Two-portal Endoscopic Carpal Tunnel Release Research Articles

Carpal tunnel pressure measurement during two-portal endoscopic carpal tunnel release

Background Although there remain concerns of median nerve damage during endoscopic carpal tunnel release for carpal tunnel syndrome, carpal tunnel pressure variations during Chow's two-portal techinique have not been well investigated. Methods We performed a modified two-portal endoscopic carpal tunnel release on 30 patients by inserting a catheter pressure transducer into the carpal tunnel for continuous pressure measurement during the procedure. Grip and pinch strengths, Semmes–Weinstein monofilament test, and nerve conduction studies were examined preoperatively and at postoperative 1, 3, and 6 months. Numbness and the Disabilities of the Arm, Shoulder and Hand score were also evaluated pre and postoperatively. Findings Subjective symptoms and nerve conduction study findings improved uneventfully. The pressure was always observed to be maximum pressure immediately before the cannula was withdrawn from the exit portal, and carpal tunnel pressure > 300 mm Hg was recorded in most of the patients. Interpretation A transient increase in the carpal tunnel pressure occurred in all the patients; however, it did not correlate with their clinical outcome or with increased risk of peri-operative complications. Since time–pressure threshold of the median nerve during endoscopic carpal tunnel release is still unknown, our results did not guarantee its safety.

Pseudoaneurysm of Ulnar Artery after Endoscopic Carpal Tunnel Release

The authors present an extremely rare case of a pseudoaneurysm of the ulnar artery as a complication of a two-portal endoscopic carpal tunnel release (ECTR). A 70-year-old man with chronic renal failure and on maintenance hemodialysis with a left arteriovenous fistula presented with paresthesia of his right hand. A clinical diagnosis of right carpal tunnel syndrome was confirmed by ultrasonography and an electrophysiologic study. He underwent two-portal ECTR, and the paresthesia was much improved. However, he presented to us one month after operation with severe pain, a tender mass distal to the right wrist crease and more aggravation of the paresthesia in the ulnar nerve distribution. Doppler ultrasound was performed and revealed a hypoechoic lesion 20 mm in diameter in the right palm, with arterial Doppler flow inside connected to the palmar segment of the ulnar artery. An ulnar artery pseudoaneurysm was diagnosed and treated by ultrasound-guided percutaneous thrombin injection. Transverse color Doppler ultrasound image showed complete thrombosis of the pseudoaneurysm and flow cessation after a total injection of 500 units of thrombin. The symptoms were also improved.

INVESTIGATION OF SEGMENTAL CARPAL TUNNEL PRESSURE IN PATIENTS WITH IDIOPATHIC CARPAL TUNNEL SYNDROME — IS IT NECESSARY TO RELEASE THE DISTAL APONEUROTIC PORTION OF THE FLEXOR RETINACULUM IN ENDOSCOPIC CARPAL TUNNEL RELEASE SURGERY?

Segmental carpal tunnel pressure was measured in 12 hands of 11 idiopathic carpal tunnel syndrome patients before and after two-portal endoscopic carpal tunnel release. We aimed to determine at which part of the carpal tunnel the median nerve could be compressed, and to evaluate whether carpal tunnel pressure could be reduced sufficiently at all segments of the carpal tunnel after the surgery. Pressure measurements were performed using a pressure guide wire. The site with the highest pressure corresponded to the area around the hamate hook; the pressure in the area distal to the flexor retinaculum could be pathogenically high (more than 30 mmHg) before the surgery. The two-portal endoscopic carpal tunnel release achieved sufficient pressure reduction in all segments of the carpal tunnel when the flexor retinaculum and the fibrous structure between the flexor retinaculum and the palmar aponeurosis were completely released.

Endoscopic release for carpal tunnel syndrome accompanied by thenar muscle atrophy.

The objective of this study was to ascertain whether endoscopic carpal tunnel release (ECTR) is indicated for treatment of carpal tunnel syndrome accompanied by thenar muscle atrophy. Prospective cohort study. Two-portal ECTR was performed on 67 hands in 52 patients with carpal tunnel syndrome accompanied by thenar muscle atrophy. Preoperative severity of thenar muscle atrophy was severe in 24 hands, moderate in 23 hands, and mild in 20 hands. Postoperative severity of thenar muscle atrophy was severe in 6 hands, moderate in 2 hands, mild in 23 hands, and none in 36 hands. Improvements with thenar muscle function in most cases of carpal tunnel syndrome can be expected with 2-portal ECTR. Level IV.

Two-portal endoscopic carpal tunnel release: an outcome analysis of 333 hands.

Outcome data were collected on 239 patients who underwent endoscopic release of the transverse carpal ligament. The procedure was performed on 333 hands in 239 patients. All patients had failed to respond to nonoperative management for carpal tunnel syndrome and had confirmatory electrodiagnostic studies. Patients underwent follow-up evaluations at 21, 28, and 42 days. Numbness and paresthesias were relieved in 98% of the operated hands, and pain was relieved in 90% of the hands. A satisfactory result was achieved in 325 hands, which resulted in a 98% overall satisfaction rate. Eighty-eight percent of the patients required only two or less doses of oral analgesic during the postoperative period. Only 50 hands undergoing endoscopic release exhibited scar tenderness or pillar pain beyond 28 days. Excluding workers' compensation patients, 83% of the patients returned to work in less than 28 days (average, 14.6 days). No operative complications were encountered, although 1 patient experienced postoperative reflex sympathetic dystrophy, which responded to conservative outpatient treatment.

Two-portal endoscopic carpal tunnel release surgery: report of early experience.

Endoscopic carpal tunnel release is increasingly performed to treat median nerve entrapment neuropathy at the transverse carpal ligament. Proponents of these procedures claim that there are early postoperative advantages to be gained by the patient in the form of decreased pain and weakness, thus facilitating an earlier return to function. However, serious complications associated with the use of these techniques have been reported, especially during the surgeon's purported initial steep learning curve. A prospective analysis of the authors' first 51 cases using a two-portal endoscopic technique was conducted to determine whether these learning curve complications occurred. The authors did experience a learning curve; however, it was not significant. They encountered no serious complications and patient satisfaction was very high. It is concluded that the procedure is relatively easy to learn and safe to perform.

Endoscopic carpal tunnel release: Prospective assessment of 255 consecutive cases

A prospective study was conducted to evaluate the efficacy and safety of two-portal endoscopic carpal tunnel release. Two hundred and fifty-five consecutive hands (204 patients) were operated on by one surgeon using general or regional anaesthesia in the first 48 hands and local anaesthesia in the following 207 hands. The patients were evaluated preoperatively and 3 and 6 months postoperatively by an independent examiner. At the 6-month follow-up, 83% reported complete relief of symptoms and 89% were satisfied with the results of surgery. The median time until return to work was 17 days. Complications included five postoperative digital neurapraxias, all occurring under general or regional anaesthesia, and four open reoperations due to persistent symptoms. Two-portal endoscopic carpal tunnel release can be effective and safe and appears to shorten the time until return to work. The use of local anaesthesia might be important in avoiding neurological complications.

A prospective, randomized study with an independent observer comparing open carpal tunnel release with endoscopic carpal tunnel release

In order to define the role of two-portal endoscopic carpal tunnel release, a prospective randomised study with an independent observer was performed to compare endoscopic and open surgery. Thirty-two hands in 29 patients, with symptoms, clinical signs and EMG changes consistent with idiopathic carpal tunnel syndrome were randomised to either endoscopic carpal tunnel release or open release. No significant difference in sick leave between the two groups could be found, being a mean of 17 days (range 0-31 days) with endoscopic surgery, and 19 days (range 0-42 days) with open conventional surgery. No differences in surgical results were found, but three patients in the endoscopic group suffered transient numbness on the radial side of the ring finger.

Early results of conventional versus two-portal endoscopic carpal tunnel release: A prospective study

The authors compare in a prospective, randomized study the early outcome of carpal tunnel release using either a conventional palmar open release (n = 40) or a two-portal endoscopic release (n = 56). Both groups were similar. No statistically significant differences were found regarding pain, disappearing of paraesthesiae or time to return to work. However, better recovery of grip strength was observed in the endoscopic group at 1 and 3 months. No surgical complications were observed in either group.

Transection of the motor branch of the ulnar nerve as a complication of two-portal endoscopic carpal tunnel release: A case report

Transection of the motor branch of the ulnar nerve as a complication of two-portal endoscopic carpal tunnel release: A case report

Sensory disturbances after two-portal endoscopic carpal tunnel release: A preliminary report

Very few complications following endoscopic carpal tunnel release have been reported. We studied the incidence and pattern of sensory disturbances in 53 consecutive cases in which the Chow two-portal technique was used. Persistent sensory disturbances for 4 months or more were noted in six hands. Sensory tests were normal or near normal in all except one case. The disturbance was described by the patients as an uncomfortable tingling sensation or hyperesthesia, and in all cases the ring finger, especially the radial half, was involved. We wish to direct attention to this potential complication and suggest possible mechanisms behind it.

Ulnar nerve transection as a complication of two-portal endoscopic carpal tunnel release: A case report

Endoscopic release of the transverse carpal ligament for relief of median nerve compression neuropathy has recently been promoted as superior to traditional open surgical methods. A decreased incidence of scar tenderness, postoperative hand weakness, and pillar pain and an earlier return to work have been suggested. As a consequence of the limited surgical exposure inherent to endoscopic procedures, there has been concern regarding potential risks to neurovascular structures in the hand. We report a case involving complete transection of the ulnar nerve during two-portal endoscopic carpal tunnel release requiring sural nerve grafting for reconstruction.

Endoscopic carpal tunnel release: An anatomic study of the two-incision method in human cadavers

To determine the relationship of neurovascular structures to the sites of portal placement and transverse carpal ligament division during two-portal endoscopic carpal tunnel release, a study of 20 fresh cadaver specimens was carried out. Open dissection of the carpal tunnel after endoscopic surgery showed complete ligamentous release in 18 hands (90%). In 10 specimens, the procedure was performed as described by Chow. There was one partial transection of the superficial palmar arch (5%), and five specimens (50%) had complete divisions of the superficial palmar fascia with considerable pressure placed on the ulnar nerve at the wrist. A modified technique was used in 10 specimens in which the proximal incision was made in a more distal location and a distally based ligamentous flap was created. The superficial palmar arch and the distal edge of the transverse carpal ligament were visualized directly before passage of the trocar. No complications were noted with this method.

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.