Features

New frontier in carpal tunnel surgery – endoscopic carpal tunnel release

By Dr. Dineshani Hettiarachchi Sirisena

Carpal tunnel syndrome is the most common nerve compression syndrome worldwide. Endoscopic carpal tunnel release (ECTR) has gained recognition as an alternative to the current gold standard, the open carpal tunnel release (OCTR).

Thus far, eight successful surgeries have been performed locally.

Consultant Plastic and Reconstructive Surgeon Dr. Kavinda Rajapakse MBBS, MD (Surgery), MRCS (UK).

To find out more about this procedure, we spoke to Consultant Plastic and Reconstructive Surgeon at the Army Hospital Colombo, Dr. Kavinda Rajapakse MBBS, MD (Surgery), MRCS (UK).

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist.

The carpal tunnel is a narrow, rigid passageway of ligaments and bones at the base of the hand. It houses the median nerve and the tendons that help bend your fingers.

The median nerve provides feeling to the palmer side of the thumb and to the index finger, middle finger, and part of the ring finger (although not the little finger). It also controls some small muscles at the base of the thumb.

Sometimes, thickening from the lining of irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. The result may be numbness, weakness, or sometimes pain in the hand and wrist, occasionally also in the forearm and arm. CTS is the most common and widely known of the entrapment neuropathies, in which one of the body’s peripheral nerves is pressed upon.

How do you know if you have CTS?

Carpal tunnel syndrome symptoms usually start gradually.

Common carpal tunnel syndrome symptoms include:

Tingling or numbness. You may experience tingling and numbness in your fingers or hand. Usually, the thumb, index, middle, or ring fingers are affected, but not your little finger. Sometimes, there is a sensation like an electric shock in these fingers.

Endoscopic carpel tunnel release

The sensation may travel from your wrist up your arm. These symptoms often occur while holding a steering wheel, phone, or newspaper. The sensation may wake you from sleep.

Many people “shake out” their hands to try to relieve their symptoms. The numb feeling may become constant over time.

Weakness. You may experience weakness in your hand and a tendency to drop objects. This may be due to the numbness in your hand or due to the weakness of the thumb’s pinching muscles, which are also controlled by the median nerve.

When to seek medical help

You should see a doctor if you have persistent signs and symptoms suggestive of carpal tunnel syndrome that interfere with your normal activities and sleep patterns. Permanent nerve and muscle damage can occur without treatment.

The work up

Your doctor will diagnose the condition based on clinical signs and symptoms and may use a nerve conduction study (NCS) and electromyography (EMG) to confirm their clinical findings. These tests are widely available islandwide.

How is it treated?

There are many non-surgical measures that can help relieve symptoms but these are temporary measures. The definitive treatment is surgery.

Non-surgical methods include:

Wrist splinting. A splint that holds your wrist still while you sleep can help relieve night-time symptoms of tingling and numbness. Night-time splinting may be a good option if you’re pregnant.

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as ibuprofen may help relieve pain from carpal tunnel syndrome in the short term. There isn’t evidence, however, that these drugs improve carpal tunnel syndrome.

Corticosteroids. Your doctor may inject your carpal tunnel with a corticosteroid such as cortisone to relieve pain. Sometimes, your doctor may use an ultrasound to guide these injections. Corticosteroids decrease inflammation and swelling, which relieves pressure on the median nerve. Oral corticosteroids aren’t considered as effective as corticosteroid injections for treating carpal tunnel syndrome.

What is the surgical treatment for CTS?

This is known as carpal tunnel release. The goal of carpal tunnel surgery is to release the median nerve from compression by cutting the transverse carpal ligament (TCL).

Surgical team led by Dr. Kavinda Rajapakse performing the procedure

Conventionally, this is done by an incision made at the wrist, under local anaesthesia, where the surgical site is kept bloodless by the use of a tourniquet (bloodless field).

This technique is widely practised by surgeons of several specialties as well as surgical trainees and senior house officers.

What is endoscopic CTR?

This is a novel approach to carpal tunnel release surgery that has been introduced to Sri Lanka last month, where the entire surgery is done as an endoscopic technique.

This has revolutionised the immediate patient outcome.

Endoscopic carpal tunnel release is also done under local anaesthesia using a tourniquet, as a day surgery. It involves only two small (3 mm) stab incisions – one in the distal forearm and the other in the mid-palm with no involvement of the grip area, in contrast to the conventional open technique. This has significantly reduced the post-operative surgical site tenderness and pain, which is sometimes debilitating, leading to delays in return to normal function.

Are there any other advantages of endoscopic carpal tunnel release other than the reduction in post-operative pain?

The endoscopic technique only cuts the tight transverse carpal ligament that causes compression of the median nerve, whereas the open technique involves the cutting of skin, palmar aponeurosis, soft tissue, thenar muscles, and finally the transverse carpal ligament. Thus, it is evident that there is less collateral damage in the endoscopic technique, which allows the carpal (wrist) bones to remain stable, preventing “pillar pain” – a dreadful complication that can only occur in the open technique.

Further, there is no risk of wound dehiscence (separation/opening up of the wound), infection, scar tenderness, and tissue swelling or oedema. Hence, the recovery is much better and faster.

What are the challenges in introducing this technique?

The procedure requires specialised training as for any other endoscopic surgical procedure.

At present, the facilities are only available at the Army Hospital, Colombo.

Open CTR has been an established technique for many years in the world, and in our setup, it is one of the procedures performed by many junior doctors in surgical units (SHOs).

There is a view among these doctors that carpal tunnel release is a procedure that can performed very easily and quickly with a tiny incision. This has led to performing incomplete releases, resulting in the worsening of symptoms. Although these patients are then categorised in to “recurrent carpal tunnel syndrome”, it is, in fact, always due to the incomplete division of the transverse carpal ligament (TCL).

Unfortunately, these patients then end up at specialised centres and the doctor does not get any feedback regarding the failure of his procedure. This simple procedure in expert hands can easily be made into a lifelong disability in some patients, leading to an entity called complex regional pain syndrome (CRPS).

Hence, Dr. Rajapakse believes this procedure is the new frontier in carpel tunnel surgery and should be available to all the patients suffering from this condition so they themselves can make an informed decision whether to go for the conventional open method or the newer endoscopic method.

Picture captions
Figure 1 – Consultant Plastic and Reconstructive Surgeon Dr. Kavinda Rajapakse MBBS, MD (Surgery), MRCS (UK).
Figure 2- Endoscopic carpel tunnel release
Figure 3 – Surgical scar ECTR vs. open method (source – Hand And Wrist Institute)
Figure 4- Surgical team led by Dr. Kavinda Rajapakse performing the procedure