w w w . r b o . o r g . b r
Review
Article
Carpal
tunnel
syndrome
–
Part
II
(treatment)
夽
,
夽夽
Michel
Chammas
a,
Jorge
Boretto
b,
Lauren
Marquardt
Burmann
c,
Renato
Matta
Ramos
c,
Francisco
Santos
Neto
c,
Jefferson
Braga
Silva
c,∗aHandandUpper-LimbSurgeryService,PeripheralNerveSurgery,HospitalLapeyronie,UniversityHospitalCenter,Montpellier,France
bHandSurgeryService,ItalianHospital,BuenosAires,Argentina
cHandSurgeryService,HospitalSãoLucas,PontifíciaUniversidadeCatólicadoRioGrandedoSul(PUC-RS),PortoAlegre,RS,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received10July2013 Accepted28August2013 Availableonline23August2014
Keywords: Carpaltunnel
syndrome/physiopathology Carpaltunnelsyndrome/etiology Carpaltunnelsyndrome/surgery Endoscopy
a
b
s
t
r
a
c
t
Thetreatmentsfornon-deficitformsofcarpaltunnelsyndrome(CTS)arecorticoid infiltra-tionand/oranighttimeimmobilizationbrace.Surgicaltreatment,whichincludessectioning theretinaculumoftheflexors(retinaculotomy),isindicatedincasesofresistanceto conser-vativetreatmentindeficitformsor,morefrequently,inacuteforms.Inminimallyinvasive techniques(endoscopyandmini-open),andeventhoughthelearningcurveislonger,it seemsthatfunctionalrecoveryoccursearlierthanintheclassicalsurgery,butwith iden-ticallong-termresults.Thechoicedependsonthesurgeon,patient,severity,etiologyand availabilityofmaterial.Theresultsaresatisfactoryincloseto90%ofthecases.Recovery ofstrengthrequiresfourtosixmonthsafterregressionofthepainofpillarpaintype.This surgeryhasthereputationofbeingbenignandhasacomplicationrateof0.2–0.5%.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Síndrome
do
túnel
do
carpo
–
Parte
II
(tratamento)
Palavras-chave: Síndromedotúneldo carpo/fisiopatologia Síndromedotúneldo carpo/etiologia
Síndromedotúneldocarpo/cirurgia Endoscopia
r
e
s
u
m
o
Ostratamentosnasformasnãodeficitáriasda síndromedotúneldocarpo(SCC)sãoa infiltrac¸ão decorticoide e/ou umaórtesede imobilizac¸ãonoturna.Otratamento cirúr-gico,quecompreendeasecc¸ãodoretináculodosflexores(retinaculotomia),éindicadoem casoderesistênciaaotratamentoconservadornasformasdeficitáriasou,mais frequente-mente,nasformasagudas.Nastécnicasminimamenteinvasivas(endoscópicaeminiopen), independentementedeacurvadeaprendizadosermaislonga,parecequearecuperac¸ão funcionalémaisprecoceemrelac¸ãoàcirurgiaclássica,mascomosresultadosemlongo prazoidênticos.Aescolhadependedocirurgião,dopaciente,dagravidade,daetiologiaeda
夽
Pleasecitethisarticleas:ChammasM,BorettoJ,BurmannLM,RamosRM,NetoFS,SilvaJB.Síndromedotúneldocarpo–ParteII (tratamento).RevBrasOrtop.2014;49(5):437–45.
夽夽
WorkdevelopedbyamultinationalteamattheHandandUpper-LimbSurgeryService,PeripheralNerveSurgery,HospitalLapeyronie, UniversityHospitalCenter,Montpellier,France,andattheHandSurgeryService,HospitalSãoLucas,PUC-RS,PortoAlegre,Brazil.
∗ Correspondingauthor.
E-mail:jeffmao@terra.com.br(J.B.Silva). http://dx.doi.org/10.1016/j.rboe.2014.08.002
disponibilidadedomaterial.Osresultadossãopróximosde90%decasossatisfatórios.A recuperac¸ãodaforc¸anecessitadequatroaseismesesapósaregressãodasdoresdotipo dordopilar(pillarpain).Essacirurgiatemareputac¸ãodeserbenignaeapresentade0.2%a 0.5%decomplicac¸ões.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Thefirstoperationinwhichtheanteriorannularligamentof thecarpuswassectionedisattributedbyAmadio,1a Cana-dianorthopedist,toHerbertPeterH.Galloway,who,onMarch 11,1924,performedexplorationofthemediannerveatthe carpaltunnelthroughanincisionof2.5cmdistallyand5cm proximally from thewrist flexion crease,in apatient with thenaratrophyandanesthesiaoftheindexfingerandthumb, subsequenttowristcompression.Althoughthepatient recov-ered sensitivity ofthe index finger, shedeveloped painful flexedcontractureofthewrist,whichwasinitiallycorrelated withaneuromaofthecutaneousbranchofthemediannerve.
Treatment
Conservativetreatment
Inrelationtocorticoidinjection,immobilizationbymeansof orthoticbracesand oral corticoid therapy, the levelof evi-dence is sufficient to confirm their effectiveness. There is controversyinrelationtoothertreatments(ultrasound,laser, diuretics,vitaminB6therapyandweightloss).Thereareno recommendationswithscientificproof,andnoconsensuses intheliterature,regardingthestrategytoadopt.2,3
Localinjectionofcorticoid
The action implemented through local corticoid injection comprisesreductionofthetenosynovialvolume,withadirect effecton themedian nerve.Themainriskis injurytothe mediannerve,whichisverypainful,withthesensationofan electricshockandtheriskofdevelopinganeurologicaldeficit andpersistentpain.Anothercomplicationistheriskoftearing thetendon.
Weuseaninjectionpointlocatedfrom4cmproximallyto thewristflexioncreasetohalfwaybetweenthetendonofthe longpalmarmuscleandtheulnarflexorofthecarpus,which isanextensionoftheaxisofthefourthfinger.After perform-inglocalantisepsis,theneedleisslowlyinsertedobliquely,at 45◦ tothecarpaltunnel.Thereshouldnotbeanyabnormal
resistance.Theotherhandisusedtocheckthattheneedleis notintheregionbetweenthetendons,andthefingersare pas-sivelymobilized.Followingthis,theinjectionismadeslowly. Atransitorypainfulreactionmayoccurafewhoursafterthe injection.
Injectionbetweentheradialflexorofthecarpusandthe longpalmarmusclecausesinjurytothemediannerve,given thepositionofthenerve.Dreanoetal.4madetheinjectionon
theulnarsideofthelongpalmarmuscle.DubertandRacasan5 reportedmeasurementsfrom themediannervetothe ten-donsofthelong palmarmuscle,radialflexorofthe carpus andulnarflexorofthecarpus,whichweremade1cm prox-imallytothewristflexioncrease.Theyidentifiedariskzone covering an area up to1cm on each sideof the long pal-martendon.Theyadvisedmakingtheinjectionthroughthe radialflexorofthecarpusatanangleof45◦distallyand45◦to
theulna.Therewouldbenodifferencebetweenaninjection made1to4cmproximallyandaninjectionatthewristflexion crease.6
Reliefisobservedstartingbetweenafewdaysandtwoto threeweeksaftertheapplication.Localinjectionof cortico-steroidshassignificantlygreaterefficacythandoesinjection ofplaceboafteronemonth,andits effectlastslonger than that of oral corticoid therapy over two to three months.7 Temporaryreliefafterlocalcorticoidinjectionisagood pro-gnostic sign for surgicaltreatment.8 Two injections donot havegreaterefficacythanoneinjectionalone.Morethanthree injections are not advisable. The minimum recommended timebetweentwoinjectionsisonemonth.Diabetesmellitusis acontraindication.Incasesofintermittentcarpaltunnel syn-drome(CTS)withoutany deficit,Agarwalet al.9foundthat 93.7% showed improvement clinically and on electroneu-romyography (ENMG)afterthreemonths,and 79% after16 months,with50%showingnormalizationofENMG.Inaseries ofpatientswithorwithoutdeficitwhoweretreatedbymeans ofinfiltrationanduseoforthoticbracesforthreeweeksand followedupforsixto26months,Gelbermanetal.10foundthat only22%didnotpresentsymptomsatthemaximum regres-sion.Thecriteriaforagoodprognosisconsistofpresentation ofsymptomsforlessthanoneyearandabsenceofmotoror sensorydeficit.
Nocturnalimmobilizationbraceswiththewristinneutral position
Modificationofmechanicalandergonomicmeasurements
Reductionofactivity,atleasttemporarily,oftenallowsrelief. Thisisparticularlyso inCTS casesinmenafterexcessive manuallabor.
Onergonomickeyboards,nosignificantdifferenceinterms ofimprovementofsymptoms and abnormalities onENMG wasfoundinrelationtotraditionalkeyboards,amongpatients withprovenCTS.15
Surgicaltreatment
Theprincipleofsurgicaltreatmentistoachieveareduction inintratunnelpressurethroughincreasingthevolumeofthe carpaltunnel,bysectioningtheflexorretinaculum.The proce-dureisdoneunderlocoregionalorlocalanesthesia,ideallyas anoutpatientprocedure,andfrequentlyusingatourniquet. Theprocedure isgenerally unilateral.Threetechniquesare currentlyused:
• Openprocedures;
• Techniquesknownas“mini-open”; • Endoscopictechniques.
Careisrequiredinordertoavoidplacingthemediannerve attheextensionoftheincisionscar,soastominimizethe postoperativeepineuraladherences.
Anesthesiaandcarpaltunnelsurgery
Carpaltunnelsurgerycanbeperformedunderlocal, locore-gional or general anesthesia. In cases of local anesthesia, tolerance of the tourniquet is the main limiting factor. Regarding locoregional anesthesia through blocking the median,ulnarandmusculocutaneoustrunks,thetoleranceof theblocksseemstobeworseinthewristthaninthebrachial canal.16
Infiltrationintothecarpaltunnelinassociationwith infil-tration into the subcutaneous tissue at the level of the incision17providesgreaterreliefforpatientsduringandafter theoperationthandoessubcutaneousinfiltrationalone.18The tourniquetisinflatedaftertheinjection.Useofepinephrine wouldavoidtheneedforatourniquet.
For endoscopic surgery, median, ulnar and musculocu-taneousdistal trunksblocks implemented6cm proximally tothewristflexioncreasemayavoidsoft-tissueinfiltration andhaveaconsiderableinfluenceonendoscopy.According toDelaunay and Chelly,19 after10min, 9%and 32% ofthe patientsrequiredadditionalanesthesia atthe levelsofthe median and ulnar nerves. No partial or total neurological deficitswereobservedaftertheoperation.
Opentechnique
Theopentechniqueistheoldestformoftreatment.An inci-sionof3–4cmismade,extendingfromthewristflexioncrease alongthe prolongationoftheradialedgeofthe fourth fin-gertoKaplan’scardinalline.Thefatpadofthehypothenar region20isinterposedattheendofthesurgerybetweenthe skinandtheflexorretinaculum.Followingthis,themiddle
palmaraponeurosisisincisedradially.Subcutaneous dissec-tionpreservingthesensorybranchesthataresusceptibleto creatingpostoperativepainwasnotshowntobesuperiorto direct incision ofthe flexor retinaculum using a scalpel.21 Hemostasisthroughbipolarcoagulationisarequirement.
Theflexorretinaculum isexposed usingseparators.The dissectionforcepsidentifythehamatehook.Themiddlepart ofthe flexorretinaculumisthen incisedon theulnar side oftheaxis,inthefourthfinger,andanulnarmarginisleft in order tolimit the subluxationofthe flexors. Sectioning oftheflexorretinaculumcontinuescautiouslyinthedistal directionuntilreachingthesuperficialpalmararchandthe median-ulnaranastomosis.Proximally,theflexorretinaculum isseparatedatdeeplevelsfromthesynoviumoftheflexors, usingdissectionscissors.Thecontentofthecarpaltunnelis ascertainedintermsofmuscleabnormalitiesandthe appear-anceofthesynovium.Toviewofthemediannerve,theradial edgeoftheflexorretinaculum needstobecarefullyraised usingaseparator.Themediannerveisthemostsuperficial andradialelement.Theskinisthenclosed.
Associatedprocedures
• Synovectomyoftheflexors:thisisnolongersystematically doneornecessary.Biopsymaybejustifiedincasesofdoubt regardingsecondarysynovitis.Intheeventthatextensive synovectomyisneeded,theproximalcutaneousincisionis extendedtothedistalpartoftheforearm,usingaseparator atthewristflexioncrease.
• Epineurotomyofthemediannerve:thisisnotsuperior22–24 and is no longer recommended, even in situations of deficit. Endoneurolysis is not recommended in pri-mary surgery, because of the risks of adherences and devascularization.25,26
• Explorationofthethenarbranch:theonlyjustificationfor thisinaprimarysurgeryisincasesofextensive synovec-tomy ofthe flexors dueto anatomical variationsand in casesofisolatedmotordeficiency.
• ReleaseofGuyon’scanalincasesofacroparesthesiaofthe fifthfinger:Intheabsenceofcompressionoftheulnarnerve inthewristthatisprovenclinicallyandviaENMG,Guyon release isnotrecommended. Ulnar-mediananastomoses maybeimplicatedifthereisnocompressionoftheulnar nerveintheelboworanyproximalpathologicalcondition (inthecervicalspineorspinalcord).Carpaltunnelsurgery enablesimprovementofthesymptoms.27 Moreover,after endoscopicoropensurgery,thepressureonGuyon’scanal decreasesbytwothirds.28
anydifference between those who were operated classi-cally and those who underwent stretching ofthe flexor retinaculum.32 More recently,treatment consistingof an implantofsiliconeandpolyethyleneterephthalate,sutured usingflapsfromtheflexorretinaculum,wasproposed.Two groupsof400patientswerecompared,andthegroupwith theimplantwasfoundtohavefasterrecoveryofstrength.33 Fiveimplantshadtoberemoved.
• Transfer of thumb opposition (Camitz technique):34 in atrophicformswithadeficit ofopposition,it ispossible to simultaneously perform release of the median nerve and transferofopposition. This indicationis rare, since theshort flexorofthethumb receives ulnar innervation and,despitetheevidentthenaratrophy,thisenables suf-ficientopposition.Iftheoppositionisinsufficient,thelong palmarmuscleisextendedtopartofthesuperficial pal-maraponeurosisand canbeusedasa transferoverthe shortabductor ofthethumb, as wasproposed byLittler andLi.35
Techniquesdescribedas“mini-open”
• Mini-open technique with incision close to the flexor retinaculum:36,37acutaneousincisionof1–1.5cmismade inthedistalpartoftheflexorretinaculum,startingfrom Kaplan’scardinalline,ontheaxisoftheradialedgeofthe fourthfinger.Theflexorretinaculumistheninciseddistally, inthedistal-to-proximaldirectionusingscissorsbymeans ofspacers,asfarastheproximalpart.Aseriespublishedin 2003didnotpresentbetterresults.36
• Mini-open technique with incision at the wrist flexion crease:the flexorretinaculumisnotviewedand thereis nointerposition,withapotentialriskofiatrogenicinjury and/or incomplete sectioning of the flexor retinaculum. Paine and Polyzoidis38 used a “retinaculotome” to pro-tectthecontentofthecarpaltunnel.Durandeau39useda probechannel forthis functionand thisisthe preferred technique.
• Mini-opentechniquewithdoubleedges:withadistaledge tohelpprotecttheneurovascularelements.Theflexor reti-naculum isagain not view, exceptwhen sectioned. The techniquesofChaiseetal.40andBowersasmentionedby Beckenbaugh41canbecited,withtheadditionofaproximal incision,1cmdistallyfromthehamatehook,witha protec-tionretractor.LeeandStrickland42 usedaspecialscalpel withtransillumination.
Endoscopicsurgeryonthecarpaltunnel
EndoscopicsurgeryonthecarpaltunnelwasstartedinJapan byOkutsu,43andthenintheUnitedStatesbyChow.44Chow’s techniqueinvolves twosurgicalapproaches,and complica-tionsinherenttothedistalincisionhavelimiteditsuse,thus favoringthetechniqueofAgeeetal.,45 whichusesasingle proximalincision.Furthermore,becausethewristisplacedin hyperextensioninChow’stechnique,theintratunnelpressure isconsiderablyincreased,whichmaycauseacute compres-sion of the median nerve before the operation. A longer learningcurveisrequired.
Agee’stechnique
Agee’s technique is the one that is used most, performed under regional anesthesia after performing local antisep-sis. Theapproach route isoflength 1cm, at adistanceof 0.5–1.0cmproximallytothewristflexioncrease,overtheulnar edgeofthe longpalmar muscle.Thesubcutaneous dissec-tionmakesitpossibletoexposethefasciaoftheforearm.It needstobecheckedwhethertheincisionisinthe extrabur-salspace.Adisposablebladeisused,lubricatedonitsdeep surface to facilitateits introduction, whichis done on the axisofthefourthfinger.Progressionoftheincisionisslow, under endoscopic control, bymeans ofsliding the dispos-ablebladeagainstthedeepsurfaceoftheflexorretinaculum. If viewingisimperfectorintroduction ofthe instrumentis difficult,theoperationshouldbeconvertedintoanopen pro-cedure.Thepatientshouldbeinformedaboutthepossibility ofconversion beforethe procedure isstarted.The incision should progressuntilthe distalfat padisseen.Sectioning oftheflexorretinaculumisstarteddistally,levelwiththefat pad.
Postoperativeperiod
Finger mobilization is possible starting in the immediate postoperativeperiod.Thestitchescanberemovedfromthe 15th day onwards. Activities requiring force are reintro-ducedpartiallyafterthreeweeksandcompletelyaftersixto eightweeks.Someauthorshaveadvisedusingpostoperative bandaging fortwotothreeweeks,withtheaimsof dimin-ishingpillarpain46andprovidingbetterhealingoftheflexor retinaculum.Onthe other hand,immobilizationmayfavor postoperative epineuraladherences.Thesuperiority ofthis immobilizationwasdemonstratedbyFinsenetal.47andBury etal.,48therebydisagreeingwithChaise.49
Resultsfromcarpaltunnelsurgery
Favorableevolution
ofsickleaveof29daysiftheywerenon-employed,42daysif theywereprivate-sectoremployeesand63daysiftheywere publicsectoremployees.
Prognosticfactors
Inananalysisoftheliterature,Turneretal.50foundthatthe worseresultswereobservedinthefollowingcases:
• Diabetesmellituswithpolyneuropathyandimpaired gen-eralcondition;
• Useofalcoholandtobacco; • PreoperativenormalENMGresults; • Occupationaldiseases;
• Thenaramyotrophy;
• Multiplenervecompressionsyndromes.
Comparisonsbetweenopen,mini-openandendoscopic surgery
Both open and endoscopic techniques are widely used. Increased carpal tunnel volume has been observed inde-pendently of the technique used for sectioning the flexor retinaculum.After open surgery, an increasein volume of 24.2±11.6%wasobserved,withpalmardisplacementofthe content of 3.5±1.9mm.51 After endoscopic surgery, the increaseinthesectionedareawasestimatedas33±15%.52
Safety,efficacy,morbidity,costandtimetaken toreturn topreoperativeactivitieshavebeencompared.Thelearning curveislongerforendoscopicsurgery.Onestudyfoundthat, oneyearaftertheoperation,therewasnodifferencebetween thetwotechniques.53Ontheotherhand,somestudieshave demonstratedthatendoscopicsurgeryenablesearlier func-tionalrecovery,especiallyoverthefirstthreemonths.31,54–57 Painatthe siteofthe surgeryhasbeen lessobservedafter Atroshi’sendoscopy.58,59 Eightstudiesoutof14showedthat therewasafasterreturntoworkafterendoscopy,witha dif-ferenceofbetweensixand25days.60However,thiscontinues tobeamatterofcontroversy,suchthattherearestudies show-ing that each of the techniqueswas superior to the other one.61
Few studies have compared endoscopy with the mini-opentechnique, and the resultshaveeitherbeen identical orhavefavoredendoscopicsurgeryregardingpostoperative pain.60AccordingtoWongetal.,62thetechniqueofLeeand Strickland42seemedtoleadtolesspostoperativepainthan didChow’sendoscopictechnique.
In comparing conventional surgery with the mini-open technique,theresultsareinconclusive,withsomeshort-term advantagesforthemini-openprocedure.60Ontheotherhand, theriskofincompletesectioningoftheflexorretinaculumis higherwiththemini-opentechnique.63
Thechoicebetweenopen,mini-openorendoscopicsurgery dependsonthesurgeon’spreferencesandhabits,64the infor-mationavailabletothepatient,thetypeofCTS,itsetiology andtheavailabilityofequipment.
ComplicationsfromsurgicaltreatmentofCTS
Theminorcomplicationsneedtobedistinguishedfromthe severecomplications.
Minorcomplications
Neurogenicpaininthescar
Fournervebranchesinvolvedininnervationofthepalmofthe hand atthe levelofthethenarand hypothenareminences are considered to beat risk in making an incision in the carpaltunnel.65 Someofthesebranches maycrosstheline thatpassesalongtheradialedgeofthefourthfinger.These branchesmaybecomeinjuredthroughtheincisionandresult inscarpainofneuromatoussyndrometype.
• Thepalmarcutaneousbranchofthemediannerve; • Thepalmar cutaneousbranchofthe ulnar nerve, which
emergesaround4.6cmproximallytothepisiformbone; • TheHenlénerveornervivasorumoftheulnarartery,which
participatesintheinnervationofthehypothenareminence in40%ofthecases;
• Thepalmartransversebranchesoftheulnarnerve,which originateinGuyon’scanaland innervate theskin inthe hypothenareminenceandpalmofthehand,intheareaof thepalmarcutaneousbranchoftheulnarnerveandHenlé nerve.
These painsarenotnormallyobservedafterendoscopic surgery.Evenwiththeclassicalincisionofthecarpaltunnel thatisrecommendedfortheprolongationoftheradialedge ofthefourthfinger,thereisnoabsolutesafetyzone,giventhe overlappingoftheareasofproximalinnervation.65,66Ozcanli advocatedthemini-opentechniquewithanincision inthe distalpartoftheflexorretinaculumbetweenthesuperficial palmararchandthedistalpartofareaofthepalmar cuta-neousbranchofthemediannerve,aspresentinglessriskof lesionsinthesuperficialnerveramifications.67However,ithas notbeendemonstratedthattheaccessopenedinthe mini-opentechnique,inthedistalpartoftheflexorretinaculum,is freefromthistypeofcomplication.36
Pillarpainorpainattheulnaredge46
Postoperativepainatthelevelofthehypothenareminence and, by analogy, at the level of the thenar eminence, is expected inthe initialphase.There isconcomitant edema inrelationtotheflexorretinaculum.Clinicalpersistenceas problemsinrecoveringactivitylevels,withlossofstrength, isfortunatelylessfrequent(1–36%ofthecases)46,68andthis may beobserved independently ofthetype ofsurgery.36,68 The pain is related to the insertions of the thenar and hypothenarmusclesattheedgesoftheflexorretinaculum, approximately at the level of the pisiform-triquetral joint, evenwithminimalmanualactivities.Theedemarelatingto sectioningtheflexorretinaculumgenerallydiminishes con-comitantlywithimprovementofthepillarpain.Ithasnotbeen demonstratedthatpostoperativeimmobilizationpreventthis complication.47,48 Itistreatedthroughnewimmobilization, reductionofactivitiesandsymptomatictreatmentwith corti-coidinfiltration.
Algoneurodystrophy
associatedwithbruisingoracutecompressionofthemedian nerveoverthecourseoftheoperation.
Instabilityoftheulnarflexortendonsthroughsectioningthe flexorretinaculum
Instabilityoftheulnarflexortendonsismarkedbyseverepain ontheulnaredgeofthecarpaltunnel,whichreturnstothe forearmonthepathoftheulnarflexorofthefingers. Section-ingoftheflexorretinaculumleavingaflapoverthehamate hookreducesthefrequency.Persistenceisrare.Thisis excep-tionallyobservedafterendoscopicsurgery,causedbythesize oftheendoscope,andleavesanedgeoftheflexorretinaculum on the ulnar side. Reconstruction of the flexor retina-culumtheoreticallymakesitpossibletoavoidthisprocess.
Complicationsofgreaterseverity
Complicationsofgreaterseverityarerare.Thisisemphasized bythe fact that this surgery, inthe minds ofthe present-daypopulation,isassociatedwithhighlysatisfactoryresults. Ina reviewofthe literaturecoveringthe period1966–2001 foropensurgeryand1989–2001forendoscopicsurgery, Ben-sonetal.69 foundthattherateofseverecomplicationswas 0.49%foropensurgeryand0.19%forendoscopy.Prevention should be prioritized, especially in casesof endoscopic or mini-opensurgery.
Nervecomplications:Theseconsistoftransitoryneuropraxia (1.45% after endoscopy and 0.5% after open surgery), par-tial or complete sectioning of the median or ulnar nerve (0.14%duringendoscopyand0.11%duringopensurgery)or oftheir branches (0.03%during endoscopyand 0.39% dur-ing opensurgery).69 Lesions ofthecommon palmardigital nerveofthethirdspaceand ofthe communicatingbranch betweenthe commonpalmardigitalnerveofthethirdand fourthspacescanparticularlybecited.Thesemaybeinjured inendoscopicsurgery withtwoincision routesor in mini-opensurgery.Theanastomosedbranchislocatedbetween2.3 and10mmfromthedistaledgeoftheflexorretinaculum.70 Incasesofpartialortotalsectioningofthenerve,theresult fromsurgicaltreatment,whichshouldbeperformedearlyon, isincomplete,withsomesevereanddefinitiveresidualpains.
Injurytothesuperficialvasculararch
Injurytothesuperficialvasculararchisreportedin0.02%of thecases.69Thesuperficialvasculararchisclosetothedistal edgeoftheflexorretinaculum.Bothmethodsenable identifi-cationofitscutaneousprojection.
• Kaplan’s cardinal line: This was described by Kaplan in 1953.Itstartsfromthedeepestpointofthefirst commis-sureandheadstowardtheulnarsideofthehand,parallel totheproximalpalmarcrease.Thesuperficialpalmararch islocatedatleast7mmfromKaplan’slineontheaxisof theradialedgeofthefourthfinger.71Thepointofmuscle penetrationofthethenarbranchislocatedbetween0.1and 1.5cmproximally,alongtheprojectionoftheradialedgeof thethirdfinger.
• Cobb’smarks: These makeitpossibletobetter locatethe hamatehook,72giventhattheydonotdependonpossible trapeziometacarpalstiffness.Thehookisatthe intersec-tionpointbetweentwolines:onefromthepisiformbone
totheproximalpalmarcreaseinrelationtotheaxisofthe indexfinger;andtheotherjoiningthemiddleofthebase ofthefourthfingertothe unionofthemiddlethirdand medialthirdofthewristflexioncrease.Thesuperficial pal-mararchisatameandistanceof2.7cm(range:1.8–4.5cm) distallyfromthehook.
Sectioningoftheflexortendonsofthefingers.
Sectioningoftheflexortendonsofthefingers hasbeen reportedafterendoscopicsurgery(0.008%).69
Informationforpatients
Thesurgeonneedstobeabletoprovethathereallygave infor-mationtohispatient.Provisionofpreoperativeinformation islegally indispensable,evenif it ispoorlyretained bythe patient.73Thiscanbedoneorally,butitisdifficulttoprove.The bestwayistogiveinformationorallyandinwriting,usingan informedconsentformthatmentionsthecomplications,even iftheseareexceptional.Asummaryofthekeyelementstobe includedwasproposedbyGoubieretal.74In2000,Julliard75 observedthatalmostthreequartersoftheprocesseswere con-secutiveandthatonequarteroftheprocedureswerepoorly justifiedduetotechnicalfailures:sectioningofnerves, infec-tion,ineffectivereintervention,etc.
TherapeuticindicationsinCTScases
AcuteCTS
Post-traumatic:Thesecasesessentiallyoccurafterfracturing ofthe distalradiusorperilunatedislocationofthecarpus. Compressionthatworsensprogressivelyneedstobe distin-guishedfrombruisingwithemblematicsymptomsandlittle edema,whichinprincipledoesnotrequiresurgicaltreatment. Incasesofcompressionwithoutsignsofdeficit,urgent reduc-tionofthedisplacementisoftensufficientforthesymptoms andcompressiontoregress.Incasesofformsofdeficitor sig-nificantedema,urgentsurgicaltreatmentisnecessary.There isroomforopensurgery.
Non-traumatic:Urgentsurgicaltreatmentisnecessary
SubacuteorchronicCTS
Non-surgical first-intentiontreatment is indicated in early forms. In intermediate forms, with nocturnal and diurnal acroparesthesia,itsefficacywillbelowerandthereisa signif-icantriskofevolutiontoaformpresentingadeficit.Primary medical treatmentor combined surgicaltreatmentmay be proposedaccordingtothecontext.
Informsthatareresistanttoconservativetreatmentand advancedformspresentingadeficit,therecommended treat-ment is surgical. Thecontraindications againstendoscopic surgeryinclude:76
• Motorformalone;
• Acutecarpaltunnelsyndrome;
• Hypertrophicsynovialpathologicalconditionsthatrequire extensive synovectomy, and intracanalicular tumoral lesions;
• Formswithdeficitincasesofasmallwrist(riskof preoper-ativehypertension).
Persistenceofsymptoms,recurrenceornewsymptoms
Inarecentanalysisonthecausesofreinterventionsurgeryin 200casesthatwereoperatedovera26-monthperiod,Stutz et al.77 found that therewas incomplete sectioning ofthe flexorretinaculumin54%;perineuralfibrosisin32% (adher-encetotheanteriorscarin23%andcircumferentialfibrosisin 9%)andiatrogenicnerveinjuryin6%.
Intheabsenceofaproximalcause,threeclinicalconditions mayjustifyreinterventionafterCTSsurgery,withfrequencies rangingfrom0.3%to12%,accordingtotheauthors.78
Persistence of symptoms: This is the commonest compli-cation after CTS surgery, mainly because of incomplete sectioningoftheflexorretinaculum,mostofteninthe dis-talportion.AccordingtoDeSmet,79incompletesectioningof the flexor retinaculum at this level is responsible for per-sistence of a positive Phalen test during the immediate postoperativeperiod,absenceofafreeinterval,persistenceof symptomsandpositivechallengetests.ENMGabnormalities maypersistdespiteeffectiverelease,butENMGnormalization eliminatespersistenceofcompression.Openreintervention surgeryisjustifiedinprinciple.
Recurrence of symptoms: After a free interval of several months(arbitrarily three), the symptoms may reappear at atimeoftrauma(fracturingofthewristorofbothforearm bones);a time ofinflammatory crisis(tenosynovitis ofthe flexors);afterhealingandreconstructionoftheflexor retinac-ulum;orafterprogressiveimprisonmentofthemediannerve inaperineuralfibrousscar,whichisresponsiblefora syn-dromeofadherencesorHunter’s“tractionneuropathy”.80 It wasonlythislastetiologythatWulle81consideredtobea“real recurrence”.Inadditiontorecurrencesofsymptoms,a pos-itive clinical examinationmay suggest that asyndrome of epineuraladherencesispresent.TheENMGresultsmayagain beabnormal.Proceduresassociatedwithnewnervereleases in order to restore the glide planes between the median nerveanditsareaareoftennecessary,suchastoconstruct asynovialflap,81hypothenarfatflap,73pedunculatedflap,82 biomaterials33ormaterialsforpreventingadherences.78
Appearanceofnewsymptoms:Thesearemainlysecondary toiatrogenicinjuriesthathaveoccurredover thecourseof releasingthecarpaltunnel.Thesemaybeinrelationtonerves (trunk of the median nerve, thenar branch, palmar digital nervesorpalmarcutaneousbranch)orinrelationtotendons. Theymayoccurseparatelyorincombinationwithoneofthe abovetwo clinical conditions.Nerve repairofthe terminal brancheshastheaimsofenablingrecoveryofsensitivityand decreasedneurogenicpain.Incasesofneuromaofthe pal-marcutaneousbranch,desensitizationisindicatedand,ifthis shouldfail,confinement.Repairofthethenarbranchis indi-catedincasesoffunctionalalterationwiththepotentialfor regeneration,accordingtothesiteinjured.
Finalremarks
Clinical knowledge about symptoms is decisive for imple-mentingthemostappropriatetreatment,particularlyincases
ofestablishinghowurgentsurgeryand postoperative treat-ment are.Inaddition,when someclinicaltreatmentssuch as corticoid injection present positive responses, this may determinetheprognosisforthesurgicaltreatmentandthus confirmthepossibilityofcombiningtreatmentsforabetter result fora particularpatient, givenhis or her comorbidi-ties.However,manyproceduresmay leadtocomplications: amongthesmallerofthese,neurogenicpaininthescarand pillarpain arethe commonesttypes.Fortunately,although themajorcomplicationsaremoresevere,theyarerare.Thus, thedecisionregardinghowtoproceedafterthediagnosisis theresponsibilitybothofthedoctor,indefiningthebest treat-mentoptions,andofthepatient,whoshouldbeawareofall thecomplicationspossiblefromthetreatmentchosen.
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