Carpal tunnel syndrome surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Dheeraj Makkar, M.D.[2]
Overview
Carpal tunnel release can be performed via open, endoscopic, or ultrasound-guided percutaneous techniques, with faster recovery for minimally invasive approaches but similar long-term outcomes. Complications include scar tenderness, pillar pain, incomplete release, and nerve injuries. Revision may be required in refractory cases. Prognosis is favorable with complete release and early symptom relief.
Carpal Tunnel Release
- Open
- Endoscopic
Earlier return to work, better key-pinch, and higher earlier patient satisfaction associated with endoscopic carpal tunnel release Long term results same as open CTR ultrasound-guided percutaneous similar advantages to endoscopic may be effective with potential for shorter recovery times vs open carpal tunnel release outcomes pinch strength returns in 6 weeks grip strength is expected to return to 100% preoperative levels by 12 weeks postop
rate of continued symptoms at 1 year is 2% in moderate and 20% in severe CTS
improved patient outcomes with surgery at 6 and 12 months as compared to splinting, NSAIDs/therapy, and a single steroid injection
- Revision CTR for incomplete release
- Indications
Failure to improve following primary surgery Incomplete release - most common reason
- Outcomes
25% will have complete relief after revision CTR 25% will have no relief Technique Open carpal tunnel release antibiotics prophylactic antibiotics, systemic or local, are not indicated for patients undergoing a clean, elective carpal tunnel release
- Approach
Kaplan's cardinal line: first web space to hook of hamate that approximates the region of the superficial palmar arch ulnar border of the long finger use a natural crease if possible, cheat ulnar to avoid the recurrent branch of the median nerve technique internal neurolysis, tenosynovectomy, and antebrachial fascia release do not improve outcomes Guyon's canal does not need to be released as it is decompressed by carpal tunnel release lengthened repair of transverse carpal ligament is only required if flexor tendon repair is performed (allows wrist immobilization in flexion postoperatively) postoperative care and rehab can use night splinting with the wrist in neutral position for 2 to 3 weeks for patient comfort begin range of motion/nerve glide exercises immediately over the counter medications provide adequate pain control
Begin strengthening exercises after 4 weeks Supervised hand therapy may be utilized to aid in recovery May use ultrasound and paraffin wax to reduce swelling and alleviate pain Nerve-gliding exercises, massage, and trigger point release
- Endoscopic carpal tunnel release
different systems available, some offering one versus two incisions technique a 1-2cm transverse incision is made just proximal to the wrist flexion crease dissection is carried down sharply just deep to antebrachial fascia a synovium elevator is used to develop a plane just deep to transverse carpal ligament a path is created in the carpal tunnel with dilators the camera/blade instrument is inserted and the transverse carpal ligament is cut under direct endoscopic visualization
- Pros
Accelerated rehabilitation and return to work
- Cons
Disadvantage is learning curve and cost Most common complication is an incomplete division of transverse carpal ligament Ultrasound-guided percutaneous carpal tunnel release
- Technique
Ultrasound identifies median nerve at the wrist and determines entry point in the palm and exit point in the wrist for the Tuohy needle entry and exit points are anesthetized with local anesthesia, with Tuohy needle being passed under carpal tunnel and above median nerve by hydro dissection needle tip pushed through exit point in the wrist and a cutting thread is passed the Tuohy needle is then passed subcutaneously above the transverse carpal ligament and the cutting thread is passed back through the needle, creating a loop that out of the entry point the cutting thread is then pulled back and forth, releasing the ligament
Complications
- Scar tenderness (most common)
incidence 19 to 61% treatment scar massage occupational therapy
- Pillar pain
deep-seated ache over the thenar or hypothenar region secondary to injury of small sensory branches of the median/ulnar nerves incidence 41% at 1 month, 25% at 3 months, 6% at 12 months treatment scar massage occupational therapy recurrence incidence 1% at 5 years 1.6% at 10 years Risk factors endoscopic was associated with an increased hazard of revision CTR compared with open 14% are due to incomplete release of transverse carpal ligament treatment
- Revision open carpal tunnel release
injury to the recurrent branch of median nerve Incidence 0.7% (endoscopic) 3% (open) risk factors transligamentous motor branch of the median nerve treatment repair outcomes acute vs chronic repairs appear to be promising with nearly 100% return to function of thenar musculature tendon transfers FDS to APB to restore opposition (Bunnell transfer)
can alternatively use EIP or PL
- Iatrogenic injury to palmar cutaneous branch of the median nerve
incidence 2.4% (endoscopic) 19% (open) treatment neuroma resection and nerve ablation
- Injury to proper palmar digital nerve to the index finger
incidence 0.25% (open) 1.45% (endoscopic) treatment observation occupational therapy arterial arch injury incidence 0.02% (endoscopic) 0% (open) treatment repair
- Prognosis
Good prognostic indicators include night symptoms small incisions relief of symptoms with steroid injections not improved when incomplete release of transverse carpal ligament is discovered