Open vs endoscopic release Aim to divide the flexor retinaculum to increase space and reduce pressure on the median nerve Open technique 3-4 cm long palmar incision Divide overlying tissue Pain & pillar pain Endoscopic - 1 or 2 incisions Reduced soft tissue disruption Aims to reduce post-operative pain and morbidity Faster recovery and return to work Materials and methods 52 patients from a single consultant’s practice February February 2010 Performed by the same surgeon No tourniquet Ultrasound is used to mark Superficial palmar arterial arch Flexor retinaculum Path of the median nerve Local anaesthetic 5mls 0.5% plain Marcaine and 5mls 1% plain Lidocaine Injected into carpal tunnel under ultrasound guidance Single transverse wrist crease incision Matthews D, Ponniah A, Atherton D, Bashir A, Ansede G, Lee J, Katsarma E. Department of Plastic and Reconstructive surgery, Hand Surgery Unit, Chelsea and Westminster Hospital, London R Scholten, A van der Molen, B Uitdehaag, L Bouter, H de Vet. Surgical treatment options for carpal tunnel syndrome. Cochrane database of systematic reviews 2007, Issue 4. Art no.: CD DOI: / CD pub3 SE Mackinnon, CB Novak. Compressive neuropathies. In: Green’s Operative Hand Surgery. 5th edition. Vol One. Pennsylvania: Churchill-Livingstone, 2005: JM Agee, HR McCarroll, RD Tortosa, DA Berry, RM Szabo, CA Peimer. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. The Journal of Hand Surgery American volume 1992;17(6): R Latinovic, MC Gulliford, RA Hughes. Incidence of common compressive neuropathies in primary care. Journal of Neurology, Neurosurgery and Psychiatry 2006;77(2):263-5 Phalen GS, Gardner WJ, La Londe AA. Neuropathy of the median nerve due to compression beneath the transverse carpal ligament. Journal of Bone and Joint Surgery Am 1950;32A(1): Tubiana R. Carpal tunnel syndrome: some views on its management. Ann Chir Main Memb Super 1990;9(5): Agee JM, Peimer CA, Pyrek JD, Walsh WE. Endoscopic carpal tunnel release: a prospective study of complications and surgical experience. Journal of Hand Surgery Am 1995;20(2): Hand surgery and Plastic Surgery department, Chelsea and Westminster Hospital, London Ultrasound guided percutaneous carpal tunnel decompression Carpal tunnel syndrome Figure 1. The flexor retinaculum compressing the median nerve Figure 3. Open carpal tunnel release scar (left) often causing pain. Endoscopic technique (right) results in less post-operative pain and quicker recovery Patient demographics 52 patients - 40 women - 12 men No difference between other demographic factors Figure 4. Post-operative scar result High satisfaction scores No complications (numbness/infection) Return of symptoms in 2 people after 6 months, 1 also suffered arthritis, 1 self declared they had delayed presentation Compression of the median nerve within the carpal tunnel in the wrist 90/100,000 of men, 280/100,000 of women in the UK In % of new cases treated operatively in the UK, equating to operations Range of symptoms and varied severity Numbness, tingling, pins & needles, pain Dropping things, grip weakness, muscle wasting Management options Analgesia Splint Steroid injection Operative Open Endoscopic Current techniques known to cause scar tenderness & pillar pain Current trend towards minimally invasive procedures Increased useage of USS in other operative techniques (A1 pulley release) with proven safety record USS guided carpal tunnel release is simple & quick Rapid return to work Male 25 (1-21 days) Female 44.8 (3-84 days) High patient satisfaction scores FemaleMale Manual : Non-manual work2 : 385 : 7 Age (years)56.05 (34-83)57.58 (44-77) Flexor retinaculum length (mm)29.59 (20-40)28.91 (22-36) Flexor retinaculum thickness (mm)1.19 ( )1.125 ( ) Distance from distal flexor retinaculum to palmar arterial arch (mm) (10-55)23.82 (13-60) Cross sectional area of median nerve pre-carpal tunnel (cm 2 ) ( ) ( ) Cross sectional area of median nerve within carpal tunnel (cm 2 ) ( ) ( ) Results Step 1. Marking of structures with the ultrasound probe Step 2. Wrist crease incision Step 3. Dissection to median nerve. Step 4. Hook knife advanced within carpal tunnel over Macdonald’s elevator. Position confirmed with ultrasound STEP 5. Flexor retinaculum divided by pulling hook knife towards skin incision STEP 6. Proximal release using tenotomy scissors. Closure of skin incision Figure 2. Splinting (left) and steroid injection (right) treatment options Pre- and post-operative standardized symptom questionnaires Outcome measures - pain, return to work, functional ability, satisfaction Flexor retinaculum Conclusions Literature cited Acknowledgement Summary