Endoscopic Carpal Tunnel Release
Reprinted from THE JOURNAL OF HAND SURGERY, St. Louis
Vol. 17, No 6, PP.
1009-1011, November, 1992
(Printed in the U.S.A.) (Copyright 1992 by Mosby-Year
Book, Inc.)
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 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.
(J. Hand Surg.1991;17A;1009-11)
Michael G. Brown, M.D.
Brent Keyser, M.D.
Eric S.
Rothenberg, M.D.
Houston, Texas
Division of tissue
overlying the transverse carpal ligament (TCL) is inherent in
the open carpal tunnel operation.1,2
The healing of these superficial tissues may result in
wound tenderness for some time after the procedure. This
tenderness of the wound and later of the scar may inhibit
application of palmar pressure and delay a return to maximum
postoperative hand function. Complications of open carpal tunnel
release have been described previously. 3,4
With the advent of new endoscopic instruments, it is now
possible to release the ligament through one or two small
incisions proximal and distal to the carpal tunnel, avoiding
incision of the major portion of the overlying skin, fascia,
muscle tissue, and possible fine nerve fibers.
Material and Methods
Our first group included 149 patients who had endoscopic
carpal tunnel release with the original Agee Inside Job
instrument before its redesign and reintroduction. The second
group of 152 patients had a two portal release with a technique
of our devising, which differs significantly from that of Chow5,6
and other.7,8. Before performing endoscopic
carpal tunnel release on patients, the surgeon performed each
procedure on twelve cadaver hands. This was followed by open
dissections, which showed the complete division of the
transverse carpal ligament and the absence of any injury to
neurovascular structures.
In all
patients carpal tunnel syndrome was diagnosed on the basis of
history and physical examination with confirmatory
nerve-conduction studies. In each case conservative treatment
with splinting and anti-inflammatory medicines failed. All
patients had normal x-ray views of the carpal tunnel. None of
the patients were pregnant, and none had clinical evidence of
thyroid disease. Three patients in the one-portal group had
concomitant ulnar nerve entrapment in Guyon’s canal and were
advised that endoscopic release might not solve their entire
problem. Both open and closed procedures were carefully
explained to each patient, and patients were allowed to choose
between the procedures or to opt for continued non-operative
therapy.
One-portal technique
For
each of the techniques, patients were under general or
intravenous regional block anesthesia and tourniquet control.
The instrument (3M Agee Inside Job) was carefully checked, and
marks were placed inside the channel to assist in proper
positioning of the blade assembly. With the patient’s hand
resting on a rolled towel, a 1.5-cm incision was made in the
distal wrist crease ulnar to the palmaris longus. The anterior
forearm fascia was exposed and an L-shaped incision was made in
it. An elevator was used to push the synovium away from the
under side of the TCL, and the "hamate finder" was
used to confirm proper positioning. The instrument was then
passed beneath the ligament until its distal edge was
identified. The end of the channel was aligned with the distal
edge of the ligament, a reference point on the ligament was
noted relative to a channel mark, and the instrument.
THE JOURNAL OF HAND
SURGERY
Results of 1236 Endoscopic Carpal Tunnel
Release
Procedures Using the Brown Technique
Michael G. Brown, M.D., Eric S.
Rothenberg, M.D.,
Brent Keyeser, M.D., Thomas T. Woloszyn,
M.D.,
Any Wolford, R.N., M.S., C.N.S.
ABSTRACT
In a series of 1236 patients who underwent
endoscopic carpal tunnel releases using the two portal Brown
technique, the results were favorable in 98%, the failure rate
was 2%, the instance of iatrogenic injury was O.O8% (one tendon
injury), and the overall complication rate was O.97%. The
patients had resolution of carpal tunnel syndrome in an average
of 14 days and returned to work in an average of 15 days.
Recurrence rate to date has been 2%, with the longest follow-up
of 80 months. These results indicate that this is a safe and
efficacious method of treatment for patients with carpal tunnel
syndrome who require surgery.
INTRODUCTION
Surgical treatment of carpal tunnel syndrome was first described
in 1947. An open approach to division of the transverse carpal
ligament has been the mainstay of surgical treatment for this
condition. With the exception of blindly-performed division of the transverse carpal ligament, open carpal
tunnel release requires division of the overlying palmaris
brevis muscle, palmar fascia, subcutaneous fat, possibly fibers
of the thenar and hypothenar muscle, and skin. Division of these
overlying structures has been cited as a cause for "pillar
pain" and delay in the patient’s return to work and
activities of daily living.
An endoscopic approach to the transverse carpal ligament was
first described in 1989. In a double blind prospective
randomized study comparing patients undergoing endoscopic carpal
tunnel release with those undergoing open carpal tunnel release,
the results were found to be superior in the endoscopic carpal
tunnel release group with respect to postoperative strength,
wound tenderness, and earlier return to work and participation
in activities of daily living. The superiority of
endoscopic carpal tunnel release was supported further by a
study demonstrating that a two-portal procedure is superior to a
one-portal procedure. Considerable controversy has arisen
regarding the ability to divide the transverse carpal ligament
safely and completely using an endoscopic technique. Two cadaver
studies using the technique described by Chow showed an
unacceptably high incidence of incomplete ligament division and
other technical complications.
Back
to Medical Information Page
