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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;
    - reference:
          - 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 twelve 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 tunnel 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.