A Cadaveric Study of the Carpal Tunnel and Anatomical Variations of the Median Nerve in Vietnamese Adults: Implications for Single Portal Endoscopic Carpal Tunnel Release

@#Introduction: Single-portal endoscopic carpal tunnel release using modified Agee technique is widely used in Vietnam. Yet information on the anatomy of the target space of Vietnamese people regarding this technique is scarce. We aimed to characterise the anatomical landmarks and variations of the carpal tunnel to propose a safer surgery. Materials and methods: All twenty hands of ten fresh frozen, unembalmed cadavers of Vietnamese adults were included. Dissection was performed after the vertical line, Kaplan’s cardinal line and the distal wrist crease were drawn. The transverse carpal ligament (TCL), ulnar neurovascular bundle and superficial palmar arch were exposed. Measurements were made using Mitutoyo calliper. The variants of the median nerve and in the course of the thenar motor branch were recorded. Results: The median distances from the TCL distal margin to the distal wrist crease and superficial palmar arch were 31.2mm and 12.7mm, respectively. The ulnar neurovascular bundle was located 5.7mm and 4.4mm ulnar to the vertical line at the level of the TCL proximal margin and at the level of the TCL distal margin, respectively. The thenar motor branch of the median nerve was extra-ligamentous in 19 hands and preligamentous in 1 hand. Conclusion: If endoscopic portal is made along the distal wrist crease, blade assembly should not be inserted beyond the 35mm mark on its scale. Instruments should be aimed toward the radial border of the patient’s ring finger. Surgeons should be aware of the preligamentous course of the thenar motor branch although this variant type is rare.

Two-port Endoscopic Surgery for Carpal Tunnel Syndrome – A Prospective Cohort Study

@#Introduction: Carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies affecting patients' life. Performing endoscopic carpal tunnel release is now a new technique that is being gradually applied in Vietnam. This paper seeks to investigate the effectiveness of Chow’s method for CTS treatment. Materials and methods: This is a prospective cohort study involving seventy-seven patients with CTS who underwent Chow’s endoscopic method at our hospital from March 2019 to January 2020. The Boston Carpal Tunnel Questionnaire and electromyography (EMG) were used primarily to evaluate surgical decompression pre-operatively, one week, three weeks, three months, and six months after surgery. We also recorded incision length, pain at the scar, the improvement of symptoms and thenar atrophy and return-towork time after surgery. Results: A total of 85.7% of the patients were women. A moderate severity of EMG was seen in 64.9% of cases. Sixmonth post-operative functional status scale (FSS) (1.05±0.1) and symptom severity scale (SSS) (1.05±0.1) showed significant improvement when compared with preoperative FSS (2.8±0.5) and SSS (3.2±0.5). Post-operative EMG showed the distal sensory latency (DSL) and distal motor latency (DML) had returned to the norm in 88% and 89.3%, respectively. The average incision length was 12.1±1.2mm. Six months after surgery, numbness and hand pain had resolved in 97.4%, a painless scar was seen in 94.7%, but full recovery of thenar atrophy was only seen in 9.1%. Patients could get back to work after 10.2±2.4 days. Conclusion: Chow’s endoscopic carpal tunnel release is a safe and effective procedure for patients suffering from carpal tunnel syndrome that showed promising outcomes on clinical symptoms and functions on EMG with minimal pain and scarring, and early return to work.

Endoscopic carpal tunnel release in jamaica: seven years experience / Liberación endoscópica del túnel carpiano en jamaica: siete anos de experiencia

OBJECTIVE: To assess the patient profile and outcome of treatment, by endoscopic release, of patients with carpal tunnel syndrome. METHODS: A descriptive study was done using data from two sets ofpatients who had endoscopic carpal tunnel release in Jamaica from 2004 to 2006 and 2006 to 2010. The medical records of patients who had a diagnosis of carpal tunnel syndrome using symptoms, clinical signs and confirmation by nerve conduction test were reviewed. The data were analysed using SPSS and Micosoft Excel®. RESULTS: A total of 68 patients with 75 cases of carpal tunnel syndrome were done. Fifty-two (76%) of these patients were females and about 50% were older than 41 years old. There were 61 (90%) unilateral cases. Of these, the majority of cases affected the right hand. All patients had improvement in symptoms after one week, required minimal analgesic use, had good compliance with rehabilitation and returned to work after about two weeks. There were three cases of pilar tenderness, two cases of transient paraesthesia in the index finger which resolved after three weeks. There were three failed cases from the first series which had to be converted to open carpal tunnel release. The complication rate was 6.7%. No serious complications occurred in the second series and all were treated successfully without interventional surgery. The rate ofconversion to open release was 4%. CONCLUSION: Carpal tunnel affects mostly middle aged females and when treatment is done by endoscopic release, there is a fast resolution of symptoms and early return to work.

OBJETIVO: Evaluar el perfil del paciente y el resultado clínico del tratamiento de pacientes con el síndrome del túnel carpiano tratados mediante liberación endoscópica. MÉTODOS: Se llevó a cabo un estudio descriptivo, usando datos de dos conjuntos de pacientes a quienes se les realizó una liberación endoscópica del túnel carpiano en Jamaica entre 2004 y 2006; 2006 y 2010. Se revisaron las historias clínicas de pacientes con un diagnóstico de síndrome del túnel carpiano, usando síntomas, senales clínicas y confirmación mediante la prueba de conducción de nervio. Los datos fueron analizados usando SPSS y Micosoft Excel®. RESULTADOS: Se analizó un total de 68 pacientes con 75 casos de síndrome del túnel carpiano. Cincuenta y dos (76%) de estas pacientes fueron mujeres, y aproximadamente 50% tenían más de 41 anos de edad. Hubo 61 (90%) casos unilaterales. De éstos, la mayoría de casos tuvo afectación de la mano derecha. Todos los pacientes experimentaron una mejoría en los síntomas después de una semana; necesitaron un uso mínimo de analgésicos, cumplieron bien con la rehabilitación, y regresaron al trabajo luego de dos semanas aproximadamente. Hubo tres casos de sensibilidad del talón de la mano, y dos casos deparestesia transitoria del dedo índice, que se resolvieron después de tres semanas. Hubo tres casos fallidos que tuvieron que ser convertidos en liberación abierta del túnel carpiano. La tasa de complicación fue 6.7%. No ocurrió ninguna complicación seria en esta serie, y todas fueron tratadas exitosamente sin intervención quirúrgica. La tasa de conversión para abrir la liberación fue 4%. CONCLUSIÓN: El túnel carpiano afecta principalmente a las mujeres de mediana edad, y cuando el tratamiento se realiza mediante liberación endoscópica, se produce una resolución rápida de los síntomas y un temprano regreso al trabajo.

Long-Term Changes of the Clinical and Nerve Electrophysiological Findings after Endoscopic Carpal Tunnel Release / 대한정형외과학회잡지

PURPOSE: The aim of this study was to analyze the clinical symptoms and function and the nerve electrophysiological changes between the pre-operative and long-term post-operative states of patients who underwent surgical treatment with endoscopic release of the carpal tunnel for idiopathic carpal tunnel syndrome. MATERIALS AND METHODS: This study was performed in 48 patients and 88 wrists with idiopathic carpal tunnel syndrome. All patients were treated with endoscopic carpal tunnel release using a single portal. The preoperative and the 3 years 5 months long-term postoperative clinical symptoms and function were evaluated using the Boston carpal tunnel questionnaire. The nerve electrophysiological status was evaluated using the Bland grade system. RESULTS: When the preoperative Bland grade was 2, 3, 4, 5, and 6, the range of the change of the symptom severity score was 1.38, 1.68, 2.40, 1.61 and 1.28, respectively, and the range of the change of the functional status score was 0.60, 1.34, 1.58, 0.93 and 0.88, respectively, at the long-term follow-up. The clinical symptoms were signifi cantly improved at the fi nal follow-up when the preoperative Bland grade was 2, 3, 4 and 5. The function was signifi cantly improved for all the preoperative Bland grades. On the nerve electrophysiological study, there was statistical improvement of the distal motor latency of the motor nerve and the nerve conduction velocity and amplitude of the sensory nerve. When the preoperative Bland grade was 2, 3, 4, 5 and 6, the extent of improved grade was 0.60, 0.75, 2.17, 2.87 and 4.25, respectively, at the long-term follow-up, and the Bland grade was signifi cantly improved when the preoperative Bland grade was 3, 4, 5 and 6. However, there was no statistical signifi cance between the Bland grade and the clinical state at the long-term follow-up. CONCLUSION: The clinical and nerve electrophysiological states were significantly improved at the long-term follow-up after endoscopic carpal tunnel release. When the preoperative Bland grade was 3, 4 and 5, the clinical symptoms, function and the nerve electrophysiological states were signifi cantly improved at the long-term follow-up.

Single Portal Endoscopic Carpal Tunnel Release in Patients Older than 65 Years

PURPOSE: There have been few reports about the endoscopic carpal tunnel release (ECTR) in elderly patients and its efficacy and safety are not well-known. We evaluated the clinical outcomes of ECTR using Agee technique in patients older than 65 years. MATERIALS AND METHODS: From October 2000 to January 2007, thirty-five patients (42 hands) who underwent ECTR using Agee technique were enrolled. The average age of the patients was 67.2 years (range, 65-71 years). The duration of symptoms averaged 10 months (range, 6-33 months). For evaluation of the clinical outcomes, physical examination and subjective assessment of the hand function using the Boston carpal tunnel questionnaire were performed at postoperative 1-year follow-up and compared with those obtained at preoperative evaluation. The mean follow-up period was 18 months (range, 12-24 months). RESULTS: There were no neurovascular injury and scar tenderness. At postoperative 1-year follow-up, paresthesia, numbness, Phalen's sign, tinel sign, two point discrimation, and grip power were significantly improved compared with those obtained at preoperation. According to the Boston questionnaire, symptom severity score improved from 3.43 preoperatively to 1.89 postoperatively, and functional status score improved from 3.18 preoperatively to 2.21 postoperatively (p<0.05). Thenar atrophy still remained in 32 hands (76.2%). CONCLUSION: Although thenar atrophy did not improve in many cases, symptom severity and functional status scores improved in most patients treated with ECTR. The single portal ECTR is a safe and efficacious treatment option in elderly patients with carpal tunnel syndrome.

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.

Endoscopic Versus Mini.open Carpal Tunnel Release in Patients with Bilateral Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study was to determine any differences in outcome and patient satisfaction between endoscopic release (ECTR) and open carpal tunnel release (OCTR) in patients with bilateral carpal tunnel syndrome who underwent both techniques. METHODS: Seven patients with confirmed bilateral idiopathic carpal tunnel syndrome were randomized to undergo endoscopic release using a single portal Agee technique to one hand and a minimal open release to the other. Subsequent assessments were made at 0, 3, and 12 months after operation using a modified Levin scale. We also analyzed subjective and objective outcomes retrospectively, including the time to return to full activity, patient preference, cosmetic satisfaction, scar tenderness, and pillar pain. The pain was assessed using a visual analogue scale from 1 to 10. RESULTS: Based on the Levin scale, there were no significant differences between hands at any follow-up interval. At the three-month follow up, mean scale scores were lower in the ECTR group; however, the differences did not reach statistical significance. Cosmetically, all patients were satisfied with their scar irrespective of the technique. There were no statistical differences in terms of scar tenderness and pillar pain. CONCLUSION:ECTR did not show any significant advantage over short-incision OCTR. Therefore, the operator's experience and skill in using a certain method is important, regardless of which technique is used.

Endoscopic Carpal Tunnel Release: Surgical Outcome in 100 Cases

OBJECTIVE: Carpal tunnel syndrome(CTS) is the most common entrapment neuropathy in the upper extremities. For the surgical treatment of CTS, endoscopic carpal tunnel release(ECTR) has been developed as a minimally invasive method, alternative to the open procedure over the past decade. The authors present clinical experience and surgical outcome of ECTR. METHODS: One hundred cases(34 right, 30 left and 19 bilateral hands) in 81 consecutive patients(mean age: 51.8 years, range: 33-77 years) with electrodiagnostically-proven CTS underwent a single-portal ECTR from January 2001 to December 2002. Preoperative clinical findings and results of electrodiagnostic studies were compared with surgical outcome respectively after 3-month-follow-up period. RESULTS: Among 100 cases 94(94%) were satisfied with complete or significant relief of symptoms and 6(6%) were dissatisfied with partial or no relief of symptoms. Major complications in 2 cases(one with ulnar nerve injury and the other one with ulnar artery laceration), developed in early experience of ECTR and recurrence in 1 case occured. Severity of electrodiagnostic abnormalities were correlated with surgical outcome but there's no statistical significance between them. Severity of clinical findings, age at onset and symptom duration were not correlated with surgical outcome respectively. CONCLUSION: ECTR is effective in relieving symptoms of CTS with a low complication rate after the learning curve period. Thus, ECTR can be the first procedure, alternative to the open surgery as an efficient, minimally invasive surgical technique for CTS.

Endoscopic Carpal Tunnel Release and Radiological Measures of Carpal Tunnel to Predict the Ease of Access / 대한정형외과학회잡지

PURPOSE: The aim of this study was to evaluate the correlation between the preoperative radiological measures of the carpal tunnel and the ease of access of the instruments into the carpal tunnel during an endoscopic carpal tunnel release (ECTR) and to estimate changes in the radiological measures after ECTR. MATERIALS AND METHODS: Carpal tunnel views were possible in 45 patients, 78 wrists taken before the ECTR and the distances between scaphoid and pisiform (S-P) and between trapezium and hamate (T-H) were measured. The correlation between the measured distances and the ease of access of instrument was analyzed. In addition, the radiographic carpal tunnel views were taken three months after surgery and the distance changes after ECTR were measured. RESULTS: In "easy" rated access, the average S-P and T-H distances were 34.5 mm and 24.8 mm in females and 37.0 mm and 26.1 mm in males, respectively. In the "difficult" rated access, the average distances were 29.5 mm and 20.0 mm in females and 32.4 mm and 22.7 mm in males, respectively. Therefore, as the distances became shorter, the insertion of the endoscopic instrument became more difficult (p<0.001). However, after ECTR, the average distances were significantly increased in all cases by 2.5 mm (7.6%) and 2.4 mm (9.6%) in females and 2.8 mm (7.9%) and 2.8 mm (11.2%) in males, respectively (p<0.001). CONCLUSION: The ease of access of an endoscopic device into the carpal tunnel on ECTR had a significant correlation with the radiological measures of the S-P and T-H distances on the preoperative carpal tunnel view. In view of such radiological measures, it is believed that the carpal tunnel is widened after ECTR.

The Safety of Entrance Reference Line in Endoscopic Carpal Tunnel Release: A Cadaveric Anatomical Evaluation

OBJECTIVE: The purpose of this study is to investigate the anatomic relationship between the neurovasular structures and transverse carpal ligment(TCL) to avoid complications during endoscopic carpal tunnel release. METHODS: Sixteen fresh cadaver hands from 3 men and 5 women(age range, 58~74 years) were used. Neurovascular structures around the TCL were meticulously dissected under a loupe magnification and several morphometric indices were calculated. RESULTS: We found an average length of TCL is 41mm and average distance between the TCL distal margin and superficial palmar arch along the flexor tendon of the ring finger is 9.2mm. In 3 hands, the looped ulnar artery, coursed 1 to 4mm radial to hook of hamate, continuing to the superficial palmar arch. During radial-to-ulnar flexion of the wrist, the looped ulnar artery beyond the hook of hamate shifts more radially (2 to 7mm) with proximal carpal bone. We also noted a Berretini branch located adjacent to the edge of the distal TCL. CONCLUSION: It is appropriate to transect the ligament at least 4mm radial from the radial margin of the hook of hamate or transect the proximal ligament in the radially deviated hand position to protect ulnar neurovascular structure. The proximal portal could be made just ulnar to the palmaris longus tendon to avoid the vascular injury in the proximal portion of the TCL.

Comparison of Clinical Results of Minimal Incision Versus Endoscopic Carpal Tunnel Release / 대한정형외과학회잡지

PURPOSE: The purpose of our study was to compare the clinical results of minimal incision carpal tunnel release with those of endoscopic release. MATERIALS AND METHODS: We analyzed 27 patients (41 cases) who had been treated by minimal incision carpal tunnel release and 20 patients (29 cases) treated by single portal endoscopic carpal tunnel release. The average follow up period was 35.2 months. Results were compared between the two groups by assessing subjective satisfaction, postoperative symptoms, grip and pinch strength, two point discrimination and time to recovery. RESULTS: According to Cseuz's criteria, the results were excellent or good in 38 cases (93%) in minimal incision carpal tunnel release group, and in 27 cases (93%) in the endoscopic carpal tunnel release group. Subjective symptoms, grip power, pinch strength, thenar muscle atrophy, two point discrimination test and recovery time were similar in the two groups. CONCLUSION: We suggest that minimal incision carpal tunnel release and endoscopic carpal tunnel release are equally efficient methods for the treatment of carpal tunnel syndrome.

Minimal invasive endoscopic management of carpal tunnel syndrome (CTS) with a report of 69 case / 中国微创外科杂志

Objective To introduce a new technique--Carpal tunnel release by Okutsu's technique Methods A 1cm skin incision was made under local anaesthesia without tourniquet. The procedure was performed by system (Universal Subcutaneous Endoscope System). Postoperative functional assessment was done by Kelly's standards. Follow-up was conducted in the first, third and twelve month after the operation. Results One hundred and forty-nine sides of 126 cases of CTS were treated with this method. And seventy eight sides of 69 cases of CTS were followed up. 54 cases were excellent; 19 cases good; 3 cases fair; 2 cases poor. The average time of the operation was ten minutes. There was less blood lost in the procedure. Complication occurred in one case. Conclusions As compared with open procedure, the method has advantage of minimal incision,less tissue damage, shorter operation time, less skin scar and no postoperatioven plastic splint. The therapeutic results was as efficient as routine procedure.

Transverse Carpal Ligament Release with Agee Endoscopic Carpal Tunnel Release System

The carpal tunnel syndrome is the most common entrapment neuropathy. Several treatment modalities are available at present time. Surgical methods vary from open surgery, alternative surgical method using retinaculatome, and endoscopic surgery. Ten patients with carpal tunnel syndrome were treated with Agee endoscopic carpal tunnel release system in our institute from Nov. 1996 to Jan. 1998. The sensory conduction velocity of the median nerve were delayed or the sensory evoked potential were not evoked in all patients preoperatively. Preoperative plain radiographs of hands(including carpal tunnel view) showed normal bony structures of the carpal tunnel in all. Symptoms were immediately relieved after surgery and complete alleviation of symptoms were observed in all but one after a follow up of three months. Although small in number of patients treated, this method seems to be a better than the other treatment modalities.

Clinical Results of Open versus Endoscopic Carpal Tunnel Release / 대한정형외과학회잡지

Open carpal tunnel release has been the standard method of sumical treatment of carpal tunnel syndrome. Recently endoscopic carpal tunnel release has been introduced and is heing used by many authors. The advantages of this new technique are less postoperative pain, rapid restoration of power and rapid return-to-work. However many considerate authors, in spite of these advantages. insist that the inevitahle risk of neurovascular injury during the endoscopic procedure should not he underestimated. The purpose of our study is to compare the clinical results of endoscopic carpal tunnel release with those of open release. 20 open carpal tunnel releases in 16 patients and 15 endoscopic carpal tunnel reieases (single-portal technique) in 11 patients were performed hy the first author. Preoperative conditions of both groups are not different. Authors compared the clinical results between the two groups with some parameters. The overall clinical results were not different significantly hetween two groups. Rapid return-to-work(36 days in endoscopic group versus 60 days in open group) and less postoperative scar and pillar pain in endoscopic group were demonstrated. However, the major complication of one median nerve injury in endoscopic group seemed to overweigh these some benefits. We suggest that the standard operative technique for carpal tunnel syndrome should be open carpal tunnel release and more considerations should be takcn in choosing endoscopic method because of its inherent risk.