Clinical Neurology and Neurosurgery 120 (2014) 96–98
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Comparison of morphologic consequences of open and endoscopic carpal tunnel release Hamidreza Aslani a , Zohreh Zafarani a , Arvin Najafi b , Khalil Alizadeh a , Reza Farjad a , Saman Ghahremani a , Masoud Mosavvari b , Farivar Abdollahzadeh Lahiji a,∗ a b
Shahid Beheshti University of Medical Sciences, Tehran, Iran Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e
i n f o
Article history: Received 9 September 2012 Received in revised form 23 February 2014 Accepted 24 February 2014 Available online 7 March 2014 Keywords: Morphologic Carpal tunnel Endoscopic Release Open surgery
a b s t r a c t Objectives: The objective of this study is to evaluate the carpal canal morphologic consequences following endoscopic carpal tunnel release compared with open approach. Methods: 48 Patients with CTS were enrolled in our prospective trial. Participants were classified in 2 groups: 24 patients underwent open surgery technique and 24 underwent endoscopic carpal tunnel decompression. Carpal canal shape and volume, configuration and position of contents, were analyzed by using imaging techniques. Results: Preoperative carpal canal volume in endoscopic patient group averaged 5.7 ± 1.4 cc and 7.3 ± 2.9 cc at 6 weeks postoperatively (28% ± 7%, p = 0.018). In contrast preoperative carpal canal volume in open carpal tunnel release group averaged 4.9 ± 1.1 cc (and increased to 6.2 ± 1.7 cc at 6-week follow up investigation (36% ± 5%, p = 0.002). Preoperative carpal arch width calculation in endoscopic carpal tunnel release group averaged 21.7 ± 1.1 mm and 21.5 ± 1.9 mm in open carpal tunnel release patients (p = 0.6575). Postoperative carpal arch width measurements in endoscopic carpal tunnel decompression group averaged 22.6 ± 4.1 mm and 22.1 ± 2.9 mm in open carpal tunnel release patient population at 6-week follow-up investigation (p = 0.628). Conclusion: Endoscopic approach causes an increment in carpal canal volume comparable to open technique and provides equivalent anatomic outcomes and will produce at least equivalent long-term clinical relief. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Carpal tunnel syndrome (CTS) is thought to be the most frequent human peripheral entrapment neuropathy all over the world. Carpal tunnel syndrome is characterized by compression of the median nerve at the wrist due to decreased free space of the carpal canal and consequently increased intracarpal canal pressure which may lead to decreased functional ability, loss of dexterity, causing hand numbness, and muscle wasting [1–6]. The open carpal tunnel release (CTR) surgical method has been considered as the gold standard technique by many surgeons [7]. The endoscopic carpal tunnel release seems to have advantages compared with open approach including earlier resumption of daily activities, quicker
∗ Corresponding author at: Velenjak st, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel.: +98 9128576268; fax: +98 21 22085855. E-mail address: [email protected] (F.A. Lahiji). http://dx.doi.org/10.1016/j.clineuro.2014.02.025 0303-8467/© 2014 Elsevier B.V. All rights reserved.
return to work, and lesser scar tenderness [8–12]. There is still some controversy about the origin of the carpal volume increment. Some authors believed that palmar opening of the edges of the ligament instead of widening the osseous carpal arch increases the palmar area of the carpal tunnel [13,14]. The objective of this survey is to evaluate the carpal canal morphologic consequences following endoscopic carpal tunnel release compared with open approach. 2. Materials and methods Forty-eight patients underwent surgery to decompress the carpal tunnel (female/male ratio 3:1) were enrolled in our study; their median age was 39.3 years (range 34–58 years). Baseline clinical characteristics of them were demonstrated in Table 1. There was no statistically significant between-groups difference regarding baseline characteristics. The diagnosis of CTS was confirmed via electrophysiological investigation. Patients with inflammatory arthritis, pregnancy, receiving anticoagulant agents, hemodialysis
H. Aslani et al. / Clinical Neurology and Neurosurgery 120 (2014) 96–98 Table 1 Characteristics of 48 patients who underwent endoscopic or open carpal tunnel release. Characteristic
Open surgery
Endoscopic release
N Age (years) Symptoms duration (months) Thenar atrophy Pisiform-scaphoid distance (mm)a Hamate Hook-trapezium distance (mm)b
24 41 ± 17 ± 1 22 ± 20 ±
24 42 ± 18 ± 1 23 ± 18 ±
a b
3 5 4 4
4 6 3 5
p Value
0.33 0.53 0.47 0.33 0.13
At the level of the pisiform-scaphoid hiatus. At the level of the hook of the hamate-trapezium hiatus.
and prior wrist or hand trauma or surgery were excluded. Participants were classified in 2 groups: 24 patients underwent open standard surgery technique as described by Phalen [15] and 24 underwent endoscopic carpal tunnel decompression via Agee monoportal method [16]. All of the patients underwent preoperative CT of the affected hand. Informed consent was obtained from each participant, and the study was conducted in accordance with the Declaration of Helsinki II. Computed tomography bone window scans of the affected hand were obtained in axial, coronal, and sagittal slices with the axial plane used for all measurements. All patients were positioned prone, while the arm over the head extended, the forearm pronated, the wrist in a neutral state and the fingers extended. Images were provided from the tip of the radius styloid process to the third metacarpal bone base. All of the patients were scanned postoperatively at 6 weeks. Carpal canal shape and volume, configuration and position of contents, were analyzed by using multiplanar reformation and three-dimensional reconstruction through a computer aided medical reconstruction and analysis software release program, on a three-dimensional imager. All measurements were conducted by a single expert radiologist. A cursor was available to outline soft tissues inside the segments applied for measurements. In order to volumetric analysis, the distal edge of the scaphoid was considered as the proximal border of the carpal canal, and the appearance of the third metacarpal base was considered as the distal border of the canal. Carpal “arch width” was defined as the distance from the palmar edge of the beak of the trapezium to the hamulus. The median nerve position regarding the hamulus trapezia1 axis was evaluated in the middle third of the canal. Nerve position, in millimeters, was reported as a positive value for positions palmar to this axis and as a negative number for positions dorsal to the hamulus trapezia1 axis. The cross-sectional surface of the median nerve at the level of the hamulus, median nerve form inside the canal, and carpal canal configuration were assessed for each hand.
3. Surgical technique All surgical manipulations were carried out under the tourniquet control and regional anesthesia. A single portal endoscopic carpal tunnel release approach was done in the first group (24 cases) and a short incision open carpal tunnel release method was performed in the second group (24 cases). In the endoscopic approach the median nerve is detected deep to the retinaculum and a synovial elevator is applied to detach the synovial tissue from the undersurface of the transverse carpal ligament. After device placement, its trigger is depressed to elevate the blade and after that the device is withdrawn to release the transverse carpal ligament. On the other hand in open surgical method first of all the superficial palmar fascia, transverse carpal ligament and antebrachial fascia are divided. None of these patients underwent either neurolysis or tenosynovectomy.
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3.1. Statistical analysis Data processing was conducted by means of commercially available statistical software (SPSS, version 18.0 for Windows, SPSS, Inc.). Values were shown as means ± SDs, and a probability value
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Comparison of morphologic consequences of open and endoscopic carpal tunnel release Hamidreza Aslani a , Zohreh Zafarani a , Arvin Najafi b , Khalil Alizadeh a , Reza Farjad a , Saman Ghahremani a , Masoud Mosavvari b , Farivar Abdollahzadeh Lahiji a,∗ a b
Shahid Beheshti University of Medical Sciences, Tehran, Iran Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e
i n f o
Article history: Received 9 September 2012 Received in revised form 23 February 2014 Accepted 24 February 2014 Available online 7 March 2014 Keywords: Morphologic Carpal tunnel Endoscopic Release Open surgery
a b s t r a c t Objectives: The objective of this study is to evaluate the carpal canal morphologic consequences following endoscopic carpal tunnel release compared with open approach. Methods: 48 Patients with CTS were enrolled in our prospective trial. Participants were classified in 2 groups: 24 patients underwent open surgery technique and 24 underwent endoscopic carpal tunnel decompression. Carpal canal shape and volume, configuration and position of contents, were analyzed by using imaging techniques. Results: Preoperative carpal canal volume in endoscopic patient group averaged 5.7 ± 1.4 cc and 7.3 ± 2.9 cc at 6 weeks postoperatively (28% ± 7%, p = 0.018). In contrast preoperative carpal canal volume in open carpal tunnel release group averaged 4.9 ± 1.1 cc (and increased to 6.2 ± 1.7 cc at 6-week follow up investigation (36% ± 5%, p = 0.002). Preoperative carpal arch width calculation in endoscopic carpal tunnel release group averaged 21.7 ± 1.1 mm and 21.5 ± 1.9 mm in open carpal tunnel release patients (p = 0.6575). Postoperative carpal arch width measurements in endoscopic carpal tunnel decompression group averaged 22.6 ± 4.1 mm and 22.1 ± 2.9 mm in open carpal tunnel release patient population at 6-week follow-up investigation (p = 0.628). Conclusion: Endoscopic approach causes an increment in carpal canal volume comparable to open technique and provides equivalent anatomic outcomes and will produce at least equivalent long-term clinical relief. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Carpal tunnel syndrome (CTS) is thought to be the most frequent human peripheral entrapment neuropathy all over the world. Carpal tunnel syndrome is characterized by compression of the median nerve at the wrist due to decreased free space of the carpal canal and consequently increased intracarpal canal pressure which may lead to decreased functional ability, loss of dexterity, causing hand numbness, and muscle wasting [1–6]. The open carpal tunnel release (CTR) surgical method has been considered as the gold standard technique by many surgeons [7]. The endoscopic carpal tunnel release seems to have advantages compared with open approach including earlier resumption of daily activities, quicker
∗ Corresponding author at: Velenjak st, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel.: +98 9128576268; fax: +98 21 22085855. E-mail address: [email protected] (F.A. Lahiji). http://dx.doi.org/10.1016/j.clineuro.2014.02.025 0303-8467/© 2014 Elsevier B.V. All rights reserved.
return to work, and lesser scar tenderness [8–12]. There is still some controversy about the origin of the carpal volume increment. Some authors believed that palmar opening of the edges of the ligament instead of widening the osseous carpal arch increases the palmar area of the carpal tunnel [13,14]. The objective of this survey is to evaluate the carpal canal morphologic consequences following endoscopic carpal tunnel release compared with open approach. 2. Materials and methods Forty-eight patients underwent surgery to decompress the carpal tunnel (female/male ratio 3:1) were enrolled in our study; their median age was 39.3 years (range 34–58 years). Baseline clinical characteristics of them were demonstrated in Table 1. There was no statistically significant between-groups difference regarding baseline characteristics. The diagnosis of CTS was confirmed via electrophysiological investigation. Patients with inflammatory arthritis, pregnancy, receiving anticoagulant agents, hemodialysis
H. Aslani et al. / Clinical Neurology and Neurosurgery 120 (2014) 96–98 Table 1 Characteristics of 48 patients who underwent endoscopic or open carpal tunnel release. Characteristic
Open surgery
Endoscopic release
N Age (years) Symptoms duration (months) Thenar atrophy Pisiform-scaphoid distance (mm)a Hamate Hook-trapezium distance (mm)b
24 41 ± 17 ± 1 22 ± 20 ±
24 42 ± 18 ± 1 23 ± 18 ±
a b
3 5 4 4
4 6 3 5
p Value
0.33 0.53 0.47 0.33 0.13
At the level of the pisiform-scaphoid hiatus. At the level of the hook of the hamate-trapezium hiatus.
and prior wrist or hand trauma or surgery were excluded. Participants were classified in 2 groups: 24 patients underwent open standard surgery technique as described by Phalen [15] and 24 underwent endoscopic carpal tunnel decompression via Agee monoportal method [16]. All of the patients underwent preoperative CT of the affected hand. Informed consent was obtained from each participant, and the study was conducted in accordance with the Declaration of Helsinki II. Computed tomography bone window scans of the affected hand were obtained in axial, coronal, and sagittal slices with the axial plane used for all measurements. All patients were positioned prone, while the arm over the head extended, the forearm pronated, the wrist in a neutral state and the fingers extended. Images were provided from the tip of the radius styloid process to the third metacarpal bone base. All of the patients were scanned postoperatively at 6 weeks. Carpal canal shape and volume, configuration and position of contents, were analyzed by using multiplanar reformation and three-dimensional reconstruction through a computer aided medical reconstruction and analysis software release program, on a three-dimensional imager. All measurements were conducted by a single expert radiologist. A cursor was available to outline soft tissues inside the segments applied for measurements. In order to volumetric analysis, the distal edge of the scaphoid was considered as the proximal border of the carpal canal, and the appearance of the third metacarpal base was considered as the distal border of the canal. Carpal “arch width” was defined as the distance from the palmar edge of the beak of the trapezium to the hamulus. The median nerve position regarding the hamulus trapezia1 axis was evaluated in the middle third of the canal. Nerve position, in millimeters, was reported as a positive value for positions palmar to this axis and as a negative number for positions dorsal to the hamulus trapezia1 axis. The cross-sectional surface of the median nerve at the level of the hamulus, median nerve form inside the canal, and carpal canal configuration were assessed for each hand.
3. Surgical technique All surgical manipulations were carried out under the tourniquet control and regional anesthesia. A single portal endoscopic carpal tunnel release approach was done in the first group (24 cases) and a short incision open carpal tunnel release method was performed in the second group (24 cases). In the endoscopic approach the median nerve is detected deep to the retinaculum and a synovial elevator is applied to detach the synovial tissue from the undersurface of the transverse carpal ligament. After device placement, its trigger is depressed to elevate the blade and after that the device is withdrawn to release the transverse carpal ligament. On the other hand in open surgical method first of all the superficial palmar fascia, transverse carpal ligament and antebrachial fascia are divided. None of these patients underwent either neurolysis or tenosynovectomy.
97
3.1. Statistical analysis Data processing was conducted by means of commercially available statistical software (SPSS, version 18.0 for Windows, SPSS, Inc.). Values were shown as means ± SDs, and a probability value
