

This prospective study evaluates if the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is an adequately responsive outcome measure in carpal tunnel syndrome by comparing it with the disease-specific Boston questionnaire (BQ). To measure responsiveness (sensitivity to clinical change), 57 patients with a clinical diagnosis of carpal tunnel syndrome completed the DASH and BQ preoperatively and again 3 months after open carpal tunnel decompression. A second group of 31 patients completed the questionnaires in the outpatient clinic and again 2 weeks later to assess test-retest reliability. The time to complete all questionnaires was recorded. Responsiveness of the DASH is comparable with the BQ with standardized response means of 0.66, 1.07 and 0.62 for the DASH, BQ-symptoms and BQ-function, respectively. Test-retest data show both questionnaires are reliable. Mean times to complete questionnaires were 6.8minutes (DASH) and 5.6minutes (BQ). This study concludes that the DASH questionnaire is a reliable, responsive and practical outcome instrument in carpal tunnel syndrome.     

Is complete release of all volar carpal canal structures necessary for complete decompression in endoscopic carpal tunnel release?

This study investigated the need to completely divide the flexor retinaculum to achieve full decompression of the median nerve in the carpal canal, using carpal canal pressure measurements at the mid-point and/or the proximal one-third of the flexor retinaculum to analyse the degree of decompression after release of successive lengths of the flexor retinaculum from the distal hold-fast fibres to its proximal margin. Pressure measurements were taken at each operative step in the resting hand position and during active power gripping. The pressure measurements indicated that decompression of the carpal canal was achieved both at rest and on active gripping after complete division of the flexor retinaculum. However, pressure measurements indicated that complete decompression had not been achieved during active power gripping with the proximal one-third of the flexor retinaculum intact. These results demonstrate the need for complete release of the full length of the flexor retinaculum, including the distal hold-fast fibres.     

Does splintage help pain after carpal tunnel release?

A prospective randomized single blind trial was performed of 102 patients undergoing carpal tunnel release. Patients received either a palmar plaster of Paris splint or a bulky wool and crepe bandage postoperatively for the first 48 h, to determine whether the plaster slab reduced postoperative pain. There were no statistically significant differences between the two groups in postoperative pain scores or analgesic use.     

The thenar motor branch during carpal tunnel decompression: “the expert opinion”

Introduction Iatrogenic injury to the thenar motor branch (TMB) of the median nerve is a rare but serious complication of carpal tunnel decompression (CTD). Variability in the anatomical course of the branch is well documented in the literature. We aimed to explore and document “expert experience and attitude” to the TMB during CTD. Materials and methods All members of the British Society for Surgery of the Hand (220) were sent a short postal questionnaire, in which 153 questionnaires (70%) were returned. Results The open technique was routinely used by 97% of the surgeons, 70% replied that either very rarely or never formally explored the TMB during CTD and 71% of surgeons saw the TMB lying superficially in less than 5% of cases. Among surgeons, 49 had never encountered an iatrogenic injury while only 14 had seen more than 5 cases in their careers. Finally, 71% of surgeons agreed that formal exploration of the nerve is not necessary during uncomplicated cases. Discussion The “consensus” view suggests that formal demonstration of the thenar branch of the median nerve during CTD is unnecessary. The incidence of iatrogenic injuries seen was low. A number of useful strategies to avoid iatrogenic injuries are suggested.     

Coincidence or complication? A systematic review of trigger digit after carpal tunnel release

Background: Carpal tunnel syndrome (CTS) and trigger digits are among the most common nontraumatic hand disorders treated by plastic surgeons. The onset of trigger digits after carpal tunnel release (CTR) has been inconsistently reported. This systematic review assessed the prevalence of trigger digits development in patients after CTR surgery.

Methods: We searched the MEDLINE, EMBASE and SCOPUS databases for papers published between January 1966 and August 2016. Eligible studies contained quantitative data on the incidence of trigger digits after CTR. The primary outcome measure was the onset of trigger digits after CTR. The secondary outcome measure was the prevalence of digital involvement in patients who developed trigger digits after CTR.

Results: A total of 5654 CTR surgeries were performed in the included nine studies, and 483 patients (8.5%) developed trigger digits after CTR. The reported incidence of trigger digits after CTR ranged from 5.2% to 31.7%. The time to development of trigger digits was approximately 6 months postoperatively. In the eight observational studies and in the randomized controlled trial, the thumb and ring finger were reported as the most commonly involved trigger digits, respectively.

Conclusions: The incidence of trigger digits after CTR surgery is not negligible. Thumbs and ring fingers are the most commonly involved digits. This topic should therefore be suitably addressed during preoperative consultations.     

Pain on administration of non-alkalinised lidocaine for carpal tunnel decompression: A comparison between the Gale and the “advancing wheal” techniques

Methods: This study compares two methods of administration of non-alkalinised lidocaine for carpal tunnel decompression in volunteers as well as in patients undergoing carpal tunnel release: The Gale subcutaneous injection technique and another subcutaneous injection technique known as the “advancing wheal” technique. The comparison was done in nine male volunteers and in 20 patients. In the volunteer part of the study, both hands were injected and, hence, each volunteer acted as his own control. In the clinical part of the study, the 20 patients were randomised, with 10 patients receiving the Gale technique and the other 10 receiving the wheal technique. Results: In volunteers, the advancing wheal technique was associated with less pain; but with a longer duration of injection and a higher number of needle pricks when compared with the Gale technique. Eight volunteers preferred the advancing wheal technique because the overall pain experience was less. One volunteer preferred the Gale technique because it took less time to complete the injection procedure. Clinically, the wheal technique also had a significantly lower mean pain score than the Gale technique. Conclusion: It was concluded that the advancing wheal technique is associated with less pain than the Gale technique.     

The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study

Background

The purpose of this study was to provide prospective independently analyzed evidence on how patients feel about a carpal tunnel release (CTR) performed under local anesthesia only (no sedation or tourniquet) versus with local anesthesia, intravenous (IV) sedation, and a tourniquet.

Methods

This prospective cohort study compared 100 consecutive CTRs done with only lidocaine and epinephrine in Saint John, New Brunswick to 100 consecutive CTRs done with IV sedation in Davenport, Iowa. Patient perspectives on the anesthesia were captured in a blinded questionnaire 1 week postoperatively.

Results

For subsequent surgery, 93 % of wide awake patients would choose local anesthesia only and 93 % of sedated patients would choose sedation. Wide awake patients spent less time at the hospital (M?=?2.6 h) than sedated patients (M?=?4.0 h; p?<?.001). Preoperative blood work, electrocardiograms, and/or chest radiographs were done for 3 % of wide awake patients and 48 % of sedated patients (p?<?0.001). Preoperative anxiety levels for wide awake patients were lower than for sedated patients (p?=?0.007); postoperative anxiety was similar. There were no anesthesia complications in either group. Narcotics were used by 5 % of unsedated patients and 67 % of sedated patients (p?<?0.001). Adequate pain control was reported by 89 % and 90 % of patients, respectively.

Conclusions

The majority of patients from both cohorts liked whichever method of anesthesia they received and would choose it again. However, sedated patients spent more time at the hospital, required more preoperative testing, and reported greater preoperative anxiety.     

Management of true recurrent carpal tunnel syndrome: is it worthwhile to bring vascularized tissue?

Since 1989, 13 consecutive cases of true recurrent carpal tunnel have been operated on. Average delay before reoperation was 20 months (3 to 60 months). Intraoperative findings were univocal: extensive fibrosis with nerve adhesion to the roof of the carpal tunnel and a lack of nerve gliding. Surgery performed was: extensive external neurolysis from distal forearm to distal to carpal tunnel to allow a complete freedom of the nerve. A vascularized flap was never performed. Mean follow-up was 27.5 months (range 4 to 74 months). Results were: complete relief of symptoms in 75%; improvement with complete disappearance of nocturnal symptoms but persistent dysesthesia in 17%; no improvement in one patient (Sudeck's dystrophy). Interests of this study are: homogeneous population (only true recurrence), no bias from work compensation, consecutive cases, one surgeon, standardized surgical procedure and one independent observer. Results suggest that main factor for true recurrent carpal tunnel syndrome is lack of normal gliding of the nerve and that an extensive neurolysis helps to restore this gliding.     

The Canaletto®™ implant for reconstructing transverse carpal ligament in carpal tunnel surgery. Surgical technique and cohort prospective study about 400 Canaletto cases versus 400 cases with open carpal tunnel surgery

The techniques used for carpal tunnel release are open surgery, endoscopy and retinaculum repair. Postoperative outcome, however, is often altered by pain, weakness, insufficient sensory or motor recovery and recurrences. We propose, since March 2001, a new surgical technique based on the reconstruction of the flexor retinaculum using the Canaletto^®? implant. The present study consists in a comparative prospective analysis of 400 patients with a Canaletto^®? implant versus 400 patients having undergone open surgery without Canaletto. The average follow-up was 31 months (1–72 months). The rate of carpal tunnel syndrome recovery (suppression of diurnal and nocturnal paraesthesia) was 97.25% in the Canaletto group and 96.11% in the group without Canaletto. The quality of healing was better in the Canaletto group, with a reduced rate of postoperative oedema. Strength recovery defined as a postoperative strength between 80 and 100% of preoperative strength, as assessed by Jamar, was obtained in 67% of patients in the Canaletto group vs. 33% in the group without Canaletto at 1 month of follow-up. There were still some early strength failures in 226 patients (56.5%) of the group without Canaletto and 31 patients (7.75%) of the Canaletto group. In the long term, patients of the Canaletto group displayed strength between 120 and 200% of preoperative strength. Sensory recovery measured by visual analogic scale in patients with preoperative loss of sensitivity was better in the Canaletto group with an average of 8.9/10 vs. 5.8/10 in the group without Canaletto. No recurrence of carpal tunnel was observed in the Canaletto group whereas four recurrences occurred in the group without Canaletto. Mean duration of sick leave decreased from 5 weeks in the group without Canaletto to 3 weeks in the Canaletto group. Such mechanical and biological properties made this implant becoming part of our surgical armamentum; we use it in about 25% of our surgical procedures for carpal tunnel syndromes. There is some limitations regarding the results of this study due to: (1) a potential selection bias between the two cohorts related to Canaletto indication, and (2) one of the authors is also the designer of the implant (the other one has no conflict of interest).     

Chemically-induced chronic nerve compression in rabbits —a new experimental model for the carpal tunnel syndrome

Summary In order to create an experimental model for the carpal tunnel syndrome without the use of the commonly applied foreign bodys (silicone or rubber tubes, tourniquets etc.), the present study tried to induce a chemically provoked compression of the median nerve in rabbits. In 9 female rabbits 1 ml of Aethoxskerol® 3% (Hydrox-polyethoxy dodecan) was instilled into the carpal tunnel around the median nerve after visualisation of the nerve. The other foreleg served as the control and was treated with the same amount of saline solution. Electroneurophysiologic parameters were registered preoperatively, 1 month and 6 months post surgery and histomorphologic investigations by light and electron microscopy were performed after 6 months. 6 months after treatment with Aethoxysklerol®, a statistically significant lenghtening of the distal latency period as well as a significant reduction of the compound potential amplitude could be observed. In accordance with these findings, morphological investigation revealed the presence of extensive granulation tissue around the median nerve together with signs of demyelination. Our results indicate that we were able to produce the development of extensive granulation tissue in the carpal tunnel of rabbits with subsequent compression of the median nerve which was confirmed by histomorphologic investigation as well as by measurement of nerve conductive velocity.

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Chemisch induzierte, chronische Nervenkompression bei Kaninchen — ein neues Tiermodell für das Karpaltunnelsyndrom

Zusammenfassung Die vorliegende Studie versuchte eine chemisch induzierte, chronische Kompression des N. medianus in einem experimentellen Kaninchenmodell, ohne Verwendung der bis dato implantierten Fremdkörper (Silikon-oder Gummischläuche, Tourniquets, etc.) zu verursachen. Nach Darstellung des N. medianus wurde bei neun weiblichen Kaninchen 1 ml Äthoxysklerol® perineural im Karpalkanal instilliert. Die andere vordere Extremität diente als Kontrolle und wurde mit der gleichen Menge Kochsalzlösung behandelt. Elektroneurophysiologische Parameter wurden präoperativ, 1 und 6 Monate nach dem Eingriff bestimmt, histomorphologische Untersuchungen mittels Licht- und Elektronenmikroskopie wurden nach 6 Monaten durchgeführt. 6 Monate nach Behandlung mit Äthoxysklerol® fand sich eine signifikante Verlängerung der distalen Latenzzeit sowie eine signifikante Erniedrigung der Summenpotentialamplitude. In Übereinstimmung mit diesen Befunden zeigte sich morphologisch überschieendes Granulationsgewebe um den N. medianus mit Zeichen der Demyelinisierung. Unsere Ergebnisse zeigen, da wir die Entstehung von Granulationsgewebe im Karpalkanal von Kaninchen provozieren konnte, welche mit einer nachfolgenden Nervenkompression einherging. Diese Veränderung manifestierte sich sowohl histomorphologisch als im Rahmen der Nervenleitgeschwindigkeit.

     

Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis

Study DesignA systematic review and meta-analysis.IntroductionCarpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment.Purpose of the StudyThis meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients.MethodsElectronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements.ResultsTen articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist–middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = −4.31, 95% CI = −5.89 to −2.74, P < .001 and MD = −2.74, 95% CI = −5.32 to −0.16, P = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies.ConclusionMetaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.     

One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?

Purpose

The purpose of this study was to evaluate whether simultaneous bilateral endoscopic carpal tunnel release could be effectively and safely performed under local anaesthesia.

Methods

We prospectively evaluated 85 consecutive patients (62 females) who underwent simultaneous one portal endoscopic bilateral carpal tunnel release with subcutaneous injection of 2 mL 2 % lidocaine. In case of pain after discharge, all patients were advised to take paracetamol (i.e., acetaminophen) and to record the dose of drug taken. Patients were reviewed at regular intervals until one year postoperatively.

Results

The mean operative time was 31.2 min. Postoperatively, only nine patients (10.6 %) received on average 611 mg of paracetamol. Significant improvement was noticed in the parameters of numbness, pain, positive Phalen and Tinel tests, pinch strength, grip strength, tip pinch strength and Quick DASH Score. Patients returned fully to work after surgery in average 2.2 weeks. Conversion to open release took place in four wrists (2.4 %). Discomfort and pain from tourniquet pressure was reported from two patients (2.4 %). Two wrists (1.2 %) required revision surgery. One patient (1.2 %) reported temporary thenar numbness and another (1.2 %) had slight scar hypersensitivity.

Conclusions

Simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia is well tolerated by patients. The technique may be of benefit in young, active, high-demand patients who require fast recovery, early return to work and less disability time.