Ligament In Carpal Tunnel Syndrome Research Articles

Endoscopic Release Superficial Rather Than Deep to the Transverse Carpal Ligament for Carpal Tunnel Syndrome Improves Immediate Postoperative Transient Symptomatic Exacerbation With Fewer Absences From Work

To determine the endoscopic release superficially rather than deep to the transverse carpal ligament to reduce the incidence of transient symptomatic exacerbation and postoperative absence from work in patients with carpal tunnel syndrome. From January 2012 to January 2018, patients with idiopathic carpal tunnel syndrome who underwent one-portal endoscopic release superficial to the transverse carpal ligament (ERSTCL) were analyzed. For comparison, a cohort treated with the conventional Chow endoscopic release between February 2008 and October 2013 were included. Transient worsening of symptoms, discrimination sensation, and days off work were assessed. The minimal clinically important difference was calculated for discrimination sensation. Severity of symptom and functional status also were assessed using the Levine-Katz Questionnaire. Significance was set at P < .05. There was a significant difference between the ERSTCL group and the control group regarding the incidence of symptomatic exacerbation 1 week after surgery (2% vs 9%; P= .003) but no difference in other time intervals within the initial 3 months. There was a significant difference in 2-point discrimination 1 week (mean change= -0.13, 95% confidence interval [CI] -0.30 to 0.04, P= .01) and 2 weeks after surgery (mean change= -0.18, 95% CI -0.36 to -0.01, P= .033). Postoperative 1 and 2 weeks, 28% and 35% patients in ERSTCL group achieved a minimal clinically important difference, respectively. Compared with control group, the difference in frequencies was statistically significant (28% vs 45%; P= .027; 35% vs 57%; P= .015). The difference between the 2 groups in postoperative absence from work was statistically significant (95% CI 1.083-4.724; P= .002), with an average reduction in sick leave of 3 days in ERSTCL group. At a mean follow-up of 3 years, no significant difference was found between the groups regarding symptom and function statuses. Endoscopic release superficial rather than deep to transverse carpal ligament for carpal tunnel syndrome improvesimmediate postoperative transient symptomatic exacerbation, which allows the patients to return to work earlier. Level III, retrospective comparative study.

Evaluation of the Transverse Carpal Ligament in Carpal Tunnel Syndrome by Shear Wave Elastography: A Non-Invasive Approach of Diagnosis and Management.

ObjectivesThe goal of this work is to determine the clinical value of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS) for guiding subsequent treatment.MethodsThis study analyzed patients who underwent median nerve (MN) ultrasound (US) examination of the wrist from April 2020 to April 2021. The cross-sectional area and anteroposterior diameter of the MN, as well as the TCL thickness and stiffness, were measured from images. The intra-group and intra-patient subgroup differences were compared using a t-test and a rank test. We also utilized receiver operating characteristic (ROC) curves to diagnose CTS and evaluate the severity.ResultsThe final cohort consisted of 120 wrists (bilateral) from 60 samples, evenly balanced across the patient and control groups according to their CTS diagnosis. In the unilateral positive patient subgroup, the MN and TCL of the positive hand were significantly thicker and stiffer than the negative counterparts (both, p < 0.05). The values from the right were also thicker and stiffer than the left (both, p < 0.05) in patients with bilateral CTS. The MN and TCL of the patient group were also significantly thicker and stiffer than those of the control group (both, p < 0.001). For diagnosing CTS, the area under the curve (AUC) of TCL thickness and stiffness at the distal carpal tunnel (DCT) ranged between 0.925 and 0.967. For evaluating CTS severity, we found that the optimal TCL stiffness is sufficient for diagnosing mild and non-mild patient cases (AUC: Emean = 0.757, Emax = 0.779).ConclusionsShear wave elastography is therefore an effective method for CTS diagnosis and management.

Limited mid palmar versus extended incision in surgical treatment of carpal tunnel syndrome: Clinical analysis

Background and objective: There are different methods and incisions to release the transverse carpal ligament in carpal tunnel syndrome. This study aimed to compare the surgical outcome of the conventional extended incision with the limited mid palmar one. Methods: The study was a prospective comparative one. Patients with carpal tunnel syndrome were divided into two groups: Group 1 was patients operated on by the conventional extended incision, Group 2 with a limited mid palmar incision. Results: The patients included were 79 with 89 hands. The age mean was 41 years. Group 1 included 47, and Group 2 included 42 hands. The differences between both groups were statistically significant regarding the operative data (the incision length and the operative time) and the post-operative data (the duration of analgesia needed, the date of starting to use the hand in daily life activities, and return to work). However, the date of improvement of the sensory symptoms from the fingers showed no significant differences. The sum of the overall complications that occurred for the cases of Group 2 was about a third of that occurred for Group 1. The highly significant difference was in the scar tenderness in the third month of the post-operative period. Conclusion: The limited mid palmar incision to release the entrapment of median nerve in carpal tunnel syndrome offers a shorter operative time, less analgesia needed post-operatively, less complication rate, less scar tenderness, earlier use of the hand in daily life activities, and return to work in a shorter period. Keywords: Carpal tunnel syndrome; Surgical treatment; Incision.

Ultrasound-guided percutaneous compartment release: a novel technique, proof of concept, and clinical relevance

ObjectiveUltrasound-guided thread release (USGTR) is a minimally invasive technique with excellent clinical outcomes currently used in clinical practice to divide the transverse carpal ligament in carpal tunnel syndrome. The purpose of this study is to determine whether this technique can be modified for use in large anatomical compartments in soft embalmed cadaveric models.Materials and methodsTwo operators adapted the USGTR technique for use in muscular compartments of the forearms and legs in a single soft embalmed cadaver. An iterative approach was used to adapt and improve the technique for use in large compartments, using equipment readily available in most radiology departments.ResultsThe USGTR technique was successfully modified and both operators were able to accurately divide fascial layers over distances of up to 30 cm using the modified technique. Fascial division was confirmed with ultrasound and dissection.ConclusionsThis adapted technique can successfully be used to divide fascial planes over longer distances than is currently achieved in clinical practice. The improved outcomes associated with USGTR at the carpal tunnel may therefore also be achievable in fasciotomy procedures in larger anatomical compartments. Further study is required to investigate the effects of this modified USGTR technique on intracompartmental pressure.

Influence of the thickness of the transverse carpal ligament in carpal tunnel syndrome

ObjectiveTo determine if the thickness of the transverse carpal ligament measured by T2 axial magnetic resonance imaging actually influences the onset of carpal tunnel syndrome. Material and method94 patients between January 2015 and June 2016, of whom 28 had carpal tunnel syndrome, underwent magnetic resonance imaging, 37 with discomfort in different carpus regions without symptoms of carpal tunnel and 29 healthy subjects. Two observers performed 3 measurements in 3 different levels, and in the 3 groups of patients. ResultsNo statistically significant differences in transverse carpal ligament thickness measurements between the carpal tunnel syndrome group and the group without carpal tunnel involvement became apparent, but statistical differences between the control group and the carpal tunnel syndrome group, and between the control group and the group without involvement of the carpal tunnel were observed. In both these groups, the thickness of the transverse ligament was higher than in the control group. DiscussionAn increase in the thickness of the transverse ligament in was found in this study in subjects with involvement of carpal tunnel syndrome as evidenced by numerous studies in the literature. There is no certain causative factor, but rather a set of facts that make onset of the syndrome possible in a specific group of patients. ConclusionCarpal tunnel syndrome is multifactorial. The thickness of the transverse ligament does not directly affect the onset of symptoms.

The effects of standardised cold and compression therapy on swelling, pain and functional outcome after division of the transverse carpal ligament in carpal tunnel syndrome

This prospective, randomised study examines the effect of standardised cold compression therapy on swelling, pain and functional outcome after division of the transverse carpal ligament in carpal tunnel syndrome in comparison to cooling alone. Fifty patients for division of the transverse carpal ligament were randomised into two groups. In group 1, postoperative conventional cooling therapy was performed. Group 2 was given standardised cooling and compression therapy with the Cryo/Cuff™-system (3 × 10 min twice daily). Follow-up examinations were performed on days 1, 8 and 21 after the operation. One patient in group 1 and 3 patients in group 2 could not be followed up. Test parameters were pain, swelling, mobility, strength, and the DASH and MHQ score. There were no significant differences between the two groups at any time point. In this study, no advantage could be demonstrated for standardised cooling and compression therapy with the Cryo/Cuff™-system in comparison with conventional cooling after division of the transverse carpal ligament.

Comparison of the Clinical Effectiveness of Ultrasound-Guided Corticosteroid Injection with and without Needle Release of the Transverse Carpal Ligament in Carpal Tunnel Syndrome

Background: To compare the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS). Methods: Between May 2014 and June 2016, 52 patients (56 wrists) with CTS were included in this study. Among these patients, 28 wrists were treated with ultrasound-guided corticosteroid injection plus needle release of the TCL (group A) and 28 wrists were treated with a single ultrasound-guided corticosteroids injection (group B). The following parameters were assessed and compared including postoperative results of procedure based on relief of symptoms, electrophysiological parameters (distal motor latency, sensory conduction velocity, and sensory nerve action potential of median nerve), and ultrasound parameters (anteroposterior diameter and cross-sectional area of the median nerve at the levels of pisiform and hamate bone, and the thicknesses of TCL on the cross-section at the level of hamate bone). Results: The overall excellent and good rate regarding the postoperative results of procedure based on the relief of symptoms at 1 month postoperatively was 82.1% in group A and 46.4% in group B (p = 0.004). There was significant difference in the above electrophysiological and ultrasound parameters between the preoperative and postoperative values in both groups (all p < 0.05). Furthermore, a significant difference was also observed in the postoperative values of the above-mentioned electrophysiological and ultrasound parameters in the 2 groups (all p < 0.05). Conclusions: Both approaches had treatment benefit in CTS. Ultrasound-guided corticosteroid injection in combination with needle release of the TCL is superior to the single ultrasound-guided corticosteroids injection.

Minimally invasive endoscopic decompression of the intermatatarsal nerve for Morton's neuroma

BackgroundWe presented case reports of endoscopic decompression for a Morton intermetatarsal neuroma. MethodsThree patients underwent surgery using an instrument designed to release the transverse carpal ligament for carpal tunnel syndrome. Each patient was 61, 56 and 24 years old. The mean follow up period was 1.5 years. ResultsAll patients experienced reduced pain postoperatively. The postoperative scar was very small (only 1 cm). There is no loss of sensation, no hematoma and no infection. ConclusionThis procedure is simple, and the postoperative morbidity for the patient is minimal. There is rapid recovery with minimal risk of complications that are associated with open techniques. Therefore endoscopic decompression for Morton neuroma offers many advantages and should be studied in a larger number of patients.

Comparison of thermal characteristics of degenerated and inflamed human collagen structures with differential scanning calorimetry

Collagen is the primary structural protein of the human body and the main component of connective tissue. In the form of elongated fibrils, collagen is mostly found in fibrous tissues such as tendon, ligament, and skin. We have already demonstrated that pathologic changes of human collagen structures could be monitored by differential scanning calorimetry (DSC), besides the classical histological methods. The aim of the study was to find whether there is a consistent increase or decrease of the thermal parameters, if we compare the changes of calorimetric enthalpy and denaturation temperature of (1) group: degenerative with (2) group: inflamed collagen structures. The degenerative samples were collected from ruptured Quadriceps, Achilles, patellar and anterior cruciate ligament, and degenerated joint capsule of the shoulder. The inflamed tissue samples were collected from palmar aponeurosis in Dupuytren disease, transverse carpal ligament in carpal tunnel syndrome (CTS), and transverse ligament of the first dorsal compartment in De Quervain disease. The thermal denaturation of human samples was monitored by a SETARAM Micro DSC-II calorimeter. All the experiments were performed between 0 and 100 °C. The heating rate was 0.3 K min−1. DSC scans clearly demonstrated significant differences between the two groups, proving that the thermal stability of the degenerative and inflamed pathologic collagens is significantly different. In cases of degenerative samples, the enthalpy decreased, while the melting temperature showed an increase. On the contrary, inflamed samples demonstrated a significant increase in the enthalpy and the melting temperature decreased. Our results indicate that DSC may be a clinically relevant method in the diagnosis of different collagen diseases.

Characteristics of the Electrophysiological Activity of Muscles Attached to the Transverse Carpal Ligament in Carpal Tunnel Syndrome

The main cause of carpal tunnel syndrome (CTS) remains unknown. Stiffness of the subcutaneous area of the volar aspect of the carpal tunnel is present in many patients and suggests that the stiffness of muscles attached to the transverse carpal ligament is increased. We performed an electrophysiological study to investigate muscle activities and to clarify whether the stiffness of muscles attached to the transverse carpal ligament is involved in the pathogenesis of CTS. The subjects of this study included 16 patients with early CTS showing no motor dysfunction. Both thenar muscles (opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis) and hypothenar muscles (opponens digiti minimi, abductor digiti minimi, flexor digiti minimi brevis) were investigated. Surface electrodes were placed on each muscle, and maximum voluntary contractions with the thumb and little finger in opposition were maintained for 3 seconds in all patients and in 7 control subjects. Electromyographs were subjected to fast Fourier transform analysis, and the root mean square (RMS) and the mean power frequency (MPF) were determined for each muscle. The RMS of the opponens pollicis was significantly less in hands affected by CTS (292.8 µV) than in healthy hands (405.9 µV). The RMS did not differ between affected hands and healthy hands for the other 2 thenar muscles but did differ significantly for the hypothenar muscles. The MPF did not differ between affected hands and healthy hands for any muscle. The results show that electrophysiological differences are present among muscles innervated by the median nerve and that hypothenar muscles originally unrelated to median nerve dysfunction are also affected in early CTS. These results suggest that modulation of muscles attached to the transverse carpal ligament is involved in the pathogenesis of CTS.

Low-level Laser Treatment Relieves Pain and Neurological Symptoms in Patients with Carpal Tunnel Syndrome

[Purpose] This placebo-controlled study investigated the therapeutic effects of low-level laser treatment (LLLT) on the transverse carpal ligament in carpal tunnel syndrome (CTS). [Subjects and Methods] Idiopathic CTS patients were recruited and were randomly assigned to two groups. The laser group (n = 45) received laser treatment (10 Hz, 60 mW, 9.7 J/cm2, 830 nm), and the placebo group (n = 42) received sham laser treatment. The visual analog scale (VAS), Boston Questionnaire scale, neurological symptoms and nerve conduction study (NCS) were conducted before, immediately after and 5 weeks after the treatment. [Results] After LLLT, there was statistically significant decrease in VAS in the laser group (p<0.05). Especially, the effect of LLLT on pain alleviation in the mild CTS group continued after five weeks. Regarding the Boston Questionnaire scale neurological symptoms and NCS, only mild CTS patients in the laser group showed statistically significant improvements after treatment (p<0.05). [Conclusions] LLLT with 830 nm diode lasers on the transverse carpal ligament had verifiable therapeutic effects for mild CTS patients.

LONG-TERM FOLLOW-UP OF DUAL-PORTAL ENDOSCOPIC RELEASE OF THE TRANSVERSE LIGAMENT IN CARPAL TUNNEL SYNDROME

The long-term efficacy of dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome is still being debated. In this study, the authors present 94 endoscopic carpal tunnel surgery cases with long-term follow-up data. The study includes 72 patients aged 17 to 86 years (mean age, 53.4 years); bilateral surgery was performed in 22 of these patients. Seventy-two hands of female patients and 22 hands of male patients were included. All procedures were performed with a dual-portal set according to the Chow technique. All patients were examined 2 to 3 months after surgery. The long-term follow-up evaluation was based on telephone interviews 5 to 12 years (mean, 8.2 years) after surgery. From a cohort of 214 cases that were treated surgically between 1995 and 2002, 94 cases (44%) could be evaluated for long-term follow-up. Four of these patients had to be excluded from long-term follow-up because of a switch to an open technique and early open revision (3-6 months after the first surgery), owing to persistent symptoms. A good to optimal postoperative outcome with improvement of neurological signs and subjective patient satisfaction was observed in 84 (93.3%) of the remaining 90 cases. There were no recurrences. The study shows that dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome is a valuable technique that produces very good long-term results and high patient satisfaction and does not result in a significant recurrence rate.

Anatomic variations of the median nerve in carpal tunnel release

Carpal tunnel syndrome (CTS) is a well-known clinical entity. Release of the transverse carpal ligament is considered to be the treatment of choice. Both open and endoscopic release of the transverse carpal ligament in CTS has yielded satisfactory results. Although these procedures are very common in surgical practice, inadequate release and intraoperative damage to neural elements are very frustrating complication for both the patient and the surgeon. The purpose of this study was to demonstrate incidental intraoperative findings of variations of the standard median nerve anatomy. We obtained incidental intraoperative identification of median nerve variations in 110 consecutive patients operated with open release of the transverse carpal ligament in CTS. Using the Amadio classification, we found intraoperatively variations of median nerve at the wrist in 11 patients. In three patients, there was an aberrant sensory branch arising from the ulnar side of the median nerve and piercing the ulnar margin of the transverse carpal ligament. Neural variations arising from the ulnar aspect of the median nerve were common and could be a cause of iatrogenic injury during endoscopic or open release. Surgeons should be aware of anomalous branches, which should be recognized and separately decompressed if needed.

Minimally Invasive Morton's Intermetatarsal Neuroma Decompression

We present the results of an alternative technique for decompression of a Morton intermetatarsal neuroma that is minimally invasive and does not require endoscopic instrumentation. Seventeen nerve decompressions were performed in 14 patients using an instrument designed to release the transverse carpal ligament for carpal tunnel syndrome. Nine women and five men (3 bilateral) had the procedure performed. The mean followup for the 17 decompression procedures was 25.92 months. Eleven of the 14 patients had absence of the neuroma symptoms after the decompression. Two patients had recurrence of symptoms; the third had sustained a crush injury to the operated foot. Both patients with recurrence required revision surgery because the initial procedure failed to relieve symptoms. One patient noted lack of relief in the immediate postoperative period (2 weeks), the other was symptom free for approximately 1 year. Only one of these individuals responded to resection of the intermetatarsal nerve, while the other continues to have pain. There were no wound healing complications or complications related to digital deformity after the procedure. The technique is simple, the postoperative morbidity to the patient is minimal, and the results in this limited number of patients was encouraging.

Dual-portal Endoscopic Release of the Transverse Ligament in Carpal Tunnel Syndrome: Results of 411 Procedures with Special Reference to Technique, Efficacy, and Complications

Endoscopic release of carpal tunnel syndrome is still under debate. The main advantages of the technique are considered to be minor postoperative pain and a more rapid postoperative recovery. Disadvantages are thought to be the impossibility of a direct median nerve neurolysis and a higher surgical complication rate, including injury to the median nerve. The results of 411 consecutive endoscopic carpal tunnel procedures performed between March 1995 and September 2004 are presented. All patients were prospectively followed. In the present series, a success rate of 98.05% was observed. There was no permanent morbidity and, in particular, there was no injury of the median nerve. In four (0.97%) patients, the preoperative symptoms did not improve. In two (0.49%) of these patients, an incomplete release of the carpal ligament occurred. In another four patients (0.97%), a switch to open surgery was required. The present data prove that the endoscopic technique is a safe and reliable technique for carpal tunnel surgery. The data do not support the current discussion of a higher risk of median nerve injury with endoscopic carpal tunnel surgery. Thus, for our group, the endoscopic technique represents the therapy of choice for the primary idiopathic carpal tunnel syndrome.

Endoscopic Release of the Carpal Ligament for Carpal Tunnel Syndrome: Long-term Results Using the Chow Technique

Summary: 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. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 4 (May-June), 1999: pp 417–421

The chow technique of endoscopic release of the carpal ligament for carpal tunnel syndrome: Four years of clinical results

This article represents a review of the clinical results of 650 consecutive cases of carpal tunnel decompression in 456 patients from the first 4 years of endoscopic carpal tunnel release: 38% returned to normal activities within 1 week, 59% within 2 weeks, 73% within 3 weeks, and 84% within 4 weeks. A total of 98% returned to their normal activities. Also included is an analysis of the workmen's compensation and pinch-and-grip studies. The results of these studies appear to indicate that endoscopic release of the carpal ligament accomplishes results similar to the standard procedure with a more rapid recovery.

Endooscopic release of transverse carpal ligament for carpal tunnel syndrome

Endooscopic release of transverse carpal ligament for carpal tunnel syndrome

Endoscopic release of the carpal ligament for carpal tunnel syndrome: 22-month clinical result

This article represents a review of 149 carpal tunnel decompressions on 109 carpal tunnel syndrome patients, and a 22-month clinical result on endoscopic carpal ligament release. The symptoms were relieved and no permanent nerve damage, vascular complications, hematomas, infections, or recurrences were reported. Postoperatively, one patient had a temporary loss of the interosseous muscle but recovered spontaneously in 4 weeks. In this 22-month survey, 28.9% of the patients were able to return to normal activities and work within 1 week, 58.5% returned within 2 weeks, 75.4% returned within 3 weeks, and 85.9% returned within 4 weeks. A pinch-and-grip study was performed; 32% regained normal pinch-and-grip strength within 1 week, 74% regained it in 2 weeks, 93% regained it in 3 weeks, and 100% regained it in 4 weeks. Based on our results, there has been rapid recovery, less scarring, decreased postoperative pain, and no loss of pinch-and-grip strength.