Outcome following epineurotomy in carpal tunnel syndrome: A prospective, randomized clinical trial

doi:10.1016/0363-5023(94)90253-4

The Journal of Hand Surgery

Volume 19, Issue 4, July 1994, Pages 539-547

https://doi.org/10.1016/0363-5023(94)90253-4 Get rights and content

Abstract

To assess the efficacy of an adjunctive epineurotomy in carpal tunnel syndrome, 36 wrists in 33 patients were prospectively randomized into epineurotomy and non-epineurotomy treatment groups. The operating surgeons and evaluating therapist were double-blinded. Patients were evaluated preoperatively and at either 6 or 12 months postoperatively, with 15 patients examined at both postoperative time points. Evaluation consisted of five sensory and four motor tests: static and moving two-point discrimination, Semmes-Weinstein monofilament testing, vibratory (30 and 256 cps) sensibility, and dynamometer testing of grip strength and lateral, three-jaw, and tip pinch strengths. Sensory testing showed overall improvement within both groups postoperatively, but there was no difference between the two groups at either 6 or 12 months postoperatively. Motor testing revealed no improvement in the grip strength or lateral, three-jaw, or tip pinch of either group at 12 months when compared to preoperative levels. Twenty-four of 26 epineurotomy patients and all 10 control patients were satisfied with their clinical outcome 30 months after surgery. The addition of an adjunctive epineurotomy, although safe, offered no clinical benefit in the surgical treatment of carpal tunnel syndrome in this series.

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Cited by (46)

Carpal tunnel syndrome - Part II (treatment)
2014, Revista Brasileira de Ortopedia
Os tratamentos nas formas não deficitárias da síndrome do túnel do carpo (SCC) são a infiltração de corticoide e/ou uma órtese de imobilização noturna. O tratamento cirúrgico, que compreende a secção do retináculo dos flexores (retinaculotomia), é indicado em caso de resistência ao tratamento conservador nas formas deficitárias ou, mais frequentemente, nas formas agudas. Nas técnicas minimamente invasivas (endoscópica e miniopen), independentemente de a curva de aprendizado ser mais longa, parece que a recuperação funcional é mais precoce em relação à cirurgia clássica, mas com os resultados em longo prazo idênticos. A escolha depende do cirurgião, do paciente, da gravidade, da etiologia e da disponibilidade do material. Os resultados são próximos de 90% de casos satisfatórios. A recuperação da força necessita de quatro a seis meses após a regressão das dores do tipo dor do pilar (pillar pain). Essa cirurgia tem a reputação de ser benigna e apresenta de 0,2% a 0,5% de complicações.
The treatments for non‐deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini‐open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long‐term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2% to 0.5%.
Rate of Infection After Carpal Tunnel Release Surgery and Effect of Antibiotic Prophylaxis
2010, Journal of Hand Surgery
Citation Excerpt :
The use of these procedures in contemporary CTR surgery is rare but may be used in the setting of a patient with extensive flexor tenosynovitis or in a patient with severe epineural scarring in a revision CTR. Although this study did not document the total number of cases with ancillary procedures, it is likely to be low, given that more recent literature failed to support such procedures in standard CTR surgery.27–31 The study strengths include the large size and diversity of the patient population and the integrated electronic medical record system used by the health care system.
To determine the rate of postoperative wound infection and the association with prophylactic antibiotic use in uncomplicated carpal tunnel release surgery.
We performed a multicenter, retrospective review of all the carpal tunnel release procedures performed between January 1, 2005, and August 30, 2007. Data reviewed included the use of prophylactic antibiotics, diabetic status, and the occurrence of postoperative wound infection. We determined the overall antibiotic usage rate and analyzed the correlation between antibiotic use and the development of postoperative wound infection.
The rate of surgical site infections in the 3003 patients who underwent carpal tunnel release surgery (group A) was 11. Antibiotic usage data were available for 2336 patients (group B). Six patients without prophylactic antibiotics had infection, as did 5 patients with prophylactic antibiotics. This difference was not statistically significant. Of the 11 surgical site infections, 4 were deep (organ/space) and 7 superficial (incisional). The number of patients with diabetes in the overall study population was 546, 3 of whom had infections. This was not statistically different from the nondiabetic population infection rate (8 patients).
The overall infection rate after carpal tunnel release surgery is low. In addition, the deep (organ/space) infection rate is much lower than previously reported. Antibiotic use did not decrease the risk of infection in this study population, including patients with diabetes. The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. Surgeons should carefully consider the risks and benefits of routinely using prophylactic antibiotics in carpal tunnel release surgery.
Therapeutic III.
Recurrent carpal tunnel syndrome
2008, Chirurgie de la Main
La récidive d’un syndrome du tunnel carpien opéré n’est pas exceptionnelle. La fréquence d’une deuxième intervention varie selon les auteurs de 0,3 à 12 %. Nous distinguons les syndromes persistants ou mieux récalcitrants et les syndromes récidivants qui réapparaissent au delà d’un délai de trois mois. Dans ces deux tableaux sont possibles la méprise du diagnostic et les atteintes neurologiques proximales. En cas de syndrome récalcitrant, la section incomplète du ligament rétinaculaire reste fréquente, parfois c’est une lésion iatrogène du nerf ou une synovite active des fléchisseurs. En cas de syndrome récidivant, il s’agit le plus souvent d’une fibrose périneurale plus ou moins étendue. Lors de la réintervention, en dehors des cas de section incomplète du ligament, il faut discuter d’associer à la neurolyse itérative un geste contre le risque de fibrose itérative. De nombreux procédés sont proposés allant de l’interposition d’un biomatériau à un lambeau d’enveloppement : à l’opposé, certains auteurs plaident une mobilisation précoce pour conserver le plan de glissement du nerf. Les résultats restent modestes, voire aléatoires après plusieurs interventions. Il faut distinguer l’amélioration du syndrome d’irritation locale qui est une priorité pour le patient et l’amélioration du syndrome neurologique au niveau des effecteurs moteurs et surtout sensitifs. Selon la littérature, 43 à 90 % des cas réopérés conserveraient des symptômes, un cas sur cinq serait un échec, alors que 80 % des premières interventions donnent un excellent résultat. Ce constat conduit à être d’une extrême rigueur technique lors du premier abord.
Recurrence of carpal tunnel syndrome following surgery is not rare. The reported frequency of reoperation varies from 0.3 to 12%. We distinguish between persistent carpal tunnel syndrome, and recurrent carpal tunnel syndrome which we define as reappearance of the condition three months or more following surgery. More proximal nerve lesions or other erroneous diagnoses may cause either persistent or recurrent syndromes. In the cases of persistent syndromes, incomplete division of the flexor retinaculum is a frequent cause, but iatrogenic nerve lesions or active flexor tenosynovitis may also be to blame. In the cases of recurrent carpal tunnel syndrome, the problem is often due to perineural fibrosis. At the time of reoperation, except in those cases where an incomplete division of the flexor retinaculum is found, one must consider whether or not to combine the neurolysis with an additional procedure to prevent or diminish recurrent fibrosis. To achieve this goal, a number of measures have been proposed, including interposition of a biomaterial or raising a local flap to surround and protect the nerve. Others recommend early mobilization to diminish fibrous adhesions between the nerve and surrounding tissues. The results are at best modest, and may be counterproductive after several interventions. It is necessary to distinguish between improvement in symptoms that are due to local irritation, the priority for the patient, and improvement in neurologic function of the motor and sensory components of the nerve. According to the literature, from 43 to 90% of patients who undergo repeat operations continue to have symptoms, and one in five get no relief, while 80% of first operations for carpal tunnel syndrome give excellent results. These findings indicate that the first intervention must be performed with the most rigorous attention to technical detail.
Compression Neuropathies of the Median Nerve
2006, Peripheral Nerve Surgery: Practical Applications in the Upper Extremity
Flexor superficialis abductor transfer with carpal tunnel release for thenar palsy
2005, Journal of Hand Surgery
In patients with advanced chronic carpal tunnel syndrome (CTS) the ability of the thumb to abduct and perform functional opposition is impaired greatly, primarily because of denervation and paralysis of the abductor pollicis brevis muscle. The purpose of this study was to evaluate the results of transfer of the flexor digitorum superficialis to the abductor pollicis brevis for restoration of thumb abduction in thenar paralysis caused by advanced chronic CTS.
Fifty patients (51 hands) with advanced CTS and loss of thumb abduction had a flexor digitorum superficialis transfer (37 small, 10 ring, 4 middle finger donors) to the abductor pollicis brevis with simultaneous carpal tunnel release (49 of 51 endoscopic). Thirty patients (60%) were women with an average age of 70 years (range, 35–90 y). Forty-three patients (84%) were in their sixth through eighth decades. We analyzed retrospectively preoperative and postoperative abduction, abduction strength, thenar muscle recovery and function, and patient satisfaction and complications.
All patients reported improved thumb and hand function. Thumb abduction increased almost 20° and 3 British Medical Research Council strength grades. Abduction was improved by the transfer in all patients, with some thenar recovery found in 35 of 40 cases followed-up longer than 12 months. Harvest of the flexor digitorum superficialis from the ring and middle fingers was associated with donor finger proximal interphalangeal joint contracture, although harvest from the small finger was not.
Carpal tunnel release with simultaneous flexor digitorum superficialis-to-abductor pollicis brevis transfer provides satisfactory results for patients with profound CTS and thenar paralysis. The use of the small finger superficialis as the donor motor has minor morbidity compared with other methods and has predictable improvement and patient satisfaction. This transfer method is combined easily with endoscopic carpal tunnel release (as in 49 of our 51 cases), 2-portal, or open method releases.
Carpal tunnel syndrome
2004, Chirurgie de la Main
Le syndrome du canal carpien est le plus répandu des syndromes canalaires au membre supérieur. Il est dans la plupart des cas idiopathique, mais peut aussi être dû à des causes anatomiques, traumatiques, endocriniennes, rhumatismales ou tumorales. Bien que la symptomatologie soit souvent typique, aucun test clinique n'a de fiabilité absolue et l'exploration électromyographique est la plupart du temps nécessaire. Celle-ci permet de confirmer le diagnostic, d'évaluer la sévérité de l'atteinte, et de dépister une autre lésion nerveuse associée. Le traitement médical peut être proposé dans les formes modérées. Son efficacité est transitoire. La prise en charge chirurgicale est nécessaire dans les formes sévères et en cas d'échec du traitement médical. Le principe du traitement chirurgical est l'ouverture du ligament annulaire antérieur. Elle peut être faite à ciel ouvert ou par voie endoscopique. L'utilisation de l'endoscopie permet une récupération postopératoire plus rapide de la force et de la fonction de la main. D'autres gestes chirurgicaux peuvent être associés en fonction de l'étiologie en cause.
Carpal tunnel syndrome is the most frequent among entrapment neuropathies at the upper limb. The usual etiology is idiopathic, but its origin can also be anatomic, traumatic, endocrine, rheumatismal or tumoral. Even though the clinical presentation is often typical, an electromyographic examination is useful for confirmation of the diagnosis, assessment of nerve lesions and detection of associated neuropathies. A medical treatment can be indicated in moderate cases. A surgical treatment is necessary in severe cases or after failure of the medical treatment. The basic procedure consists in opening of the transverse carpal ligament, achieved by open or endoscopic technique. The use of endocscopy leads to a faster postoperative recovery of hand strength and function. Other surgical procedures can be associated to carpal tunnel release depending on the etiology of the compression.

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^☆: Investigation performed at the Division of Orthopaedics, John A. Burns School of Medicine, The Queen's Medical Center, Honolulu, HI.

^☆☆: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Original communicationOutcome following epineurotomy in carpal tunnel syndrome: A prospective, randomized clinical trial☆,☆☆

Abstract

J Hand Surg

J Hand Surg

Hand

J Hand Surg

J Hand Surg

Nerve compression injury and increased endoneurial fluid pressure: a “miniature compartment syndrome.”

J Neurol Neurosurg Psychiatry

Pathophysiology of nerve compression

The palmar approach for the visualization and release of the carpal tunnel

Plast Reconstr Surg

Original communication
Outcome following epineurotomy in carpal tunnel syndrome: A prospective, randomized clinical trial☆,☆☆