Carpal tunnel release

Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a surgery in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended when there is constant (not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms of pain in the carpal tunnel. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually. Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a surgery in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended when there is constant (not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms of pain in the carpal tunnel. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually. The procedure is used as a treatment for carpal tunnel syndrome and according to the American Academy of Orthopaedic Surgeons (AAOS) treatment guidelines, early surgery is an option when there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. Management decisions rely on several factors, including the etiology and chronicity of CTS, symptom severity, and individual patient choices. Nonsurgical treatment measures are appropriate in the initial management of most idiopathic cases of CTS. Splinting and corticosteroid injections may be prescribed, and they have proven benefits. Steroid injections can provide relief if symptoms are of short duration. If no improvement is seen following steroid injection, carpal tunnel release may not be as effective. Surgical treatment is indicated in acute cases of CTS from trauma or infection, in chronic cases with denervation of the abductor pollicis brevis muscle or a pronounced sensory loss, and in cases unresponsive to conservative management. Before pursuing CTR, confirmation of the diagnosis of carpal tunnel syndrome is recommended, given that the symptoms of median nerve entrapment can overlap with other disorders including: cervical radiculopathy, thoracic outlet syndrome, and pronator syndrome. Beyond physical exam testing, confirmatory electrodiagnostic studies are recommended for all patients being considered for surgery. Nerve conduction studies are reported to be 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome. These studies provide the surgeon with a patient baseline and can rule out other syndromes that present similarly. Specifically, a distal motor latency of more than 4.5 ms and a sensory latency of more than 3.5 ms are considered abnormal. Of note, these electrodiagnostic studies can yield normal results despite symptomatic median nerve compression. In this scenario, CTR should be considered only if physical signs of median nerve dysfunction are present in addition to classical symptoms of CTS. The goal of any carpal tunnel release surgery is to divide the transverse carpal ligament and the distal aspect of the volar ante brachial fascia, thereby decompressing the median nerve and providing relief. The transverse carpal ligament is a wide ligament that runs across the hand, from the scaphoid bone to the hamate bone and pisiform. It forms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the ring finger) it no longer presses down on the nerve inside, relieving the pressure. The two major types of surgery are open carpal tunnel release and endoscopic carpal tunnel release. Open carpal tunnel release can be performed through a standard incision or a limited incision. Endoscopic carpal tunnel release, which can be performed through a single or double portal. Most surgeons historically have performed the open procedure, widely considered to be the gold standard. However, since the 1990s, a growing number of surgeons now offer endoscopic carpal tunnel release. Existing research does not show significant differences in outcomes of one kind of surgery versus the other, so patients can choose a surgeon they like and the surgeon also will practice the technique they like. Historically, carpal tunnel release was performed under general anesthesia with a tourniquet, however the worldwide trend is now for 'wide awake hand surgery': with no tourniquet, no general or regional anesthesia and no sedation; which also enables carpal tunnel release to be performed under local anesthesia as a one stop procedure. After carpal tunnel surgery, the long term use of a splint on the wrist should not be used for relief. Splints do not improve grip strength, lateral pinch strength, or bowstringing. While splints may protect people working with their hands, using a splint does not change complication rates or patient satisfaction. Using splints can cause problems including adhesion and lack of flexibility. Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic surgeon, or plastic surgeon. Open carpal tunnel release (OCTR) has long been considered the gold-standard surgical treatment for CTS. This approach allows for direct visualization of the anatomy and possible anatomical variants, which minimizes the risk of damaging critical structures. It also provides the surgeon with the option of probing the carpal canal for other structures that may be contributing to the compression of the median nerve, include ganglions and tumors. The technique involves placement of a longitudinal incision at the base of the hand. The length of the skin incision varies but typically is <4 cm. The subcutaneous tissue, the superficial palmar fascia, and the muscle of the palmaris brevis (if present) are also incised in line with the incision, thereby exposing the TCL. With the incision of the transverse carpal ligament longitudinally, the median nerve is exposed. The release is extended to the superficial palmar arterial arch distally and for a limited distance proximally beneath the wrist flexion creases. For optimal outcomes, the TCL must be completely released while avoiding damage to the vital structures. The flexor tendons can be retracted to inspect the floor of the canal for lesions. Scar tenderness, pillar pain, weakness, and delays in return to work can occasionally be seen following an OCTR.