Carpal Tunnel

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Treatment can be nonoperative or operative, and should be based on the following:
    • Nonoperative treatment
      • Night splints and injection of cortisone preparations
      • Five important factors in determining success:
        • Age over 50 years
        • Duration longer than 10 months
        • Constant paresthesia
        • Stenosing flexor tenosynovitis
        • Positive Phalen test result in less than 30 seconds.
      • Cure rate with medical therapy:
        • 0 factors: 66%
        • 1 factor: 60%
        • 2 factors: 20%
        • 3 factors: 10%
        • 4-5 factors: 0%
    • If symptoms are mild and there is no thenar muscle atrophy, medical therapy can be attempted
  • Operative management
    • If signs and symptoms are persistent and progressive, especially if they include thenar atrophy, operative management is indicated.
CONTRAINDICATIONS
  • No specific contraindications to open release
  • Contraindications for endoscopic surgery include:
    • Need for neurolysis, tenosynovectomy, Z-plasty of the transverse carpal ligament, or decompression of Guyon's canal
    • Space-occupying lesion or other severe abnormality of the muscles, tendons, or vessels in the carpal tunnel.
    • Infection or severe hand edema
    • Tenuous vascular status of the upper extremities
    • Revision surgery for unresolved or recurrent carpal tunnel syndrome
    • Significant anatomical variation in the median nerve
      • This is suggested by clinical findings of wasting in the abductor pollicis brevis muscle without significant median sensory changes.
    • Previous tendon surgery or flexor injury
      • This causes scarring in the carpal tunnel, preventing the safe placement of the instruments for endoscopic carpal tunnel release.
EQUIPMENT
  • Standard hand set
  • Open procedure
    • Blunt dissector, such as a McDonald dissector
  • Agee single-portal technique
    • MicroAire Carpal Tunnel Release System
      • Includes synovial elevator and several hamate finders
    • Ragnell right-angle retractors
    • Tenotomy scissors
  • Chow two-portal technique
    • ECTRA System
      • 4.0 mm × 30± endoscope
      • Slotted cannula
      • Rigid obturator
      • Curved blunt dissector
      • Self-retaining retractor
      • Hand holder
      • Probe
      • Palmar arch suppressor ("Chow catcher")
    • ECTRA Disposable Kit
      • Probe knife
      • Retrograde knife
      • Triangle knife
      • Hand pad
ANATOMY
  • Boundaries of carpal tunnel:
    • Dorsal: transverse arch of the carpal bones
    • Ventral: flexor retinaculum, with three components: deep forearm fascia (most proximal), transverse carpal ligament (TCL) (over the wrist) and distal aponeurosis between thenar and hypothenar muscles (most distal)
      • Flexor retinaculum attachments:
        • Medial: pisiform and hook of hamate
        • Lateral: scaphoid tubercle and trapezium at the beak and body
    • Medial (ulnar): hook of hamate, triquetrum, pisiform
    • Lateral: scaphoid, trapezium, fibroosseous flexor carpi radialis (FCR) sheath
  • Once through the carpal tunnel, the median nerve divides into:
    • Lateral digital branch
      • Enters the thenar eminence and supplies abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, and first lumbrical muscles
    • Medial digital branch
      • Divides into variable number of digital nerves; supplies second lumbrical muscle
  • Carpal tunnel pressures (mean):
    • Wrist in neutral position
      • 25 mm Hg, healthy
      • 32 mm Hg, CTS
    • 90 degrees of wrist flexion
      • 31 mm Hg, healthy
      • 99 mm Hg, CTS
    • 90 degrees of wrist extension
      • 30 mm Hg, healthy
      • 110 mm Hg, CTS

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Standard Open Approach
  • Post-Procedure: Endoscopic Release Through Single Incision (Agee Single-Portal Technique)
  • Post-Procedure: Endoscopic Release Through Two Incisions (Chow Two-Portal Extrabursal Technique)

Post-Procedure: Standard Open Approach

POST-PROCEDURE CARE
  • Post-procedure care is largely similar whether an open, single-port arthroscopy or double-port arthroscopy technique is used.
  • Postoperative splinting remains somewhat controversial.
    • A compression dressing and volar splint can be applied.
  • Active use of hand should occur as soon as possible after surgery.
    • Progression of light activities of daily living is allowed at about 2 to 3 weeks.
    • More strenuous activities are added in the next 4 to 6 weeks.
  • The sutures are removed after 10 to 14 days.
  • The splint is continued for comfort as needed for 14 to 21 days.
COMPLICATIONS
  • For open release, complications and failures are estimated to be between 3% and 19%:
    • Incomplete release of the transverse carpal ligament
    • Reformation of the flexor retinaculum
    • Scarring in the carpal tunnel
    • Median or palmar cutaneous neuroma
    • Palmar cutaneous nerve entrapment
    • Recurrent granulomatous or inflammatory tenosynovitis
    • Hypertrophic scar in the skin
  • The open approach may cause prolonged scar tenderness and weakness of grip within the first 6 months postoperatively.
  • The complications relating to endoscopic procedures are evolving as the procedures are modified from their original descriptions.
  • Incomplete release is a common complication
    • Major injuries, such as complete or near-complete transection, have occurred endoscopically and include injury to the median and ulnar nerves, flexor tendons, and superficial palmar arch.
ANALYSIS OF RESULTS
  • Nonoperative management including corticosteroid injections and splinting has long-term benefit in 10% of patients.
  • Maximum benefit of operative management is at 6 months.
  • There are no significant differences between endoscopic and open carpal tunnel release.
OUTCOMES AND EVIDENCE
  • Nonoperative management
    • Graham et al: corticosteroid injection and splinting
      • Long-term benefit in 10% of patients
    • Weiss, Sachar, and Gendreau: compared the efficacy of steroid injection with splinting
      • Response to injection treatment was faster in men and in patients over 40 years of age.
    • Kaplan, Glickel, and Eaton: success of nonoperative treatment in a study of 331 patients with carpal tunnel syndrome
      • 5 important factors in determining the success of nonoperative treatment:
        • Age over 50 years
        • Duration longer than 10 months
        • Constant paresthesia
        • Stenosing flexor tenosynovitis
        • A positive Phalen test result in less than 30 seconds.
      • 0 factors present: 66% cured by medical treatment
      • 1 factor present: 60% cured by medical treatment
      • 2 factors present: 16% cured by medical treatment
      • 3 factors: 7% cured by medical treatment
      • 4-5 factors: 0% cured by medical treatment
  • Operative
    • Guyette and Wilgis: prospective study
      • Maximum improvement in the first 6 months after carpal tunnel release
      • After 6 months, there was no significant improvement in the Tinel and Phalen tests, pinch strength, motor latency, symptom severity, or functional scoring.
        • Although thenar atrophy may disappear, it resolves slowly, if at all.
    • Leit, Weiser, and Tomaino
      • 70 years old with advanced disease
        • May not achieve complete relief of all symptoms
  • Endoscopy
    • Ferdinand and MacLean, and Macdermid et al: prospective studies comparing open and endoscopic carpal tunnel release
      • No significant differences in function
    • Macdermid et al
      • Immediate postoperative advantages of the endoscopic technique in grip strength and pain relief disappeared after 12 weeks.
Procedure: Standard Open Approach

Post-Procedure: Endoscopic Release Through Single Incision (Agee Single-Portal Technique)

POST-PROCEDURE CARE
  • Post-procedure care is largely similar whether an open, single-port arthroscopy or double-port arthroscopy technique is used.
  • Postoperative splinting remains somewhat controversial.
    • A compression dressing and volar splint can be applied.
  • Active use of hand should occur as soon as possible after surgery.
    • Progression of light activities of daily living is allowed at about 2 to 3 weeks.
    • More strenuous activities are added in the next 4 to 6 weeks.
  • The sutures are removed after 10 to 14 days.
  • The splint is continued for comfort as needed for 14 to 21 days.
COMPLICATIONS
  • For open release, complications and failures are estimated to be between 3% and 19%:
    • Incomplete release of the transverse carpal ligament
    • Reformation of the flexor retinaculum
    • Scarring in the carpal tunnel
    • Median or palmar cutaneous neuroma
    • Palmar cutaneous nerve entrapment
    • Recurrent granulomatous or inflammatory tenosynovitis
    • Hypertrophic scar in the skin
  • The open approach may cause prolonged scar tenderness and weakness of grip within the first 6 months postoperatively.
  • The complications relating to endoscopic procedures are evolving as the procedures are modified from their original descriptions.
  • Incomplete release is a common complication
    • Major injuries, such as complete or near-complete transection, have occurred endoscopically and include injury to the median and ulnar nerves, flexor tendons, and superficial palmar arch.
ANALYSIS OF RESULTS
  • Nonoperative management including corticosteroid injections and splinting has long-term benefit in 10% of patients.
  • Maximum benefit of operative management is at 6 months.
  • There are no significant differences between endoscopic and open carpal tunnel release.
OUTCOMES AND EVIDENCE
  • Nonoperative management
    • Graham et al: corticosteroid injection and splinting
      • Long-term benefit in 10% of patients
    • Weiss, Sachar, and Gendreau: compared the efficacy of steroid injection with splinting
      • Response to injection treatment was faster in men and in patients over 40 years of age.
    • Kaplan, Glickel, and Eaton: success of nonoperative treatment in a study of 331 patients with carpal tunnel syndrome
      • 5 important factors in determining the success of nonoperative treatment:
        • Age over 50 years
        • Duration longer than 10 months
        • Constant paresthesia
        • Stenosing flexor tenosynovitis
        • A positive Phalen test result in less than 30 seconds.
      • 0 factors present: 66% cured by medical treatment
      • 1 factor present: 60% cured by medical treatment
      • 2 factors present: 16% cured by medical treatment
      • 3 factors: 7% cured by medical treatment
      • 4-5 factors: 0% cured by medical treatment
  • Operative
    • Guyette and Wilgis: prospective study
      • Maximum improvement in the first 6 months after carpal tunnel release
      • After 6 months, there was no significant improvement in the Tinel and Phalen tests, pinch strength, motor latency, symptom severity, or functional scoring.
        • Although thenar atrophy may disappear, it resolves slowly, if at all.
    • Leit, Weiser, and Tomaino
      • 70 years old with advanced disease
        • May not achieve complete relief of all symptoms
  • Endoscopy
    • Ferdinand and MacLean, and Macdermid et al: prospective studies comparing open and endoscopic carpal tunnel release
      • No significant differences in function
    • Macdermid et al
      • Immediate postoperative advantages of the endoscopic technique in grip strength and pain relief disappeared after 12 weeks.
Procedure: Endoscopic Release Through Single Incision (Agee Single-Portal Technique)

Post-Procedure: Endoscopic Release Through Two Incisions (Chow Two-Portal Extrabursal Technique)

POST-PROCEDURE CARE
  • Post-procedure care is largely similar whether an open, single-port arthroscopy or double-port arthroscopy technique is used.
  • Postoperative splinting remains somewhat controversial.
    • A compression dressing and volar splint can be applied.
  • Active use of hand should occur as soon as possible after surgery.
    • Progression of light activities of daily living is allowed at about 2 to 3 weeks.
    • More strenuous activities are added in the next 4 to 6 weeks.
  • The sutures are removed after 10 to 14 days.
  • The splint is continued for comfort as needed for 14 to 21 days.
COMPLICATIONS
  • For open release, complications and failures are estimated to be between 3% and 19%:
    • Incomplete release of the transverse carpal ligament
    • Reformation of the flexor retinaculum
    • Scarring in the carpal tunnel
    • Median or palmar cutaneous neuroma
    • Palmar cutaneous nerve entrapment
    • Recurrent granulomatous or inflammatory tenosynovitis
    • Hypertrophic scar in the skin
  • The open approach may cause prolonged scar tenderness and weakness of grip within the first 6 months postoperatively.
  • The complications relating to endoscopic procedures are evolving as the procedures are modified from their original descriptions.
  • Incomplete release is a common complication
    • Major injuries, such as complete or near-complete transection, have occurred endoscopically and include injury to the median and ulnar nerves, flexor tendons, and superficial palmar arch.
ANALYSIS OF RESULTS
  • Nonoperative management including corticosteroid injections and splinting has long-term benefit in 10% of patients.
  • Maximum benefit of operative management is at 6 months.
  • There are no significant differences between endoscopic and open carpal tunnel release.
OUTCOMES AND EVIDENCE
  • Nonoperative management
    • Graham et al: corticosteroid injection and splinting
      • Long-term benefit in 10% of patients
    • Weiss, Sachar, and Gendreau: compared the efficacy of steroid injection with splinting
      • Response to injection treatment was faster in men and in patients over 40 years of age.
    • Kaplan, Glickel, and Eaton: success of nonoperative treatment in a study of 331 patients with carpal tunnel syndrome
      • 5 important factors in determining the success of nonoperative treatment:
        • Age over 50 years
        • Duration longer than 10 months
        • Constant paresthesia
        • Stenosing flexor tenosynovitis
        • A positive Phalen test result in less than 30 seconds.
      • 0 factors present: 66% cured by medical treatment
      • 1 factor present: 60% cured by medical treatment
      • 2 factors present: 16% cured by medical treatment
      • 3 factors: 7% cured by medical treatment
      • 4-5 factors: 0% cured by medical treatment
  • Operative
    • Guyette and Wilgis: prospective study
      • Maximum improvement in the first 6 months after carpal tunnel release
      • After 6 months, there was no significant improvement in the Tinel and Phalen tests, pinch strength, motor latency, symptom severity, or functional scoring.
        • Although thenar atrophy may disappear, it resolves slowly, if at all.
    • Leit, Weiser, and Tomaino
      • 70 years old with advanced disease
        • May not achieve complete relief of all symptoms
  • Endoscopy
    • Ferdinand and MacLean, and Macdermid et al: prospective studies comparing open and endoscopic carpal tunnel release
      • No significant differences in function
    • Macdermid et al
      • Immediate postoperative advantages of the endoscopic technique in grip strength and pain relief disappeared after 12 weeks.
Procedure: Endoscopic Release Through Two Incisions (Chow Two-Portal Extrabursal Technique)
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