Patients' Perspective on Carpal Tunnel Release with WALANT or Intravenous Regional Anesthesia.

Abstract

Sir: We have read the article “Patients’ Perspective on Carpal Tunnel Release with WALANT or Intravenous Regional Anesthesia” by Ayhan and Akaslan.1 According to our clinical experiences, there are some points that should be illuminated. The “wide-awake, local anesthesia, no tourniquet” (WALANT) method is gaining popularity, with more hand surgeons using the aforementioned method recently. Management of carpal tunnel syndrome is a challenging process, whether it is preoperatively, operatively, or postoperatively.2 We praise the authors for carrying out such a valuable study regarding such a complex condition. Although the importance and value of the study are obvious, there are a few questions we desire to ask. The anatomy of the carpal tunnel possesses such a complex structure that to preserve the median nerve and its branches, dissection must be carried out meticulously. Even a slight, involuntary movement of the patient might increase the risk of injury of the median nerve and its branches. Because WALANT is a method based on local anesthesia, there might be a possibility for the patient to move their limbs. As the authors carried out their surgical procedures by using intravenous regional anesthesia and WALANT methods, is there any risk for patients to move their hand voluntarily or involuntarily, which can increase the risk of median nerve injury for the latter method? During carpal tunnel surgery, not only neural decompression by releasing adjacent extraneuronal structures but also decompression by dissecting epineurium might be requisite.3 By performing such procedures, surgical manipulations involving epineurium can cause pain or discomfort in patients. Were there any cases in need of such epineural dissection within their study? If yes, did the WALANT method provide the patient or surgical team sufficient comfort regarding the pain caused by such types of dissections? The median nerve can be affected by tumors originating in the neural or epineural structures or compression by lipomas, cysts, congenital muscular, or tendinous abnormalities.4 Those types of lesions can affect the nerve by compressing it, dislocating its structure, and disturbing its vascular flow, and may lead to clinical findings such as pain, paresthesia, and carpal tunnel syndrome.5 Those types of lesions can affect bony structures or joints. Lesions with such involvements might require deeper anesthesia and analgesia. Can the WALANT method provide sufficient anesthesia regarding the lesions with joints or bony structures? Did the authors perform any studies such as radiologic imaging aiming to rule out the type of lesions that can cause symptoms related to median nerve compression? In terms of diagnosis, nerve conduction studies can provide quantitative findings.6 Have the authors conducted any nerve conduction studies? If yes, were there any differences between the quantitative outcomes of patients that went through surgery by using WALANT and intravenous regional anesthesia? WALANT and intravenous regional anesthesia both aim to provide effective hemostasis, but use of the tourniquet, without a doubt, makes the latter method uncomfortable. This type of lack of comfort not only disturbs the patient but also affects the surgical team in a negative manner. However, it is undeniable that a lack of hemostasis may also lead the surgical team to such discomfort. Because Ayhan and Akaslan have performed all these procedures, we assume that by using the WALANT method, they have successfully managed to have hemostasis as well. Were there any quantitative parameters of blood loss using the WALANT method that can be comparable to intravenous regional anesthesia? Our clinic’s treatment protocol for carpal tunnel syndrome is standardized; carpal tunnel operations are mostly performed by intravenous regional anesthesia, which provides sufficient comfort for the surgeon and the patient and helps us avoid the aforementioned risks and obstacles. For postoperative follow-up, we use splinting for 10 days, and our overall outcomes are satisfactory. WALANT is a useful method for tendon transfer surgery to adjust optimal tension for the tendons.7 However, with all due respect, from our point of view, it is unclear why we should prefer the WALANT method over intravenous regional anesthesia for carpal tunnel surgery. We would like to conclude by thanking Ayhan and Akaslan for their informative study and for sharing their valuable experience with us. DISCLOSURE The authors have no relationships that would represent a conflict of interest. No funding was received for this communication. Alper Aytaç, M.D.Can Ilker Demir, M.D.Murat Şahin Alagöz, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryKocaeli University Faculty of MedicineKocaeli, Turkey