A Minor Surgery

A minor disease

AND

Carpal Tunnel SyndromeThe Mother Hospital Experience

with mini open releaseDr.Ram Mohan.K.P;

Dr.Dejo.A.J, Prof.Sunny Pazhayatil

Carpal Tunnel syndrome

• First described by Paget in 1854, Carpal Tunnel Syndrome (CTS) remains a puzzling and disabling condition

• It is a compressive neuropathy, caused by mechanical distortion produced by a compressive force

• CTS is the most well-known and frequent form of median nerve entrapment , and accounts for 90% of all entrapment neuropathies .

• An entrapment neuropathy is a chronic focal compressive neuropathy caused by a pressure increase inside non-flexible anatomical structures .

• CTS is caused by entrapment of the median nerve at the level of the Wrist, delimitated by the carpal bones and by the transverse carpal ligament ..

ANATOMY• The carpal tunnel is composed of a bony canal,

consisting of carpal bones, the roof of which is the fibrous but rigid transverse carpal ligament.

• The carpal tunnel contains the nine flexor tendons and the median nerve.

• Sensory branches from the median nerve supply the 3 radial digits and the radial half fourth digit

• The palmar sensory cutaneous branch of the median nerve supplies the cutaneous skin of the palm, and arises, on average, 6 cm proximal to the transverse carpal ligament (TCL) but may pierce at different levels

Area supplied by the median nerve

Transverse carpal ligament

Median nerve

Superficial palmar arch

EPIDEMIOLOGY• Incidence rates of up to 276:100,000 per year have

been reported .• More common in females than in males.• Occurrence is common bilaterally with a peak age range

of 40 to 60 years; although it occurs in all age groups.• an increase incidence is reported in work-related

musculoskeletal disorders caused by strain and repeated movements

• Diabetic patients have a prevalence rate of 14% and 30% without and with diabetic neuropathy,

• the prevalence of CTS during pregnancy has been reported to be around 2%

CLINICAL PRESENTATION

• Primary features of CTS include pain in the hand, unpleasant tingling, pain or numbness in the distal distribution of the median nerve

• Many patients report symptoms outside the distribution of the median nerve as well

• Reduction of the grip strength and function of the affected hand .

• Symptoms tend to be worse at night, and clumsiness is reported during the day with activities requiring wrist flexion

Stages:• Stage 1: Patients have frequent awakenings during

the night with a sensation of a swollen, numb hand., and an annoying tingling in their hand and fingers (brachialgia paraesthetica nocturna). Hand shaking (the flick sign) relives the symptoms.

• Stage 2: The symptoms are present also during the day, mostly when the patient remains in the same position for a long time. When motor deficit appears, the patient reports that objects often fall from hands

• Stage 3: This is the final stage in which atrophy (wasting) of the thenar eminence is evident,. In this phase, sensory symptoms may diminish..

Medical risk factors

• 1. extrinsic factors that increase the volume within the tunnel ---pregnancy, menopause, obesity, renal failure, hypothyroidism, the use of oral contraceptives and congestive heart failure

• intrinsic factors within the nerve--tumours and tumour-like lesion

• extrinsic factors that alter the contour of the tunnel-malunited fractures of the distal radius, directly or via posttraumatic arthritis

• Neuropathic factors, such as diabetes, alcoholism,• and exposure to toxins

Nerve Injury

• Demyelination occurs when the nerve is repetitively subjected to mechanical forces

• The median nerve will move up to 9.6 mm with wrist flexion and slightly less with extension .

• Chronic compression results in fibrosis, which inhibits nerve gliding, leading to injury and therefore scarring of the mesoneurium.

• This causes the nerve to adhere to the surrounding tissue, resulting in traction of the nerve during movement as the nerve attempts to glide from this fixed position-Nerve Tethering

provocative tests• Phalen’s test, the patient is asked to flex their wrist and

keep it in that position for 60 seconds. A positive response is if it leads to pain or paraesthesia in the distribution of the median nerve

• Tourniquet test A positive result is the development of paresthesia in the distribution of the median nerve when a blood pressure cuff around the patient’s arm is inflated to above systolic pressure for a minute or two

• Tinel’s test is performed by tapping over the volar surface of the wrist. A positive response is if this causes paraesthesia in the fingers innervated by the median nerve

Surgical treatments

• Carpal tunnel release (CTR) is the most common hand and wrist surgery performed in the US, with an estimated 400,000 operations performed per year

• Open carpal tunnel release (OCTR) ( Classical Full-open and Mini-open)• and endoscopic carpal tunnel release (ECTR)

OCTR

Mini-open carpal tunnel release

minimal incision release offered superior outcomes in terms of symptom relief, functional status, and scar tenderness.Mini incision CTR had superior outcomesover the standard technique in terms of recovery time, pillarpain, and recurrence rate

Endoscopic carpal tunnel releaseIt is assumed that preservation ofthe superficial fascia and adipose tissue over the flexor retinaculum allows faster recovery of grip strength, less scar tenderness and pillar pain, and earlier return to work

In recent studies comparingOCTR and two portal ECTR, Atroshi et al37 reported that he outcomes were equivalent, other than ECTR offering ashorter recovery period. However, critics of ECTR reporthigher complication rates due to the technical difficulty of the procedure, as well as greater cost when compared with OCTR.

Patients who underwent Carpal Tunnel release in Dept.of Orthopaedics during 2000-2014

Total patients-348No.of hands operated-452

Total patients Total hands0

50100150200250300350400450500

Gender –females—304(87%) males-----44(13%)

among 304 females167---post menopausal (55%)137 ---pre menopausal (45%)

male female0

50100150200250300350

Series 1

Age wise Break up(Range—22 yrs to 74 yrs)

• 20-30yrs- 34 Pts (8%) • 30-40yrs -85Pts(24%)• 40-50yrs- 122Pts (35%) • 50-60yrs- 90 Pts(26%)• 60-70Yrs- 16 Pts(6%)• Above 70yrs—1 pt • Total—348 Pts

40-50yrs

60-70yrs

Year wise breakup ;No. of hands operated(452)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

10

20

30

40

50

60

70

Dr. R M-214hands166Pts Dr.Dejo-206hands,159PtsDr.Sunny -29Hands,20Pts

Dr.MPJ-3Hands,3PtsNeurosurgery-48 hands,40 Pts

Dr. R M Dr.Dejo Dr.Sunny Dr.MPJ Neurosurgery0

50

100

150

200

250

Reference pattern

• Mother hospital Neurologists• Dr.Abdul Majeed---------178 pts• Dr.Firoz Khan--------------- 54 pts• Other doctors of Mother hospital—34 pts• Outside doctors---------24 pts• Self diagnosed by surgeon----58 pts

Presenting symptoms in our patients

• Pain,Numbness and paraesthesia of hands (95%)

The sensory symptoms were not essentially restricted to median sensory distribution and 20% had symptoms in whole hand in spite of close questioning

• 40 % had aching extending to forearm and arm up to shoulder

• Nocturnal paraesthesia interfering with sleep (85%)----This was the most distressing symptom that made patients come forward, ready for surgery

• Patients will wake up around 1 to 2 AM and flick and wave their hands and massage which gave some relief and they can continue the sleep

Activities of daily living

• Severe numbness on holding objects like knife or broom—66%

• Numbness while holding Hand- bar while travelling in a bus-50%

• Distressing numbness while holding a phone-25%( Recently more on holding a mobile for lengthy conversations)

• Inability to appreciate texture of a cloth-15%

Motor disabilities

• Frequent falling down of objects from hand-35%

• Inability to perform fine activities like threading a needle—25%

• Workplace disabilities• Compromised household chores• Altered signature --6 pts• Writers cramps----4 pts

• Out 304 female pts, 200 pts(66%) were house wives

• Among 104 working female patients, 46 pts were doing clerical work, 38 pts were doing heavy work like in

construction, 12 were house servants , 4 were Lady doctors and 4 were nurses• All 48 male patients were doing reasonably

heavy work and 11 of them were carpenters

NERVE CONDUCTION STUDIES

• Gold standard in the diagnosis of CTS.• The standard method of diagnosis is comparing the

latency and amplitude of a median nerve segment across the carpal tunnel to another nerve segment that does not go through the carpal tunnel, such as the radial or ulnar nerve.

• The nerve is stimulated by transcutaneous pulse of electricity, which induces an action potential in the nerve. A recording electrode, placed either distally or proximally, detects the wave of depolarization as it passes by the surface electrode

Nerve Conduction Analysis

• Negative CTS: Normal findings on all tests (including comparative and segmental studies)

• Minimal CTS: Abnormal findings only on comparative or segmental tests

• Mild CTS: SCV slowed in the finger-wrist tract with normal DML(distal motor latency)

• Moderate CTS: SCV slowed in the finger-wrist tract with increased DML

• Severe CTS: Absence of sensory response in the finger-wrist tract with increased DML

• Extreme CTS: Absence of thenar motor response

Nerve conduction study in our patients

• All 452 hands operated in 348 patients had NCS done

• Moderate CTS—262 Hands(58%)• Severe CTS-------174 Hands(38%)• Extreme CTS----- 16 Hands (4%)• Of the 244 patients who had one hand release

only, the opposite hand showed mild CTS in 178 patients and 66 had normal study

• 73 patients who underwent simultaneous bilateral release had bilateral symmetric findings in 48 patients and varying severity in 25 patients

• Of the 31 patients who came for second hand release at a later date, 14 had mild CTS in unoperated hand and 10 had moderate CTS and 7 had severe at initial NCS

Co-relation of NCS findings and clinical features

• In majority of patients, NCS findings co related well with clinical features

• 25 hands which had Mild CTS in NCS had distressing parasthesia ,but most of them settled without surgery

• We had operated only on moderately severe and higher grades of CTS .

• Temporary CTS may occur in pregnancy , lactation etc

Delayed Second hand release in Patients operated on One hand initially

Total no of patients---31 Second release time interval range- 9 Days to 9 YrsLess than 3 months—11 Pts 3 Months to 1 Yr------ 71 Yr to 5 yrs----------- 55 yrs to 9 yrs------------8Patients coming to the same institution for second

surgery may imply success of initial surgery!!

• 104 patients had bilateral release • 244 patients had only One hand release These patients on follow up up to 5 yrs were

relatively symptomless on un-operated hand even though initial NCS had shown mild (180) and moderate(64) conduction delay

No knowledge of patients undergoing second hand surgery elsewhere

It may indicate a spontaneous regression of symptoms in mild cases

Associated surgical releases

• Trigger finger------58 patients(17%)• Simultaneous release----20• Delayed release---------- 20• Local steroid injection-- 8

• Simultaneous Dequervains release-18 patients

Associated diseases

• Hypothyroidism-----52 patients(15%) ( Pre existing—34 Pts Newly diagnosed—18)• Rheumatoid arthritis------31 Patients(9%)• Cervical spondylosis-------32 Patients• Diabetes mellitus--------76 (22%)• Hypertension-------------56• Malunited distal radius fracture---4• Ganglion in carpal tunnel------2

Anasthesia

• Local xylocaine infilteration anaesthesia- in 336 of 348 patients (97%)• Intravenous regional analgesia---6 patients

• General anaesthesia ---6 pts ,all bilateral, on patients request

Tourniquette

• Pneumatic tourniqutte used in all cases• Average tourniqutte inflation time was 13 mts• When inflation exceeded 20 mts patients

generally complained of discomfort and intolerance

• Average pressure of inflation was 270 mm of Hg

The Procedure

OP procedure- 164 pts 1 day Admission- 180 pts 2 days admission- 4 pts

OP procedure

1 day Adm

2 days adm

0 20 40 60 80 100 120 140 160 180

No of ptsColumn1Column2

Complications

• Intra-operative• Injury to Median nerve----Nil• Injury to superficial palmar arch---3• Injury to palmar cutaneous branch of Median

N.--------------2• Inadequate Anaesthesia---3• Tourniquet paralysis--Nil

• Wound healing problems---56 patients• Skin dehiscence after suture removal, delayed

skin healing• This was especially noticed in patients doing hard

work with thick, scarred palmar skin• Infection Superficial infection------13 PtsDeep infection---1 patientIn spite of delay in skin healing, all these patients

had a well acceptable scar and none had scar hypertrophy or scar complaints

Delayed skin healing

Old large incision release in Rt hand and recent mini open on Lt.side

Invisible scar in a bilateral case

Thenar wasting not recovered after 3 yrs

Pillar pain

• (tenderness adjacent to the actual ligament release, where the prominences of the trapezial ridge and the hook of the hamate are closest to the skin.

• The transverse retinacular ligament, divided during carpal tunnel release, attaches to these structures, and the inflammatory reaction of normal wound healing is most obvious at these points, often more than the central area of the actual release

Follow up

• We had follow up ranging from 3 months to 13 yrs

• I personally had opportunity to review 25 patients after a period of 5 yrs after surgery

and 8 patients ,beyond 10 yrs• These long follow ups were mainly when they

came for some other problems and incidentally mentioned old surgery

Follow up

Range—3 months to 13yrs8-cases— >10yrs55 cases---- 5-10 yrs62 cases----- 2 to 5yrs68 cases-----1 to 2 yrs61 cases-----4months to 1 yr94 patients –3 months and then lost to follow up

Results analyzed based on following criteria

• Relief of distressing nocturnal parasthesia interfering with sleep

• Relief of numbness on activities of daily living• Relief of motor symptoms• Pain over scar or other parts of hand including “pillar

pain”• Return to previous activities and work• Regaining of motor power and improvement in Thenar

muscle wasting, Grip and pinch strength• Overall satisfaction of patients

Recovery patterns

• Relief of distressing Numbness and sleep interference---Immediate in all patients

• Some parasthesia and numbness remained upto 3 Months in 25 % of patients

• Tips of middle and index fingers were the last to recover• 22% had some form scar tenderness and pillar pain lasting for 1

to 4 months and then spontaneously regressed• All patients had functional and symptomatic improvement at 3

and 6 months• The Thenar wasting showed only marginal recovery in patients

with wasting but there was subjective improvement in motor power

Average time delay before return to work and previous lifestyle

• 2 weeks or less-----180 pts(52%)

• 2-4 wks-------------94 pts(28%)

• 4-6 wks-------------74 pts(20%)

Analysis of results as per patients perception

• Excellent—210pts (60%)

• Good-------114 Pts (32%)

• Fair----------24 Pts (8%)

• Poor---------Nil

Fair(8%)

Good(32%)

Excellent(60%)

Discussion

• CTS is a widely prevalent condition in the middle aged female.

• Hypothyroidism and rheumatoid arthritis patients are more likely to develop CTS.

• Incidence in Diabetic patients are higher• No special occupational hazard could be

noticed in our pts. except an increased incidence in male carpenters

Discussion

• Surgical decompression is the only sure way to give lasting relief to patients with moderate and severe comprssion of CT while milder form of disease may alleviate with conservative measures like splinting, drugs or local steroids

• The mini open method of CT release is safe and cheap procedure with predictable good results

• Immediate wound healing problems are the main problem in OCTR due to peculiarity of palmar skin and ECTR may have higher favorable results in this regard.

• Use of tourniqutte helps the procedure considerably and does not have much risk if used carefully

• The relief provided is lasting and recurrence rate is nil if executed properly

• In severe cases with thenar atrophy, regaining motor power is unpredictable

Acknowledgments

• Dr.Dejo.A.J• Prof.Sunny Pazhayatil• Dr.M.P.Joseph• Dr.Abdul Majeed• Dr.Firoz Khan• Mother hospital managment

Thank you for Listening