By: Dave Parker
What is Carpal Tunnel Release (CTR)?
First, let me explain what Carpal Tunnel Syndrome (CTS) is before I continue with CTR. It is the condition where the median nerve is entrapped in the tunnel space that it shares with nine flexor tendons. Above this tunnel space is the transverse carpal ligament.
https://images.app.goo.gl/TKHd7pQ85j9fpuvY7
When this tunnel space swells up, the median nerve can be pressed against the flexor tendons, the transverse carpal ligament, and the tunnel space. When this occurs, numbness, tingling, and pain may occur in the hand that shoots up to the thumb, index finger, long finger, and half of the ring finger. This can be due to a variety of reasons which include: fractures, swelling during pregnancy, arthritis, thyroid conditions, as well as job-related tasks such as a baker, a cashier, a farmer, a mechanic, a gardener, a musician, a front office assistant (using computer all shift), and many more jobs that require the frequent repetitive use of the hands.
After tests are completed and a diagnosis for CTS is done, all conservative treatment (non-surgical) will be attempted first with surgery as the last resort. Some conservative treatments include:
- Changing patterns of hand use to reduce pressure
- Keeping the wrist splinted in a straight position to reduce pressure
- Wearing wrist splints at night to relieve symptoms that interfere with sleep
- Steroid injections into the carpal tunnel to reduce swelling
- Outpatient Physical Therapy or Occupational Therapy can help reduce pain levels
If these treatment options do not work, then the physician would talk to the client about choosing surgery to relieve the pain and discomfort.
American Society for Surgery of the Hand – Carpal Tunnel Syndrome
According to Atroshi, et al, surgery for CTS is one of the most performed procedures being done in the U.S. with 350,000 procedures performed annually. The largest proportion are done amongst the working adult and more often amongst women.
What is Open Carpal Tunnel Surgery for CTS?
This surgery is done on the outside of the skin in order to make an incision inwards to cut the transverse carpal ligament to relieve pressure placed on the median nerve. According to University of Michigan, cutting the base of the palm of the hand involved with CTS helps the doctor to see the transverse carpal ligament. It is done with local anesthesia, stitches after surgery, and the client gets to go home the same day.
University of Michigan Medicine
***Be aware this video contains graphic images of surgery being performed***
What is Endoscopic Carpal Tunnel Surgery for CTS?
This type of surgery is done using a thin tube with a camera attached. The endoscope will help guide the surgeon through the small incision made on the wrist. The cutting tools for this type of surgery are tiny and will also be inserted along side the endoscope. When the transverse carpal ligament is found, the cutting tool will be used to make cut this ligament freeing the median nerve from pressure.
Endoscopic Carpal Tunnel Surgery
***Be aware this video contains graphic images of surgery being performed***
The question is: which type of surgery would be better for the patient with CTS?
I currently work at an outpatient Physical Therapy clinic, and most (if not all) of my clients had the Open Release done for CTR surgery. I had only seen one Endoscopic Release client, but it was at my prior job. From my experience treating these two post-operations (post-op) for therapy, it appears that the clients I had worked with who had the open release done had more pain and discomfort than the one I had seen with the endoscopic release.
Aforementioned earlier in this blog, CTS symptoms usually occur amongst adults – more frequently among the working adult population. In this case, many working adults who are highly recommended to have surgery done will want to go back to work immediately or as soon as possible. However, this invasive surgery takes time when it comes to the healing process. It is dependent on the individual on how quickly the hand will heal. I have observed an elderly woman in her 90s who had CTR done with the open release option, who had no pain and was able to function normally after several days post-op. Then I remember vividly a teacher who I had worked with in her late 40s who also had the open release surgery done, but it took 4-6 months for the intense pain to subside. She had what was known as pillar pain. In regards to pillar pain, the client I worked with who had endoscopic surgery done did not experience pillar pain.
According to Feller, et al. pillar pain “is a known complication following carpal tunnel release and can be debilitating, causing a decrease in strength and delayed return to work/recreational activities. It is defined as pain and tenderness localized to the prominences of the trapezial ridge, scaphoid tubercle, pisiform or hook of the hamate.”
When planning for CTR surgery, the clients should be given all treatment options for consideration, especially these two options. Expert surgeons continue to debate about carpal tunnel syndrome treatment and the following are their reasoning.
Pro Open Release
Traditional open carpal tunnel release (CTR) gives surgeons full visualization of the hand structures, which may decrease the risk for nerve damage. The trade-off: increased sensitivity.
“Overall, I think that the incidence of complications for an open carpal tunnel release done in experienced hands is very low,” said Simmons, who is also an Orthopedics Today editorial board member. “[It is] probably in the 0.02% complication rate, meaning nerve injury. But, the major thing is the tenderness in the palm.”
Pro Endoscopic Release
James Chow, MD, who is president of the Arthroscopy Association of North America (AANA) and developer of the Chow technique, explained the reasoning behind the benefits of endoscopic release. He states the following:
Endoscopic carpal tunnel release has three purposes: preserve normal anatomical structures, increase safety and avoid serious complications. However, critics of endoscopic surgery state that there is short-term benefits and has increase complications to this surgical option. “This is a misconception. Let’s ask ourselves a few questions. First, what is the fundamental difference between endoscopic and open carpal ligament release?” he said. “The open surgery cuts from the outside in, and the endoscopic procedure cuts from the inside out. Next, where are the important structures? Are they inside the carpal canal or outside the carpal canal? Then ask yourself, which is safer: To cut it before you see it or to see it before you cut it?
Read the full article here: Expert surgeons continue the heated debate about carpal tunnel syndrome treatment
STUDY DONE OF CTR SURGERY: Open Release vs Endoscopic Release
Another article that I found had completed a study to compare both the open release surgery and endoscopic release surgery and post-op conditions regarding pain, sensations, and functionality to go back to work. The study appear to back up the information that Dr. Chow described aforementioned. In this study, 128 employed clients ranging from 25-60 years old were clinically diagnosed and electrophysiologically confirmed with idiopathic carpal tunnel syndrome.
Main outcome measures: The primary outcome that were being observed was the severity of post-operative pain in the scar or proximal palm and the degree to which pain or tenderness limits activities, each rated on a 4 point scale, transformed into a combined score of 0 (none) to 100 (severe pain or tenderness causing severe activity limitation). The secondary outcomes were length of post-operative work absence, severity of symptoms of carpal tunnel syndrome and functional status scores, SF-12 quality of life score, and hand sensation and strength (blinded examiner); follow-up at three and six weeks and three and 12 months.
Results: There were 63 patients who had undergone endoscopic surgery and 65 patients who had open surgery, with no withdrawals or dropouts. Pain in the scar or proximal palm was less prevalent or severe after endoscopic surgery than after open surgery, but the differences were generally small. At three months, pain in the scar or palm was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat 3.4, 95% confidence interval 2.3 to 7.7) and the mean score difference for severity of pain in scar or palm and limitation of activity was 13.3 (5.3 to 21.3). The median length of work absence after surgery was 28 days in both groups. Quality of life measures improved substantially.
Conclusions: In carpal tunnel syndrome, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain.
See the full article: Outcomes of endoscopic surgery compared with open surgery
REFERENCES
Healthwise Staff. (2017). Endoscopic Carpal Tunnel Surgery for Carpal Tunnel Syndrome. Cigna International. Retrieved: May 8, 2019. <https://www.cigna.com/individuals-families/health-wellness/hw/medical-topics/endoscopic-carpal-tunnel-surgery-for-carpal-tunnel-hw212492>.
CCOHS. (2014). Carpal Tunnel Syndrome. Canadian Centre for Occupational Health and Safety. Government of Canada. Retrieved: May 8, 2019. <https://www.ccohs.ca/oshanswers/diseases/carpal.html>.
Healio. (2006). Expert surgeons continue the heated debate about carpal tunnel syndrome treatment. Orthopedics today. Retrieved: May 8, 2019. <https://www.healio.com/orthopedics/hand-wrist/news/online/%7B576e9ea9-2568-4420-bd11-3df553434589%7D/expert-surgeons-continue-the-heated-debate-about-carpal-tunnel-syndrome-treatment>.
Healthwise Staff. (2018). Open Carpal Tunnel Surgery for Carpal Tunnel Syndrome. Michigan Medicine. University of Michigan. Retrieved: May 8, 2019. <https://www.uofmhealth.org/health-library/hw212359#hw212359-Bib>.
ASSH. (2015). Carpal Tunnel Syndrome. American Society for Surgery of the Hand. Retrieved: May 8, 2019. <https://www.assh.org/LinkClick.aspx?fileticket=7ToQme1rt_k%3D&portalid=1>.
Feller, et al. (2017). Prospective Evaluation of Patients Undergoing Carpal Tunnel Release and the Development of Pillar Pain. Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI. Retrieved: May 8, 2019. <https://www.ors.org/Transactions/63/2117.pdf>.
Atroshi, et al. (2006). Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial. US National of Library of Medicine National Institute of Health. NCBI. Retrieved: May 8, 2019. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1482334/>.
Dacus, et al. (2014). Open Carpal Tunnel Release – Dr. Dacus. UVA Hand Center. University of Virginia School of Medicine. Retrieved: May 8, 2019. <https://www.youtube.com/watch?v=HgjpjSGhzt8>.
Yanish. (2011). Endoscopic Carpal Tunnel Release. Retrieved: May 8, 2019. <https://www.youtube.com/watch?v=XA4xaB7MZA4>.