Carpal Tunnel Release Operation Research Articles

Clinic Carpal Tunnel Release Surgery Outcomes and High-Value Care.

As healthcare costs continue to rise, the importance ofdelivering high-value healthcare increases.The volume of carpal tunnel release surgeries performed annually generates a significant cost burden for the healthcare system. The fundamental expenses of carpal tunnel release surgery are facility fees, anesthesia fees, and surgeon fees. Performing open carpal tunnel release surgeries in the clinic utilizing local anesthesia and field sterilization minimizes facility and anesthesia costs. We compared patient outcomes, as measured by infection and revision rates, between hospital-based, ambulatory surgery center-based, and clinic-based carpal tunnel release operations. Three hundred and eighty-eight patients were treated with isolated mini-open carpal tunnel release procedures by three fellowship-trained hand surgeons: 12 patients had hospital-based procedures, 229 had ASC-based procedures, and 147 had clinic-based procedures. All procedures were performed using amini-open approach. No patients were diagnosed with deep infections post-procedurally, irrespective of venue. Our results show no significant difference in outcomes between venues. Therefore, we conclude that the outcomes of open carpal tunnel release surgeries performed in the clinic were not inferior to carpal tunnel release operations performed at the ambulatory surgery center or the hospital. The cost savings from field sterilization, local anesthesia, and the absence of a facility fee provide an opportunity to expand high-value care.

Neuroelectrophysiological Evaluation of Carpal Tunnel Syndrome before and after Surgical Intervention

Background: Carpal tunnel release operation (CTR) is required to alleviate the symptoms of carpal tunnel syndrome (CTS), the most common entrapment neuropathy. Methods: Thirty-two patients (39 hands) of CTS were subdivided into Group I is moderate CTS (n = 9 hands), Group II is severe CTS (n = 14 hands), and Group III is extreme CTS (n = 16 hands) and underwent conventional electrophysiological evaluation and short segment transcarpal nerve conduction studies preoperatively and 1 and 3 months after open CTR operation. Results: In the case of motor conduction parameter, distal motor latency showed statistically significant improvement after 1 month of CTR (P < 0.05) in all three groups of patients, and improvement consistently increased during 3rd month follow-up (P < 0.001). In Group III patients, preoperatively forearm motor conduction velocity (FMCV) and transcarpal motor conduction velocity (TMCV) were nonrecordable, FMCV became recordable in 6 hands, while TMCV in all 16 hands post CTR. In case sensory parameters, both distal sensory latency (DSL) and sensory nerve conduction velocity (SNCV) showed significant improvement in Group I, and no improvement was noted in Group III patients. Group II (6 of 14 hands) patients showed a reappearance of DSL and SNCV at 1-month follow-up and continued a steady improvement in 3rd month after CTR. Conclusion: We found that TMCV is a more sensitive parameter in assessing improvement of median nerve function after CTR. It is possible to identify patients with a poor outcome by performing electrophysiological studies.

Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients.

The clinical features of classic carpal tunnel syndrome are well known. However, some patients who display atypical symptoms and signs of pain and dysesthesias in the hand, worsening of symptoms at night, and above all, inability to make a full fist, respond equally well to carpal tunnel release. This same clinical picture was shared by some patients labeled as having complex regional pain syndrome. Because of the poor outcome of complex regional pain syndrome patients with current regimens, the authors tested the hypothesis that carpal tunnel release could be effective on them. The purpose of this article is to report the outcome of carpal tunnel release in complex regional pain syndrome patients who presented the above signs and symptoms. Fifty-three patients with an average age of 55 years presenting the above cluster of symptoms were operated on. All were unilateral cases, had sustained trauma, and were treated for complex regional pain syndrome before referral for an average of 16 months. All patients underwent carpal tunnel release. At a minimum of 6 months' follow-up, pain dropped 7.5 points on a numerical rating scale of 0 to 10 ( p < 0.001). Disabilities of the Arm, Shoulder and Hand scoring fell from 82 to 17 ( p < 0.001). Six patients had an unsatisfactory result. Some patients with complex regional pain syndrome may respond successfully to a carpal tunnel release operation. Recognition of this possibility is crucial, as the symptoms and signs might lead the clinician away from the proper diagnosis and treatment. Therapeutic, IV.

Welcome message from the Editor-in-chief

It is with much pleasure that I welcome you to volume 2 issue 2 of the Health Sciences Investigations Journal. The Journal remains committed to reaching the global community with open access publications from basic and clinical health sciences. According to the World Health Organization “Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”. Thus, our multi-disciplinary journal consistently provides an avenue for communication of research findings in health, the science of well-being. The current issue of the Journal contains a case study on the bifid median nerve, an anatomical variation that is caused by the early and proximal division of the nerve trunk preceding entry into the carpal tunnel. The bifid median nerve was identified in an adult male Wolof cadaver during dissection of the anterior region of the wrist. The nerve within the carpal tunnel had a cleavage at the superficial finger flexor muscles. his is a rare condition that hand surgeons must know to avoid the median nerve in carpal tunnel release operations. In this issue, we also present data on clinical features of 57 children (12-17 years) infected with the novel coronavirus disease (COVID-19) in the Accra Regional Hospital in Ghana. The most common symptom was a headache (50%) and this was followed by cough (35.7%). Two other articles in Child Health in this issue are multivariate analysis of risk factors associated with severe underweight among children under 5 years and screening for wasting and underweight in sick children (6-59 months). In the former study, both child and maternal risk factors were associated with being underweight, and these include multiple births, small size at birth, mother’s education and the number of children under 5 years. Improvement in maternal education, socio-economic status of families and family planning were considered key in resolving the challenge of child underweight. In the latter article, 4% (out of 199) of children were classified as being severely wasted by Mid Upper Arm Circumference Measurement, whereas 3% were diagnosed to have severe acute malnutrition. Analogous to the former study, determinants of wasting were the low level of maternal education and age of children (&lt;24 months). We highlight these publications because globally malnutrition constitutes a critical cause of the increase in mortality of children under 5 years of age. I am grateful to the hardworking Editorial Team and the Reviewers for their effort in ensuring that the Journal publishes good articles for our cherished readers. The Advisory Board, Authors and Publishers are also acknowledged for their contributions. I welcome suggestions, complaints, discussions, and thoughts from authors and readers to help us to maintain high standards. I look forward to receiving your high-quality manuscripts for publication. Thank you. Acknowledgements he University of Ghana College of Health Sciences, the copyright owner, the patron, and sponsor of HSI Journal has always shown a deep interest in the affairs of its constituent institutions. The Journal is indeed grateful to Professor Julius Fobil, the Provost of the University of Ghana College of Health Sciences, for his immense support and leadership

Morphological variations of median nerve observed in patients during carpal tunnel release surgery: A cross-sectional study conducted in a Tertiary Care Hospital of District Nowshera, Pakistan.

Objective: To study the morphological variations of median nerve observed in sick persons during carpal tunnel release operation. Study Design: Cross Sectional study. Setting: Qazi Hussain Ahmad Medical Complex, Nowshera. Period: One year (November, 2019 till October, 2020). Material &amp; Methods: This Cross-sectional study was conducted after obtaining ethical approval from the Institutional Ethical Review Board (IERB), NMC in which people were tracked with mild to severe carpal tunnel symptoms for a year. Less than 24 hours after their arrival, the victims were operated on under local anesthesia in Qazi Hussain Ahmad Medical Complex, Nowshera, Pakistan. Each surgical method viewed the nerve. Branches around the carpal tunnel were seen and documented on a spreadsheet. 150 were planned. The statistics were in percentages. Results: In 150 instances, 102 (68%) were female and 48 (32%) were male. 138 (92%) individuals showed normal median nerve morphology, whereas 12 (8%) had aberrant branching. The transverse carpel ligament had significant splitting. There was a persisting median in three of the 12 instances. Conclusion: The top division of the median nerve showed altered branching morphology. As with the persistent median artery, recurring median artery raises the chance of median nerve dysfunction.

The Carpal Tunnel Syndrome and the Double Crush Syndrome Hypothesis: Revisited

AbstractBackground: The commonest application of the double crush hypothesis is its association to median nerve entrapment at the wrist. The double crush concept has gained popularity because it provides a reason to evaluate the cervical spine and roots when treating carpal tunnel syndrome (CTS). It is more likely for CTS to occur as DCS rather than occurring by itself. Up to 90% of CTS patients are misdiagnosed, whereas only 10% have the problem at their wrists.Aim of Study: To examine the validity of DCS hypothesis in CTS patients, to support or disregard the theory.Patients and Methods: This study was conducted on 80 patients; 40 patients claiming failed carpal tunnel release operation (Group I) and 40 cases presenting with brachialgia (Group II). Diagnostic work up included neurological exam-ination, Phalen test, Tinel sign, electromyographic examination (EMG) and nerve conduction studies (NCS) and cervical MRI. Group I patients had undergone the EMG and NCS at our laboratory pre and post operatively.Results: EMG and NCS showed 10 cases with CTS (25%), 20 (50%) with DCS and 10 (25%) with cervical radiculopathy in group I, while group II patients showed 10 cases (25%) with CTS and 30 (75%) with DCS. In all patients, 50 cases (62.5%) showed DCS. On comparing the EMG and NCS preoperative results of Group (I), with their postoperative follow-up results, there was a high statistically significant difference (p-value <0.001) with 34 cases (85%) who showed improvement of the NCS results, while 6 cases (15%) deteri-orated postoperatively. There was a high statistically significant difference between both; CTS and DCS (p-value <0.001), denoting a positive correlation between the two syndromes.Conclusion: The DCS hypothesis was supported, while the concept of frequent failure of CTS release surgery was not supported for the benefit of DC hypothesis.

Palmar Digital Neuropathy With Anatomical Variation of Median Nerve: Usefulness of Orthodromic Technique: A Case Report

Anatomic variation of palmar digital nerve pathways were reported in several cases. Selective exploration of palmar digital nerves with a nerve conduction study has been challenging, because of technical issues. We report a patient who received bilateral carpal tunnel release operation, complaining of a tingling sensation, and hypoesthesia on the middle and ring fingers. An electrodiagnostic study revealed a sensory neuropathy of palmar digital nerve of the left median nerve, supplying the ulnar side of the middle finger, and radial side of the ring finger. She underwent re-operation of open left carpal tunnel release, and a branching site of common digital nerves of the median nerve was identified not at the palm, but at a far proximal site around the distal wrist crease. Usefulness of an orthodromic sensory conduction study was clarified to eliminate volume conducted response or co-activation of nearby nerves in the patient with selective involvement of palmar digital nerve.

Use and Associated Spending for Anesthesiologist-Administered Services in Minor Hand Surgery.

Evidence is lacking to support the use of specialized anesthesia providers in minor surgical operations for patients without medical necessity. The authors sought to estimate the extent of potentially discretionary service use (anesthesiologist-administered anesthesia services among low-risk patients). The authors performed a retrospective claims analysis using the Truven MarketScan Database to estimate the prevalence and cost of anesthesiologist-administered anesthesia services provided to patients undergoing minor hand surgery (i.e., carpal tunnel release, trigger finger release, or de Quervain release) from 2010 to 2015. A predictive probability model was created to estimate patient risk status. The authors examined the relationship between patient risk status and anesthesia use using multivariable regression models. Of 441,579 eligible procedures, 352,779 (80 percent) involved anesthesiologist-administered anesthesia services. The total proportion of estimated anesthesiologist-administered anesthesia use in low-risk patients who did not need anesthesiologist support declined over the study period (from 69.7 percent in 2010 to 65.8 percent in 2015). Although total payments for these services remained steady between 2010 and 2014, the average payment per procedure increased regardless of procedure type (from $376.8 in 2010 to $427.9 in 2015 for a carpal tunnel release operation). Approximately 83.7 percent of payments ($133 million) to anesthesia providers is credited to services in low-risk patients. Anesthesiologist-administered anesthesia services are commonly rendered to low-risk surgical patients. Existing health care reform efforts do not adequately address discretionary services that can be a targeted area for cost saving. It is important to consider the implications of potentially discretionary use of specialized anesthesia providers, particularly with the advancement of bundled payment models.

Utilization and Associated Spending for Anesthesia Services During Ambulatory Hand Surgery

There is no financial information to disclose. We aimed to (1) describe trends of anesthesiologist-administered anesthesia services (AAS) for three common, minor hand operations, (2) investigate demographic factors associated with AAS services in low-risk patients, and (3) estimate supplementary costs incurred for potentially discretionary anesthesia administration. We hypothesized that despite the threat of bundled payment, a substantial percentage of minor procedures still employed potentially discretionary anesthesiologist-administered anesthesia services (use of a specialized anesthesia provider in patients lacking medical necessity), marking increased healthcare costs and decreased take home income for surgeons and the practice. We performed a retrospective analysis using the Truven MarketScan database to estimate the prevalence and cost of AAS in patients who underwent carpal tunnel release, trigger finger release, or de Quervain release between January 1, 2010 and September 31, 2015. Medical necessity for anesthetic service was characterized according to the American Society of Anesthesiologists physical status classifications. Three unique predictive probability models were created to estimate an individual’s risk status for each procedure. We used the chi-squared test to determine significance between categorical variables (age, sex, region, and insurance type) and outcomes. We examined the relationship between patient risk-status and anesthesia use using multivariable regression models. Of 441,579 eligible procedures, 352,779 (80%) involved anesthesiologist-administered anesthesia services. The total proportion of estimated anesthesiologist-administered anesthesia use in low-risk patients who do not require anesthesiologist support declined over the study period (69.7% in 2010 to 65.8% in 2015; Fig. 30-1). Being female and a younger age (18-34) was significantly correlated with potentially discretionary anesthesiologist-administered anesthesia service utilization (P < 0.001). Although total payments for anesthesiologist-administered anesthesia services remained steady between 2010 and 2014, the average payment per procedure increased regardless of procedure type (from $376.8 in 2010 to $427.9 in 2015 for a carpal tunnel release operation). Approximately $133 million (83.7%) of the total payment to anesthesia providers is credited to services in low-risk patients (Table 30-1). •Although prevalence rates decreased over the study period, more than two-thirds of patients receiving AAS lacked medical necessity for a specialized anesthesia provider.•A substantial amount of healthcare expenditure in hand surgery is attributed to potentially discretionary anesthesia service use.•Given the persistence of anesthesia services that ignore the advancement of viable, cost-saving alternatives, health reforms efforts must consider the impact and value of every facet of care individually.Table 30-1Comparison of Payments for Anesthesiologist-administered Anesthesia Service Utilization during Minor Hand Surgery Procedures, 2010-2015*201020112012201320142015TotalCarpal Tunnel ReleaseTotal payment for AAS (in million dollars)20.421.725.219.418.79.0114.6Proportion of payment associated with potentially discretionary AAS, %85.7%84%83.4%84.5%81%82.4%83.6%Average payment for AAS per procedure (dollars)376.8368.9380.1387386.5427.9382.8Trigger Finger ReleaseTotal payment for AAS (in million dollars)5.76.27.46.25.93.034.2Proportion of payment associated with potentially discretionary AAS, %85.1%83.5%83.4%84.1%80.8%82.1%83.3%Average payment for AAS per procedure (dollars)287.9282.6290.9291.7289.7316.3290.8De Quervain ReleaseTotal payment for AAS (in million dollars)1.61.72.21.71.70.89.7Proportion of payment associated with potentially discretionary AAS, %87.7%86.2%86.9%85.3%85%84.3%86.1%Average payment for AAS per procedure (dollars)380.8375.3394.6401.5386.1430.9391.3*All prices adjusted to the 2015-dollar value using the consumer price index.Source: 2010-2015 Truven Health MarketScan Research DatabaseAAS, anesthesiologist-administered anesthesia services Open table in a new tab *All prices adjusted to the 2015-dollar value using the consumer price index. Source: 2010-2015 Truven Health MarketScan Research Database AAS, anesthesiologist-administered anesthesia services

Elevated cerebrospinal fluid protein in diabetic lumbosacral radiculoplexus neuropathy

An 86-year-old ex-sailor with Type 2 diabetes was admitted in September 2010, with a 3-year history of weakness and pain in his legs, ataxia, recurrent falls, significant difficulties in walking and getting up, intermittent paraesthesia in his feet with strong jerks in the lower limbs and unintentional weight loss of 4 stones over the last few years. He was an ex-smoker and had previous history of chronic pancreatitis, Stage 3 chronic kidney disease, right shoulder pain with impingement syndrome, bilateral Dupuytren's contracture, right carpal tunnel release operation, bilateral cataracts surgery and early dry macular degeneration. He underwent left hemicolectomy for Dukes’ B adenocarcinoma of the splenic flexure with no distal metastases. His medication included Metformin and Creon. Three years earlier, he was investigated in the neurology clinic, with similar complaints of falls and ataxia. He had stopped drinking excessive amounts of alcohol by 2006. Previous investigations revealed normal or negative results including haematinics, erythrocyte sedimentation rate, autoantibody screening, antineutrophilic cytoplasmic antigen (ANCA: c and p), serum immunoglobulins, paraneoplastic antibodies (negative for HU, YO, RI, MA, TA and TR), blood and cerebrospinal fluid (CSF) treponemal antibodies, HIV 1 and 2 antibodies, coeliac disease screening, rheumatoid factor, complement and prostatic specific antigen. CSF showed normal cytology, glucose and no oligoclonal bands were detected; CSF protein was high at 2.84 g/l while CSF serology for Lyme disease was negative. Previous Computerized tomogram (CT) of abdomen and pelvis was consistent with calcified chronic pancreatitis. Previous nerve conduction study/Electromyography (NCS/EMG) showed axonal sensory and motor generalized neuropathy; repeat study in 2008 showing extensive polyradiculoneuropathy, with prolonged F wave latences in the upper limbs, some degree of demyelination in the nerve roots but no electrophysiological evidence of distal demyelination at this stage. He was initially treated in 2007–08 with diazepam, baclofen and clonazepam as an inpatient for …

An Assessment of Symptomatic Relief after Carpal Tunnel Release in Patients on Haemodialysis

Patients receiving haemodialysis for chronic kidney disease are at risk of developing β₂-microglobulin-related carpal tunnel syndrome (CTS). There is a lack of evidence regarding outcome of this complication following surgical treatment. The current study specifically addressed the relief of symptoms after carpal tunnel release in this particular group of patients. Materials and Method: 26 carpal tunnel release operations were performed in 19 patients (12 males, 7 females) between 1992 and 1996. The mean age of the patients was 59 years (range 41–78) with a mean duration of haemodialysis of 12.6 years. Patients were dialysed the day before surgery with low-dose heparin. All procedures were performed using 1% Xylocaine with adrenaline 1:200,000 without tourniquet as day cases. Relief of weakness of the hand, tingling, pain at rest, pain on use, nocturnal paraesthesiae and scar pain were assessed. Results: All outcome measures showed marked improvement and 84% (16/19) of patients were satisfied with the outcome. One patient showed worsening of pain at rest and pain on use of hand. Conclusion: Release of carpal tunnel in patients on haemodialysis helps alleviation of symptoms due to median nerve compression and improves the function of hand and quality of life in the majority of patients. There can still be a small minority of patients who may not show any improvement and a few may rarely get worse.

Superficial palmar communications between the ulnar and median nerves in Turkish cadavers

The superficial palmar communicating branch between the ulnar and median nerves, the ramus communicans (RC), has been investigated by anatomical dissections in 30 hands of 15 cadavers in the Turkish population. A communicating branch between the ulnar and median nerves was found in 18 hands (60%). It was classified into 4 types: Type 1-RC emerging from the ulnar 4th common digital nerve (CDN) and uniting with the median 3rd CDN, Type 2-RC emerging from the median 3rd CDN and uniting with the ulnar 4th CDN, Type 3-RC extending horizontally between the 3rd and 4th CDN, Type 4-a plexiform RC formed by multiple twigs. Twelve hands (40%) showed the Type 1 arrangement, one was Type 2 (3.3%), two were Type 3 (6.7%) and three (10%) were Type 4, based on the classification devised by Meals and Shaner ([1983] J Hand Surg Am 8:411-414) and modified by Bas and Kleinert ([1999] J Hand Surg Am 24:1171-1184). Knowledge of the anatomical characteristics of this branch is important for surgical interventions, especially in carpal tunnel release operations.

Distal forearm regional block anesthesia for carpal tunnel release

A technique of nerve block in the distal forearm is described for use in carpal tunnel release operations. In 70 operations, the extremities of 52 patients have been successfully anesthetized in this manner without complication. This simple anesthetic technique is recommended for use by the hand surgeon.

Endoscopic carpal tunnel release

We have performed 149 consecutive one-portal and 152 consecutive two-portal endoscopic carpal tunnel release operations. Average time to cessation of preoperative symptoms was 15 days in both the one-portal and two-portal groups. The average time of return to work was 16 days in the one-portal group and 17 days in the two-portal group. The complication rate in the one-portal group was 6%, and in the two-portal group it was 5%. In our opinion, the one-portal release technique is much more difficult and inherently more dangerous than the two-portal technique, and we recommend the latter for endoscopic carpal tunnel release.

Carpal tunnel syndrome in children with mucopolysaccharidoses: needs for surgical tendons and median nerve release.

This report analyzes the clinical and electrophysiological results of the carpal tunnel release operation in mentally retarded children with mucopolysaccharidoses and discusses the needs for early surgical intervention.

Peripheral Nerve Involvement in Hunter Syndrome (Mucopolysaccharidosis II)

A 20-year-old man with confirmed Hunter syndrome had entrapments of median and ulnar nerves. Sural nerve biopsy specimen revealed clear, lamellated, and granular inclusions in Schwann cells, fibroblasts, and perineurial cells. The clear inclusions are believed to represent storage of mucopolysaccharide, and the zebra bodies, ganglioside. Focal alterations in myelin were found, associated with moderately dense granular inclusions. Following carpal tunnel release operations, the patient experienced dramatic releif of symptoms.