Endoscopic Carpal Tunnel Release 

                                                                                                                    - Case Example by Dr. James R. Urbaniak MD
- Equipement:
      - 4 mm 30 deg endoscope;
      - hook knife;
      - slotted cannula;
      - long cotton padded Q tips;
- Anesthesia:
    - ensure that lidocaine does not contain epinephrine;
    - median nerve block may be useful but does not allow the patient to demonstrate activity of the motor branch at the end of the case;
    - local injection over proximal and distal incisions, but avoid infiltrating lidocaine in mid palmar area;

- Positioning:
    - supine w/ arm on hand table;
    - mark out landmarks;

- Proximal Incision:
    - just proximal to the proximal wrist flexion crease along the ulnar border of the palmaris longus;
    - a proximally based flap of superficial fascia is created and is elevated w/ a small clamp;
           - immediately underneath this fascia lies the median nerve;
    - probing the undersurface of the TCL should give a washer-board sensation;
           - if washer-board sensation is not present then the probe is either in Guyon's Canal or is superficial to the TLC;


- Distal Incision:
    - just distal to the distal edge of the transverse carpal ligament
    - a blunt tipped obturator is placed into the carpal tunnel and is pushed distally to the distal border of the TCL;
          - hazards include the superficial palmar arch;
          - wrist flexion draws the superficial palmar arch away from the TCL;
    - the tip of the obturator is then gently pushed upwards so that its tip can be palpated underneath the skin (just distal to the TLC);
          - this tip marks the proper location for the distal incision;


- Preparation for TCL Transection:
    - blunt antatomy probe is used to gently probe the undersurface of the TLC;
          - the "washer board" feel of the undersurface of the TLC helps confirm that the probe lies within the carpal tunnel;
    - carefully pass sequentially larger dilators into the carpal tunnel;
    - slotted cannula is placed into distal incision and into the carpal tunnel, w/ the slot point slightly to Guyon's Canal (about 11 o'clock), and parallel to the patient's arm;
    - extension of the patients thumb, places tension on the TLC, facilitating transection;
    - just distal to the TCL, a superficial layer of subcutaneous fat is seen;
    - sterile Q tips are used to clean the undersurface of the TLC;
    - references:
          - A simple technique for identification of the distal extent of the transverse carpal ligament during single-portal endoscopic carpal tunnel release.

- Transection of TLC:
    - the hook knife is placed into the obturator which already lies with in the distal incision;
          - the blade is inserted into the mid-aspect of the TLC;
          - the blade is then pulled from proximal to distal
    - the cannula and arthroscope positions are reversed;
          - the blade is placed in the mid aspect of the TLC (where the TLC was first transected) and then under direct vision, the blade is pulled from proximal to distal;




- Transection of the Palmar Fascia:
    - incomplete release of the palmar fascia is a common cause for recurrent CTS;
    - take care to avoid injury to the palmar cutaneous branch (radial side) and the ulnar artery (ulnar side);


The ulnar neurovascular bundle at the wrist - a technical note on endoscopic carpal tunnel release

Carpal arch alteration and related clinical status after endoscopic carpal tunnel release.

Endoscopic carpal tunnel release.

Carpal Tunnel Release. A Prospective, Randomized Assessment of Open and Endoscopic Methods.

Results of endoscopic management of carpal-tunnel syndrome in long-term haemodialysis versus idiopathic patients.

Endoscopic carpal tunnel release: an anatomic study.

Anatomic relationships of an endoscopic carpal tunnel device to surrounding structures.

Endoscopic carpal tunnel release in cadavera. An investigation of the results of 12 surgeons with this training model.

Endoscopic carpal tunnel release: an anatomic study of the two-incision method in human cadavers.

Endoscopic release of the carpal tunnel: a randomized prospective multicenter study.

Endoscopic carpal release: a cadaveric study.

Ulnar nerve transection as a complication of two portal endoscopic carpal tunnel release: a case report.

Endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome. A prospective, randomised, blinded assessment.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, December 11, 2012 3:17 pm