Endoscopic versus open carpal tunnel release: A short-term comparative study

Objective: To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS). Materials and Methods: Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signsor symptoms and electro-diagnostic findings consistent with carpaltunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient’s symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months. During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.

he carpal tunnel syndrome (CTS) is a common that the endoscopic carpal tunnel release is associated with pathology, recognized since one and a half century.
quicker functional recovery and less postoperative pain. 8

Carpal tunnel syndrome (CTS) is caused by
Concerns persist with the possibility of endoscopic release compression of the median nerve at the wrist resulting in resulting in incomplete release, higher rate of recurrence hand numbness, loss of dexterity, muscle wasting and along with questionable safety of endoscopic techniques, decreased functional ability at work. Open Carpal tunnel cost of endoscopic equipment and training and difficulty release (CTR) has been considered the operative procedure of the surgery. 1,4 of choice for decompression of the median nerve at the wrist in patients who have idiopathic CTS. [1][2][3] Recently, there We conducted a randomized, prospective study to investigate whether early and late recovery after open CTR is comparable with endoscopic carpal tunnel release. The clinical as well as electrophysiological assessment of the early as well as late recovery was made following both the surgical procedures and the results were compared. We also compared the rate of recurrence, the need for revision surgery and the incidence of complications following the two procedures.

Endoscopic CTR
A 1.0 cm transverse incision is made at the level of the distal wrist crease in the center of the volar aspect of the wrist. The incision is centered over the palmaris longus if it is present. The palmaris longus is retracted radially to specificity associated with the clinical tests the diagnosis protect the palmar cutaneous branch of the median nerve. was confirmed by electrophysiological studies. Patients with Scissors are used to make a distally based flap in the flexor inflammatory conditions, concomitant pregnancy, patients retinaculum. The median nerve is identified deep to the on anticoagulants or with bleeding or coagulation disorders, retinaculum and a synovial elevator is used to reflect the patients on hemodialysis and patients with previous hand synovial tissue from the undersurface of the transverse trauma were excluded. Preoperatively grip strength and carpal ligament. Dilators are used to provide a space for pinch strength were recorded. Electrophysiological study the device. The device is inserted to a depth of <3.0 cm to was performed preoperatively to confirm the diagnosis, avoid injury to the superficial palmar arch or the common postoperatively at the end of one month to compare the digital nerve to the fourth web space. Once the device is early recovery and was repeated at the end of six months in place, its trigger is depressed to elevate the blade and for long-term benefit. Electrophysiological confirmation then the device is withdrawn to release the transverse carpal was established with use of the combined sensory index, ligament. Several passes may be required when the which is the sum of three latency differences: median-ulnar transverse carpal ligament is very thick. The incision is across the palm (palmdiff), median-ulnar to the ring finger closed with monofilament sutures. (ringdiff) and median-radial to the thumb (thumbdiff). 9 All patients included in the study met the American Association

Open CTR
of Electrodiagnostic Medicine diagnostic criteria for CRS. 9, 10 The incision is made 2 mm ulnar to the thenar crease, just distal to the Kaplan oblique line and extended 3.0 to 4.0

Endoscopic group
cm proximally toward the distal wrist crease. The superficial There were 36 patients in this group. Out of these 30 palmar fascia, transverse carpal ligament and antebrachial patients were available for follow-up. The mean age was fascia are divided. The tourniquet is deflated after the 44.6 years and the dominant hand was involved in 23 wound is closed with monofilament sutures. Neither patients. Twelve of the patients were female. The mean tenosynovectomy nor neurolysis was performed in this duration of symptoms was 5.1 months (range, 4-10 group. months). Twelve patients had been treated with a splint for six weeks prior to the surgery. Three patients had been Postoperatively, we used a bulky soft dressing covering treated with a steroid injection.
the wrist and hand. This dressing worked as good as a splint. This dressing was kept in place till suture removal at Open-release group the end of two weeks. After this patients were started on There were 34 patients (35 wrists) in this group. Out of active assisted exercises for a period of two to four weeks these, 30 patients (31 wrists) were available for follow-up. One patient had a bilateral wrist involvement. The mean age was 45.3 years and the dominant hand was involved in 22 patients. Twenty-three of the patients were female. The mean duration of symptoms was 6.5 months (range, 3-12 months). Ten patients had been treated with a splint for six weeks prior to the surgery. Seven patients had been treated with a steroid injection prior to the surgery.

Surgical technique
All surgical procedures were performed under the tourniquet control. Patient preference for general anesthesia or regional anesthesia was accommodated. A single portal endoscopic carpal tunnel release was performed in the first followed by passive exercises and normal activity.

Postoperative evaluation
Postoperative evaluation was done at one month and six months after the surgery. Early recovery and completeness of recovery were assessed. Recording was made of the improvement in symptoms, function and electrophysiological studies and the complications of the surgical procedure. Symptoms were evaluated by eliciting the severity of incisional pain, changes in severity of pain, tingling sensations, severity of nighttime numbness and hand weakness. Function was evaluated by grip strength and pinch strength and compared with preoperative values. The time taken to resume the daily activities was recorded. Any residual pain or scar tenderness was elicited.   group. Average duration to return to daily activities was   However, no appreciable difference could be noted in the pattern of recovery between the two groups.

Complications
Symptoms consistent with reflex sympathetic dystrophy, with swelling, redness and increased sweating, developed

Electrophysiological results [Tables 3 and 4]
in two patients in the open release group. In one, the At one month after the surgery, the distal latency (both symptoms were mild and resolved after a brief course of motor and sensory) of the median nerve across the wrist physical therapy. In the other patient, the symptoms were was reduced and the nerve conduction velocity (both motor more protracted and a regular therapy program as well as and sensory) was increased in all the patients in both the the use of nortriptyline was required.
Postoperative parameters of the two groups are presented In the endoscopic CTR group the average distal latency in Table 2. and conduction velocity recorded in the preoperative period was 4.7 ms and 40 m/s respectively. Six months   Endoscopic release of the carpal tunnel was introduced as an alternative method in the hope of decreasing the rate of these complications. 4 Endoscopic CTR is claimed to be associated with minimal pain and scarring due to minimal incision, a shortened recovery period and a high level of patient satisfaction. 6 Analysis of the outcomes of our study demonstrates that the patients who had undergone endoscopic release had greater relief of symptoms, improvement in function and satisfaction for the first three months following the surgery. Furthermore, they had faster