EXPERIENCE IN TREATING CTS by Mini open method

2. Carpal Tunnel Syndrome
The Mother Hospital Experience
with mini open release
Dr.Ram Mohan.K.P;
Dr.Dejo.A.J, Prof.Sunny Pazhayatil

3. 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

4. • 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 ..

5. 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

7. Area supplied by the
median nerve
Transverse carpal ligament
Median
nerve
Superficial palmar arch

8. 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%

9. 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

10. 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..

11. 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

12. 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

13. 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

14. 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)

15. OCTR

16. 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 outcomes
over the standard technique in terms of recovery time, pillar
pain, and recurrence rate

17. Endoscopic carpal tunnel release
It is assumed that preservation of
the 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 comparing
OCTR and two portal ECTR, Atroshi et al37
reported that he outcomes were equivalent,
other than ECTR offering a
shorter recovery period.
However, critics of ECTR report
higher complication rates due to the technical
difficulty of the procedure, as well as greater cost
when compared with OCTR.

18. Patients who underwent Carpal Tunnel release
in Dept.of Orthopaedics during 2000-2014
Total patients-348
No.of hands operated-452
0
100
200
300
400
500
Total patients Total hands

19. Gender –females—304(87%)
males-----44(13%)
among 304 females
167---post menopausal (55%)
137 ---pre menopausal (45%)
0
100
200
300
400
male female
male
female

20. 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
50-60yrs
30-40 yrs
20-30yrs
60-70yrs

21. Year wise breakup ;
No. of hands operated(452)
0
10
20
30
40
50
60
70
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

22. Dr. R M-214hands166Pts
Dr.Dejo-206hands,159Pts
Dr.Sunny -29Hands,20Pts
Dr.MPJ-3Hands,3Pts
Neurosurgery-48 hands,40 Pts
0
50
100
150
200
250

23. 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

24. 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

25. • 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

26. 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%

27. 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

28. • 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

29. 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

31. 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

32. 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

33. • 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

34. 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

35. 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 Yrs
Less than 3 months—11 Pts
3 Months to 1 Yr------ 7
1 Yr to 5 yrs----------- 5
5 yrs to 9 yrs------------8
Patients coming to the same institution for second
surgery may imply success of initial surgery!!

36. • 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

37. Associated surgical releases
• Trigger finger------58 patients(17%)
• Simultaneous release----20
• Delayed release---------- 20
• Local steroid injection-- 8
• Simultaneous Dequervains release-18 patients

38. 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

39. 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

40. 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

41. The Procedure

51. OP procedure- 164 pts
1 day Admission- 180 pts
2 days admission- 4 pts
0 50 100 150 200
OP procedure
1 day Adm
2 days adm No of pts
Column1
Column2

52. 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

53. • 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 Pts
Deep infection---1 patient
In spite of delay in skin healing, all these patients
had a well acceptable scar and none had scar
hypertrophy or scar complaints

54. Delayed skin healing

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

56. Invisible scar in a bilateral case

59. Thenar wasting
not recovered after 3 yrs

60. 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

61. 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

62. Follow up
Range—3 months to 13yrs
8-cases— >10yrs
55 cases---- 5-10 yrs
62 cases----- 2 to 5yrs
68 cases-----1 to 2 yrs
61 cases-----4months to 1 yr
94 patients –3 months and then lost to follow up

63. 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

64. 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

65. 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%)

66. 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%)

67. 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

68. 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

69. • 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

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