Standard Open Carpal Tunnel Release Research Articles

Pillar Pain After Minimally Invasive and Standard Open Carpal Tunnel Release: A Systematic Review and Meta-analysis

Pillar Pain After Minimally Invasive and Standard Open Carpal Tunnel Release: A Systematic Review and Meta-analysis

The safety and accuracy of various carpal tunnel injection techniques.

Carpal tunnel (CT) syndrome continues to be a commonly treated hand pathology. We aimed to evaluate several CT injection techniques for (1) spatial accuracy within the CT and (2) risk of median nerve (MN) injury. Our purpose was to evaluate for any significant differences in accuracy of needle placement within the carpal tunnel and final distance between the needle tip and the MN with each technique. Fifteen fresh frozen cadaveric arms were used for this study. Six different injection techniques for CT injection were performed on each specimen, including palmaris longus, ulnar to flexor carpi radialis, trans-flexor carpi radialis, volar radial, volar ulnar, and direct through the palm techniques. After needle placement, a standard open CT release was performed to assess for accuracy of placement within the CT and measure needle position in relation to the MN and other anatomic structures. Accurate intra-CT needle placement was seen in 91% of injections. While there was no significant difference between injection techniques for distance to nearest tendon (p = 0.1531), the trans-flexor carpi radialis (tFCR), volar radial (VR), and volar ulnar (VU) techniques consistently provided the greatest intra-CT distance from needle tip to median nerve (p = 0.0019). The least incidence of intraneural needle placement was found with the tFCR and VR approaches. All six injection techniques reliably enter the CT space. The lowest risk to the MN was found with tFCR and VR techniques, and we recommend these techniques for safe and effective needle placement to avoid iatrogenic intraneural injection. Level V: Cadaveric Study.

Minimal Invasive Surgery by Wongsiri Technique versus Standard Open Carpal Tunnel Release: A Randomized Trial

Objective: To study the results of carpal tunnel release in patients with carpal tunnel syndrome with Minimal invasive surgery by Wongsiri technique compared to the standard open technique. Materials and Methods: Randomized trial in patients who released carpal tunnel into two groups with 20 patients each. The study group underwent minimally invasive surgery using the Wongsiri technique while the other group had the standard open surgery. Postoperative results at one month were compared for time to return to work, residual numbness, wound satisfaction, and complication such as hand stiffness, pillar pain, painful scar, and infection. Results: There were no statistically significant difference between the two groups of patients in gender, age, occupation, and duration of preoperative symptoms. The results one month after surgery showed that patients in the minimally invasive surgery group returned to work faster than the standard open surgery at 7.32±1.85 and 17.45±5.45 days, respectively (p<0.001). There was no difference in residual numbness at 1.80±0.57 and 1.69±0.49 (p=0.170). Patients in the minimally invasive surgery group were more satisfied with the wound cosmetic at 4.78±0.50 and 3.90±0.32 (p<0.001). Hand stiffness was found less in patients with minimally invasive surgery at 1 and 5 (p<0.001). There was no difference in pillar pain, with one and two cases (p=0.556). There was no painful scar, or infection. Conclusion: Minimally invasive carpal tunnel released by the Wongsiri technique is a surgical method that reduces hand stiffness. The patients returned to work quicker and were more satisfied with the wound cosmetic. Keywords: Carpal tunnel syndrome; Standard open carpal tunnel release; Minimally invasive carpal tunnel released; Wongsiri technique

Splinting after Carpal Tunnel Surgical Treatment: Does It Really Matter?

Background: Splinting of the wrist after carpal tunnel release (CTR) has been practiced by many surgeons especially in North America. The main reason wasto prevent possible adverse events of bowstringing of flexor tendons and the median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect of splinting after standard CTR had dismal results. The duration of splinting in standard CTR has been either too long (for 2-4 weeks) or too short (48 hours only). Objective: The aim of our study was to compare the effects of post-operative splinting for duration of one week with no splinting. Patients and Methods: All 20 of our patients underwent a standardized open CTR. Post operatively, they were randomized into a splinted (n=10) and a non-splinted (n=10) group. The splint was kept for 2 weeks. Patients were reviewed at regular intervals of one week, two weeks and three months. At each follow up, these patients were clinically assessed for outcome of the Boston questionnaire. Results: All patients presented with significant improvement in the post-operative evaluation within each group. However, there was no significant difference between the two groups for any of the outcome measurements at sequential and at final follow-up. Conclusion: We concluded that wrist splinting in the immediate post-operative period has no advantage when compared with the non-splinting wrist after a standard open carpal tunnel release.

Splinting after Carpal Tunnel Surgical Treatment: Does It Really Matter?

Background: Splinting of the wrist after carpal tunnel release (CTR) has been practiced by many surgeons especially in North America. The main reason wasto prevent possible adverse events of bowstringing of flexor tendons and the median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect of splinting after standard CTR had dismal results. The duration of splinting in standard CTR has been either too long (for 2-4 weeks) or too short (48 hours only). Objective: The aim of our study was to compare the effects of post-operative splinting for duration of one week with no splinting. Patients and Methods: All 20 of our patients underwent a standardized open CTR. Post operatively, they were randomized into a splinted (n=10) and a non-splinted (n=10) group. The splint was kept for 2 weeks. Patients were reviewed at regular intervals of one week, two weeks and three months. At each follow up, these patients were clinically assessed for outcome of the Boston questionnaire. Results: All patients presented with significant improvement in the post-operative evaluation within each group. However, there was no significant difference between the two groups for any of the outcome measurements at sequential and at final follow-up. Conclusion: We concluded that wrist splinting in the immediate post-operative period has no advantage when compared with the non-splinting wrist after a standard open carpal tunnel release.

Endoscopic release for carpal tunnel syndrome

Endoscopic release for carpal tunnel syndrome

Outcome of Carpal Tunnel Release: a prospective study

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy and is manifested by characteristic signs and symptoms resulting from median nerve compression at the carpal tunnel. The diagnosis is essentially clinical, which is further confirmed by nerve conduction studies. Surgical release of the transverse carpal ligament is advised when conservative treatment fails. METHODS: This prospective study evaluates the outcome of standard open carpal tunnel release performed at our center* from June 2004 to July 2007. Thirty two patients with idiopathic carpal tunnel syndrome, with failed conservative treatments, either with NSAIDs and/or local infiltration with corticosteroid injections plus night splint, or recurrence after conservative treatment were subjected to open carpal tunnel release after getting approval from the local ethical committee and getting a written and informed consent from the patient. Clinical assessment was done preoperatively and at 6 weeks, 3 months and 6 months following the procedure and included the two-point discrimination test at the tip of the index finger and Boston questionnaires as an outcome measurement of symptoms severity. All the patients were followed up for a period of six months. RESULTS: All the patients presented improvement in the postoperative evaluations in all the analyzed parameters. CONCLUSION: Open carpal tunnel release is a safe and effective method for the treatment of CTS and can be carried out when the conservative means fail to relieve the symptoms. DOI: http://dx.doi.org/10.3126/noaj.v1i1.8129 Nepal Orthopaedic Association Journal Vol.1(1) 2010

Should aspirin be stopped before carpal tunnel surgery? A prospective study

To determine whether patients taking aspirin during carpal tunnel release had an increase of complications. Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release (CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant per- or post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d (before resuming aspirin in group 2) and 14 d (after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery. There was no significant difference in the incidence of complications in the three groups. A total of 3 complications (2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1 (non stop aspirin) and in group 3 (never antiaggregated). The minor complication, observed in one patient of group 2 (stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma (score > 20 cm(2)) was observed in 8 patients. A minor haematoma (score < 20 cm(2)) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy. Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.

Flexor retinaculum division: does it contribute to the success of carpal tunnel release?

Yuval Krieger, Avia Moses, Eldad Silberstein, Shimon Weitzman, Naftali Liberman, Amiram Sagi Aims: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Open decompression of the median nerve is considered the standard surgical treatment for CTS. This article describes a study to assess and compare the clinical efficacy of operative treatment performed by transverse carpal ligament release alone (limited carpel tunnel release (CTR)), to that achieved after transverse carpal ligament release with additional division of the proximal portion of the flexor retinaculum (extended CTR) which is continuous with the deep investing fascia of the forearm. Methods: A retrospective cohort study was performed by telephone interview, using a modified Levine scale to assess symptoms and functional impairment 4–7 years post-operatively in two patient groups who were operated using two different techniques, over a two year period. One group (N = 73) had open CTR by limited transverse carpal ligament division alone, performed by one hand surgeon; the second group (N = 83) had open CTR by division of the transverse carpal ligament and the proximal portion of the flexor retinaculum, performed by another hand surgeon. Findings: Pre-operatively the two groups were similar, both in terms of patient characteristics and of disease severity. Both groups improved significantly. No clinical difference was demonstrated in terms of symptom relief, recurrence or complication rate. Conclusions: This study suggests that adjunctive division of the proximal portion of the flexor retinaculum, although safe, offers no advantage over division of the transverse carpal ligament alone in standard open carpal tunnel release.

Surgical treatment options for carpal tunnel syndrome

Carpal tunnel syndrome is a common disorder for which several surgical treatment options are available. To compare the efficacy of the various surgical techniques in relieving symptoms and promoting return to work or activities of daily living and to compare the occurrence of side-effects and complications in patients suffering from carpal tunnel syndrome. We updated the searches in 2006. We conducted computer-aided searches of the Cochrane Neuromuscular Disease Group Trials Register (searched in June 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (January 1966 to June 2006), EMBASE (January 1980 to June 2006) and also tracked references in bibliographies. Randomised controlled trials comparing various surgical techniques for the treatment of carpal tunnel syndrome. Two review authors performed study selection, assessment of methodological quality and data extraction independently of each other. Thirty-three studies were included in the review of which 10 were newly identified in this update. The methodological quality of the trials ranged from fair to good; however, the use of allocation concealment was mentioned explicitly in only seven trials. Many studies failed to present the results in sufficient detail to enable statistical pooling. Pooling was also impeded by the vast variety of outcome measures that were applied in the various studies. None of the existing alternatives to standard open carpal tunnel release offered significantly better relief from symptoms in the short- or long-term. In three studies with a total of 294 participants, endoscopic carpal tunnel release resulted in earlier return to work or activities of daily living than open carpal tunnel release, with a weighted mean difference of -6 days (95% CI -9 to -3 days). There is no strong evidence supporting the need for replacement of standard open carpal tunnel release by existing alternative surgical procedures for the treatment of carpal tunnel syndrome. The decision to apply endoscopic carpal tunnel release instead of open carpal tunnel release seems to be guided by the surgeon's and patient's preferences.

Treatment of carpal tunnel syndrome by low-level laser versus open carpal tunnel release

Carpal tunnel syndrome (CTS) is an entrapment neuropathy of the median nerve at the wrist. It is one of the most common peripheral nerve disorders. The cause of idiopathic CTS remains unclear. The diagnosis of CTS is still mainly clinical. Open carpal tunnel release is the standard treatment. The present study was conducted to evaluate the effectiveness of low level laser treatment (LLLT) for CTS in comparison to the standard open carpal tunnel release surgery. Out of 54 patients, 60 symptomatic hands complaining of CTS were divided into two equal groups. Group A, was subjected to LLLT by Helium Neon (He-Ne) laser (632.8 nm), whereas group B was treated by the open approach for carpal tunnel release. The patients were evaluated clinically and by nerve conduction studies (NCSs) about 6 months after the treatment. LLLT showed overall significant results but at a lower level in relation to surgery. LLLT showed significant outcomes in all parameters of subjective complaints (p < or = 0.01) except for muscle weakness. Moreover, LLLT showed significant results in all parameters of objective findings (p < or = 0.01) except for thenar atrophy. However, NCSs expressed the same statistical significance (p < or = 0.01) after the treatment by both modalities. LLLT has proven to be an effective and noninvasive treatment modality for CTS especially for early and mild-to-moderate cases when pain is the main presenting symptom. However, surgery could be preserved for advanced and chronic cases. Refinement of laser tools and introduction of other wavelengths could make LLLT for CTS treatment a field for further investigations.

Endoscopic Carpal Tunnel Release: A Review of 753 Cases in 486 Patients

Endoscopic carpal tunnel release is gaining increasing acceptance relative to the standard open carpal tunnel release for the treatment of carpal tunnel syndrome. Concerns about endoscopic carpal tunnel release include effectiveness of therapy and complication rates. This study attempted to evaluate outcomes of endoscopic carpal tunnel release in a large patient cohort. Four hundred eighty-six patients (753 hands) with carpal tunnel syndrome who underwent endoscopic carpal tunnel release by a single surgeon were reviewed retrospectively. Data included demographics, subjective complaints, prior interventions, preoperative examination findings, and postoperative follow-up. All follow-up data were obtained from a single, independent, occupational therapy clinic. Median patient age was 48 years. Three hundred seventy-seven patients were gainfully employed at presentation, and 206 filed a worker's compensation claim. Median symptom duration was 2 years. Nonoperative therapy was ineffective in 151 patients. Preoperative nerve conduction studies were consistent with carpal tunnel syndrome in 472 patients (97 percent); all patients had either physical examination findings or nerve conduction studies consistent with carpal tunnel syndrome. Four hundred eighty-six patients (100 percent) obtained symptom relief. Complications included one transient median nerve neurapraxia, six complaints of residual pain, and one complaint of hypersensitivity. Worker's compensation patients and non-worker's compensation patients returned to work full-duty at similar times postoperatively. Ninety percent of employed patients returned to their original occupation. The authors' data indicate that an endoscopic approach for the treatment of carpal tunnel syndrome is safe and effective. Patients demonstrated a high return-to-work rate and an extremely low complication rate. The data challenge the belief that endoscopic carpal tunnel release results in higher complication rates.

Systematic review of randomized clinical trials of surgical treatment for carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is a common disorder for which several surgical treatment options are available. However, there is no consensus on the most effective method of treatment. The object of this systematic review is to compare the efficacy of the various surgical techniques in relieving the symptoms of CTS and promoting return to work and/or activities of daily living. Computer-aided searches of Medline, EMBASE and the Cochrane Controlled Trials Register were conducted, together with reference checking. A rating system, based on the number of studies and their methodological quality and findings, was used to determine the strength of the available evidence for the efficacy of the treatment. Fourteen studies were included in the review. None of the alternatives to standard open carpal tunnel release (OCTR) seems to offer better relief of symptoms. There is conflicting evidence about whether endoscopic carpal tunnel release results in earlier return to work and/or activities of daily living. Standard OCTR is still the preferred method of treatment for CTS. It is just as effective as the alternatives, but is technically less demanding, so incurs a lower risk of complications and of added costs.

Identification and preservation of palmar cutaneous nerves during open carpal tunnel release

We looked for crossing cutaneous nerve branches during standard open carpal tunnel release and attempted to preserve them. Open carpal tunnel release was performed on 34 hands in 29 patients. Crossing cutaneous nerves were identified in 47% of hands and successfully preserved in each case. No patient experienced postoperative pillar pain or scar hypersensitivity.

Endoscopic versus open carpal tunnel release: Clinical results

This article reviews the results of endoscopic carpal tunnel release surgery. Comparison with a matched population of patients undergoing standard open carpal tunnel release was performed with respect to safety and return to work times. The newer technique was found to be safe because no surgical complications were noted in the study group. Patients undergoing the endoscopic technique with private insurance returned to work 15.6 days sooner than their open counterparts. Patients with workers' compensation claims returned to work at the same time regardless of the technique used.