Combined Cubital and Carpal Tunnel Release Results in Symptom Resolution Outside of the Median or Ulnar Nerve Distributions

Background: Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after combined release of the ulnar nerve at the elbow with simultaneous release of the median nerve at the carpal tunnel. Methods: 20 patients with combined cubital and carpal tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected pre-operatively and at six-week follow-up. Results: Probability of resolution was greater in the median nerve distribution than the ulnar nerve for numbness (71% vs. 43%), tingling (86% vs. 75%). Seventy percent of the cohort reported at least one extra-anatomic symptom pre-operatively, and greater than 80% of these resolved at early follow-up. There was a decrease in pain as measured by validated questionnaires. Conclusion: This study documents resolution of symptoms in both extra-ulnar and extra-median distributions after combined cubital and carpal tunnel release. Pre-operative patient counseling may therefore include the likelihood of symptomatic improvement in a non-expected nerve distribution after this procedure, assuming no other concomitant pathology which may cause persistent symptoms. Future studies could be directed at correlating pre-operative disease severity with probability of symptom resolution using a larger population.

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Median Nerve and Carpal Tunnel Morphology Before and After Endoscopic Carpal Tunnel Release: A 6-Year Follow-up Study

Hand ◽

10.1177/15589447211058819 ◽

2021 ◽

pp. 155894472110588

Author(s):

Louis C. Grandizio ◽

Daniela F. Barreto Rocha ◽

John D. Beck ◽

Sean Hostmeyer ◽

Matthew L. Chorney ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Median Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Morphological Features ◽

Resonance Imaging ◽

Symptom Resolution ◽

Tunnel Morphology

Background: Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR). Methods: In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point. Results: All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years. Conclusions: We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.

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Aberrant Positioning of the Ulnar Nerve Found During Carpal Tunnel Release: A Case Report

Orthopedic Reviews ◽

10.4081/or.2019.7795 ◽

2019 ◽

Author(s):

David R. Veltre ◽

Kelvin Naito ◽

Xinning Li ◽

Andrew B. Stein

Keyword(s):

Case Report ◽

Median Nerve ◽

Ulnar Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Distal Forearm ◽

Anatomic Variations ◽

Transverse Carpal Ligament ◽

Iatrogenic Injuries ◽

Flexor Retinaculum

Introduction: Aberrant positioning of the ulnar nerve volar to the transverse carpal ligament is a rare anatomic variation.Case Presentation: We present the case of a 55-year-old female with unique ulnar nerve anatomy that was discovered introperatively during carpal tunnel release. The ulnar nerve was running directly adjacent to the median nerve in the distal forearm and as the median nerve traversed dorsal to the transverse carpal ligament (flexor retinaculum) to enter the carpal tunnel the ulnar nerve continued directly volar to this structure before angling towards Guyon’s Canal. The unique ulnar nerve anatomy was successfully identified, carefully dissected and managed with a successful patient outcome.Conclusion: Variations of the anatomy at the level of the carpal tunnel are rare but do exist. Awareness of these anatomic variations and adequate visualization of the ulnar nerve along with the surrounding structures is crucial to avoid iatrogenic injuries during carpal tunnel release.

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Report of a Transligamentous Ulnar Nerve Sensory Branch

Hand ◽

10.1177/1558944719831338 ◽

2019 ◽

Vol 15 (1) ◽

pp. NP11-NP13

Author(s):

Christina R. Vargas ◽

Kyle J. Chepla

Keyword(s):

Median Nerve ◽

Ulnar Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Anatomical Variation ◽

Dominant Male ◽

Transverse Carpal Ligament ◽

Anatomical Variant ◽

Motor Branch ◽

Right Hand

Background: Several anatomical variations of the median nerve recurrent motor branch have been described. No previous reports have described the anatomical variation of the ulnar nerve with respect to transverse carpal ligament. In this article, we present a patient with symptomatic compression of the ulnar nerve found to occur outside the Guyon canal due to a transligamentous course through the distal transverse carpal ligament. Methods: A 59-year-old, right-hand-dominant male patient presented with right hand pain, subjective weakness, and numbness in both the ulnar and the median nerve distributions. Electromyography revealed moderate demyelinating sensorimotor median neuropathy at the wrist and distal ulnar sensory neuropathy. At the time of planned carpal tunnel and Guyon canal release, a transligamentous ulnar nerve sensory common branch to the fourth webspace was encountered and safely released. Results: There were no surgical complications. The patient’s symptoms of numbness in the median and ulnar nerve distribution clinically improved at his first postoperative visit. Conclusions: We have identified a case of transligamentous ulnar nerve sensory branch encountered during carpal tunnel release. To our knowledge, this has not been previously reported. While the incidence of this variant is unknown, hand surgeons should be aware of this anatomical variant as its location puts it at risk of iatrogenic injury during open and endoscopic carpal tunnel release.

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Surgical Release of the Median Nerve under Local Anaesthesia for Carpal Tunnel Syndrome

Journal of Hand Surgery (European Volume) ◽

10.1016/0266-7681_88_90163-5 ◽

1988 ◽

Vol 13 (4) ◽

pp. 395-396

Author(s):

M. ALTISSIMI ◽

G. B. MANCINI

Keyword(s):

Median Nerve ◽

Carpal Tunnel ◽

Local Anaesthetic ◽

Local Anaesthesia ◽

Subcutaneous Tissue ◽

Carpal Tunnel Release ◽

Skin Incision ◽

Tunnel Syndrome ◽

Surgical Release

Carpal tunnel release was performed under local anaesthesia in 124 wrists of 108 patients. The local anaesthetic was injected into the carpal tunnel and into the subcutaneous tissue under the line of the skin incision. A tourniquet was used in all cases. Analgesia was complete in all but six patients. Only one patient had real difficulty in tolerating the tourniquet. In 18 cases the median nerve, when exposed at operation, showed evidence of some damage caused by the needle or by injection of local anaesthetic but, at follow-up, no symptoms or signs related to this damage were found.

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Endoscopic Carpal Tunnel Release: A Retrospective Study of the Modified Okutsu Technique Using Glass Tubes

Hand Surgery ◽

10.1142/s0218810497000203 ◽

1997 ◽

Vol 02 (02) ◽

pp. 123-127

Author(s):

TM Tsai ◽

M. Favetto ◽

R. Elluru

Keyword(s):

Retrospective Study ◽

Grip Strength ◽

Median Nerve ◽

Ulnar Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Patient Questionnaire ◽

Endoscopic Carpal Tunnel Release ◽

Glass Tubes

We evaluated 108 endoscopically assisted carpal tunnel releases in 90 patients in a retrospective study to determine the efficiency and safety of a modified Okutsu endoscopic carpal tunnel release (ECTR) technique. The modification consisted of the use of glass tubes 5, 7, and 9 mm in diameter and a sharp tipped hook knife. The results were evaluated using a patient questionnaire, time off from work, grip strength, and two point discrimination. Symptoms were resolved in 71% of the patients, improved in 19.4%, and not improved in 9.3%. In this series, 59 patients were gainfully employed: 84.7% returned to work, half within 2 weeks of surgery. Severe complications included one laceration of the ulnar nerve, and one neuroma in continuity of the median nerve. ECTR using this modification of Okutsu's technique is effective in the relief of symptoms and returning patients to work quickly.

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CARPAL TUNNEL RELEASE IN PATIENTS WITH NEGATIVE NEUROPHYSIOLOGICAL EXAMINATIONS

Neurosurgery ◽

10.1227/01.neu.0000343546.21265.88 ◽

2009 ◽

Vol 65 (suppl_4) ◽

pp. A171-A173 ◽

Cited By ~ 13

Author(s):

Massimo Lama

Keyword(s):

Median Nerve ◽

Nerve Injury ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Cervical Radiculopathy ◽

Clinical Findings ◽

Work Related ◽

Persistent Symptoms ◽

Operative Findings ◽

Median Nerve Injury

Abstract OBJECTIVE In 16% to 34% of patients with classic symptoms of carpal tunnel syndrome (CTS), neurophysiology is negative. Few studies have concentrated on patients with symptoms compatible with CTS with normal examinations. The purpose of our study was to examine the clinical and surgical characteristics of this subtype of CTS in order to clarify a correct approach toward these patients. METHODS We studied a subpopulation of 25 patients (31 hands) with typical CTS symptoms despite normal neurophysiological examinations. All of the patients were initially treated with conservative therapy, and patients with work-related symptoms were advised to change their duties. In patients with persistent symptoms, wrist ultrasound and radiographic and blood examinations with rheumatic screenings were performed. Cervical magnetic resonance imaging was performed in some cases to exclude cervical radiculopathy. Other pathologies were found in 5 cases. Nine patients improved with nonsurgical therapy. Six months later, electric examinations were repeated and 3 patients with a confirmed median nerve injury underwent surgery. Eight patients with negative examinations underwent surgery (10 hands). All patients were advised of the possibility of incomplete pain remission after surgery. RESULTS All patients improved after surgery. Median nerve injury was confirmed by operative findings according to Tuncali grading. CONCLUSION A combination of clinical findings and instrumental procedures is required when selecting patients for successful surgery.

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Abductor Digiti Minimi Flap for Vascularized Coverage in the Surgical Management of Complex Regional Pain Syndrome Following Carpal Tunnel Release

Hand ◽

10.1177/1558944716681977 ◽

2016 ◽

Vol 12 (6) ◽

pp. 546-550 ◽

Cited By ~ 2

Author(s):

Kevin Cheung ◽

Melissa A. Klausmeyer ◽

Jesse B. Jupiter

Keyword(s):

Median Nerve ◽

Complex Regional Pain Syndrome ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Donor Site ◽

Retrospective Chart Review ◽

Pain Syndrome ◽

Outcome Instrument ◽

Abductor Digiti Minimi

Background: The development of Complex Regional Pain Syndrome (CRPS) represents a potentially devastating complication following carpal tunnel release. In the presence of a suspected incomplete release of the transverse carpal ligament or direct injury to the median nerve, neurolysis as well as nerve coverage to prevent recurrent scar has been shown to be effective. Methods: Retrospective chart review and telephone interview was conducted for patients who underwent abductor digiti minimi flap coverage and neurolysis of the median nerve for CRPS following carpal tunnel release. Results: Fourteen wrists in 12 patients were reviewed. Mean patient age was 64 years (range, 49-83 years), and the mean follow-up was 44 months. Carpal tunnel outcome instrument scores were 47.4 ± 6.8 preoperatively and 27.1 ± 10.6 at follow-up ( P < .001). Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores at follow-up were 29.4 ± 26. No significant postoperative complications were identified. Conclusions: The abductor digiti minimi flap is a reliable option with minimal donor site morbidity. It provides predictable coverage when treating CRPS following carpal tunnel syndrome.

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Prognostic Value of Ultrasound Imaging of the Median Nerve in Carpal Tunnel Syndrome

Hand ◽

10.1177/1558944720919182 ◽

2020 ◽

pp. 155894472091918

Author(s):

Cory Demino ◽

John R. Fowler

Keyword(s):

Carpal Tunnel Syndrome ◽

Median Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Ultrasound Measurement ◽

Diagnostic Modality ◽

Cross Sectional ◽

Patient Reported ◽

Tunnel Syndrome

Background: Ultrasound has been well established as a diagnostic modality for carpal tunnel syndrome, but its prognostic utility has not been deeply investigated. Few studies, showing contradictory results, exist investigating ultrasound results as a predictor of patient outcomes. Methods: Patients with ultrasound measurement of the cross-sectional area (CSA) of the median nerve who completed the Boston Carpal Tunnel Questionnaire (BCTQ) and followed up after surgery were included in the study. A total of 199 wrists from 172 patients met the inclusion criteria. Preoperative CSA of the median nerve at the wrist was compared with change in BCTQ at various follow-up times postoperatively. Results: The BCTQ score was found on average to decrease for patients after surgery at all 3 follow-up times. There was a larger decrease in the preoperative BCTQ with each progressive follow-up time, with the largest change of 1.43 points coming at 6+ months. The average change in BCTQ at each follow-up time was found to be greater than the minimal clinically important difference. The greatest R2 for preoperative CSA compared with change in BCTQ was 0.0552 for the 6+ month visits. No specific CSA value or range above or below which patients have better postoperative outcomes was found. Conclusions: Higher preoperative CSA, signifying worse carpal tunnel severity, showed almost no correlation with better outcomes after carpal tunnel release surgery as measured by improvement in patient-reported outcome scores.

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Carpal Tunnel Syndrome: Surgical Landmarks which Increase Safety in Carpal Tunnel Release Procedures

Revista de Chimie ◽

10.37358/rc.20.1.7870 ◽

2020 ◽

Vol 71 (1) ◽

pp. 426-429

Author(s):

Marian Turbatu ◽

Laura Stroica ◽

Ana Maria Oproiu ◽

Adrian Barbilian ◽

Chen Feng-Ifrim ◽

...

Keyword(s):

Median Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Flexor Digitorum Profundus ◽

Medical Patients ◽

Persistent Symptoms ◽

Post Surgery ◽

Tunnel Syndrome ◽

Flexor Digitorum ◽

Formalin Fixed

The carpal tunnel is an osteofibrous canal situated in the volar wrist. It contains the median nerve and nine tendons: the flexor pollicislongus, the four flexor digitorum superficialis and the four flexor digitorum profundus. Patients presenting carpal tunnel syndorome often complain about pain, tingling and numbness in the first 3 fingers and lateral half of the IVth finger. While initial treatment may be medical, patients often require surgical release of the transverse carpal ligament. Even though the surgical procedure is considered to have low difficulty it is accompanied by a significant morbidity and sometimes persistent symptoms post-surgery. In this study we dissected both hands of 9 formalin fixed cadavers and measured fixed landmarks in order to enhance the safety of a surgical decompression of the median nerve.

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