Orthopedic Surgery for Carpal Tunnel Syndrome Treatment & Management

  • Author: David A Fuller, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Sep 22, 2010
 

Medical Therapy

Steroid injection and wrist splinting have been used effectively in patients with milder symptoms of carpal tunnel syndrome.[4] A study reported complete relief of all symptoms in 76% of hands at 6 weeks after treatment, but more than 12 months after treatment, the proportion of hands experiencing complete relief deteriorated to only 22%.[26] Similar positive results have been reported with steroid injection alone in a double-blind, placebo-controlled trial.[27]

Other nonoperative treatments have been proposed, but they have not been studied as rigorously; they include nonsteroidal anti-inflammatory drugs (NSAIDs),[28] vitamins (B complex), workstation redesign, ergonomic tool modification, acupuncture,[29] and yoga.

A systematic review of nonsurgical treatments for carpal tunnel syndrome by Huisstede et al found strong and moderate evidence for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads. However, the only treatment for which long-term results were reported was steroids, and there was no evidence for the long-term effectiveness of steroids.[30]

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Surgical Therapy

Open and endoscopic surgical techniques have been described for treatment of carpal tunnel syndrome (CTS). Both operative techniques are effective for the treatment of chronic CTS. Potential benefits of the endoscopic technique, including a more rapid functional recovery, have to be weighed against the technique's increased cost and higher complication rate. The reliability of and good visualization provided by the open technique continue to make it the preferred operation for many hand surgeons. Both techniques are described in the following section. Open release with an extended surgical incision is recommended for acute CTS.

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Intraoperative Details

Open carpal tunnel release

General, regional, or local anesthesia can be used for the procedure. Surgery is performed with a tourniquet inflated around the arm to control bleeding in the operative field. Open carpel tunnel release is performed as follows:

A longitudinal incision in the base of the palm is used (see image below). The incision is made in line with the flexed ring finger. The intersection of this longitudinal line with the Kaplan line (a line parallel to the ulnar aspect of the extended thumb) marks the distal extent of the incision. Proximally, the incision ends a few millimeters distal to the distal wrist flexion crease.

Surgical incision for an open carpal tunnel releasSurgical incision for an open carpal tunnel release is depicted. The incision can be extended proximally across the wrist flexion crease for a more extended exposure.

Following the incision, the subcutaneous fat is retracted radially and ulnarly, exposing the superficial palmar fascia. The superficial palmar fascia is divided sharply in line with the skin incision. Retractors are placed deeper to expose the TCL.

A blunt, curved hemostat clamp or similar instrument can be passed deep to the distal edge of the TCL to help confirm position and to protect the contents of the carpal canal. The TCL is divided sharply along its ulnar aspect. Distally, the superficial palmar arch marks the end of the TCL and must be protected. Proximally, the ligament is transected to the level of the distal wrist crease under direct vision.

Blunt dissecting scissors are used to spread superficial and deep to the antebrachial fascia. Angled retractors are placed proximally under the skin flap so that the antebrachial fascia can now be divided for 2-3 cm proximally under direct vision, using the blunt scissors partially opened in a pushing fashion.

If visualization is poor, the skin incision may need to be extended proximally. If the incision needs to extend across the distal wrist crease, it should be angled.

Tenolysis, neurolysis, synovectomy, or reconstruction of the TCL is not routinely performed.

Prior to closure, the tourniquet is deflated and hemostasis is obtained with bipolar electrocautery. No deep sutures are used. The skin is closed with 4-0 nylon. A soft, sterile dressing is applied.

Postoperative splinting has been recommended to prevent prolapse of nerve, entrapment of nerve in scar tissue, or tendon bowstringing. However, splinting has not been demonstrated to have any beneficial effect and can increase pain and scar tenderness.

Endoscopic carpal tunnel release

One- and 2-incision (ie, portal) techniques are performed as follows:[31, 32]

In both techniques, the first incision is made transversely, just proximal to the wrist flexion crease between the palmaris longus and the flexor carpi ulnaris (see image below).

Surgical incisions for an endoscopic (1- and 2-incSurgical incisions for an endoscopic (1- and 2-incision) carpal tunnel release are depicted. Precise location of the incisions is critical and depends on individual anatomy.

In the 1-incision technique, the blade assembly and viewing device are inserted into the carpal canal anterograde through the proximal incision. With the wrist in extension, the device is advanced to the distal edge of the TCL. Video images, ballottement, and transillumination can be used to confirm the position. When correctly positioned, the cutting blade is elevated, and the device is withdrawn, cutting the distal half of the ligament. The device is then reinserted to inspect ligament division, and additional passes are then made to complete the division of the remaining proximal portions of the ligament. The skin incision is sutured closed.

In the 2-incision technique, the second incision is made transversely in the palm on a line bisecting the angle formed by lines drawn along the distal border of the fully abducted thumb and the third webspace (see image below). Blunt dissection is performed in the palm to identify the superficial palmar arch, the common digital nerves, and the distal edge of the TCL. Following the axis of the forearm, a blunt, curved instrument is inserted into the carpal canal through the proximal incision to free soft tissues from the undersurface of the TCL.

Surgical incisions for an endoscopic (1- and 2-incSurgical incisions for an endoscopic (1- and 2-incision) carpal tunnel release are depicted. Precise location of the incisions is critical and depends on individual anatomy.

A trocar-and-sheath assembly is passed anterograde from the proximal incision to the distal incision through the carpal canal. The fingers and wrist are then extended and secured in a custom holder. The trocar is removed, and the endoscope is inserted into the sheath through the proximal incision.

The distal half of the ligament is then divided with special upward and reverse cutting knives placed in the distal sheath while being viewed through the endoscope.

The endoscope then is removed and reinserted into the sheath through the distal incision, and the reverse cutting knife is inserted into the sheath through the proximal incision. By withdrawing the reverse cutting knife, the proximal half of the ligament is released. Skin incisions are sutured closed.

The 1- or 2-incision technique, if visualization is not satisfactory, should be abandoned and the surgery converted to open carpal tunnel release.

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Complications

Complications are not common following open or endoscopic surgical techniques.[33] Major complications with either technique can include nerve laceration, vessel laceration, and tendon laceration. Laceration of the palmar cutaneous branch of the median nerve with painful neuroma formation is reported to be the most common complication of open carpal tunnel release.

Incomplete release of the TCL is reported to be the most common complication of endoscopic carpal tunnel release. Loss of grip strength and tenderness of scars following open carpal tunnel release tend to resolve with time.

The general consensus among surgeons is that nerve injuries occur more frequently with endoscopic release than they do with open release. Nerve injuries with the endoscopic technique are not necessarily related to the skill and experience of the surgeon but may be associated with the nature of the procedure, the anatomy of the carpal canal, and the device used.

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Outcome and Prognosis

Lasting relief of pain, numbness, and paresthesia can be expected in more than 90% of patients with carpal tunnel syndrome who are treated with open or endoscopic carpal tunnel release; patient satisfaction is high. The endoscopic technique is associated with a shorter interval before the patient returns to work and with less incisional pain.[31] The primary reason for a poor result is an error in diagnosis.

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Future and Controversies

The etiology of CTS and its relationship to the workplace will continue to be better understood in the coming decades. It is already apparent that the etiology of CTS is multifactorial, and although work-induced, repetitive trauma may not be the major cause of CTS, it may contribute in some way.

A realized goal of the less invasive endoscopic technique is to return individuals to work sooner. However, concerns over safety and cost have prevented endoscopic techniques from being widely accepted and used. It is hoped that in the future, safer endoscopic methods and less invasive or nonoperative techniques that provide safe and lasting treatment for CTS will be developed.

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Contributor Information and Disclosures
Author

David A Fuller, MD  Assistant Professor of Surgery, Director of Hand Surgery, University of Medicine and Dentistry of New Jersey, Cooper University Hospital

David A Fuller, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Pennsylvania Orthopaedic Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael S Clarke, MD  Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Thomas R Hunt III, MD  John D Sherrill Professor and Director of Orthopaedic Surgery, Surgeon in Chief of UAB Highlands Hospital, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham

Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association

Disclosure: Tornier Consulting fee Review panel membership; Tornier Royalty None; Tornier Ownership interest None; Lippincott Royalty Independent contractor

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

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Cross sections of the carpal canal at the levels of the proximal and distal carpal rows are depicted. The transverse carpal ligament bridges the carpal tunnel and is under tension.
Surgical incision for an open carpal tunnel release is depicted. The incision can be extended proximally across the wrist flexion crease for a more extended exposure.
Surgical incisions for an endoscopic (1- and 2-incision) carpal tunnel release are depicted. Precise location of the incisions is critical and depends on individual anatomy.
 
 
 
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