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Research Article | Volume 14 Issue 5 (Sept - Oct, 2024) | Pages 551 - 556
Minimally Invasive Surgery for Carpal Tunnel Syndrome: A New Simple, Easy and Effective Technique in A Setup with Limited Resources: Mushtaq’s Technique Mini OCTR Through A 10 Mm Wrist Crease Incision
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 ,
1
Associate Professor Surgery SMHS GMC Srinagar India190001
2
PG Scholar Department of Anesthesiology and Critical care GMC Srinagar India 190001
3
Registrar Department of Plastic surgery SSH GMC Srinagar India 190001
Under a Creative Commons license
Open Access
Received
Aug. 30, 2024
Revised
Sept. 15, 2024
Accepted
Sept. 20, 2024
Published
Oct. 15, 2024
Abstract

Purpose: The surgical treatment of carpal tunnel syndrome (CTS) has been enriched, by different minimally invasive techniques to decompress the median nerve at the wrist as the endoscopic approaches or modified open technique. However, controversy remains about their safety and complication rate. We present the results of our minimally-invasive technique to median nerve release at the wrist. Methods: The study was conducted in the department of Plastic and Reconstructive surgery GMC Srinagar. The patients who underwent treatment for carpal tunnel syndrome from March -2018 to Feb -2022 were the subjects of study. Results:  The study included 63 patients, majority of patients were females (55 patients), and median age was 45 years. 16 patients had bilateral disease; right hand was predominantly involved. All the procedures were done under regional anesthesia under Tourniquet control. Average time taken was 15-20 minutes. Most patients returned to normal routine work in 2 to 3 weeks, with immediate and significant relief of symptoms. Complications were recorded in 3 patients, which included mild scar tenderness in two patients and minor hematoma in one patient. Follow up ranged from 6 months to 2 years. No patient required any repeat surgery for incomplete release of carpal tunnel. Conclusion: It is a simple, easy and effective technique, in a setup with limited resources, with all the advantages of an ECTR and having significantly reduced the complications of conventional open surgical techniques.

Keywords
INTRODUCTION

The median nerve entrapment at the wrist, which defines carpal tunnel syndrome (CTS), represents the most common compressive neuropathy which is encountered clinically with a prevalence of up to 4-7% in. (1) Common comorbid conditions associated with increased risk of developing CTS include advanced age, female gender, obesity, diabetes, and pregnancy. A variety of additional etiologic conditions have been implicated, including hypothyroidism, rheumatologic and autoimmune diseases, alcoholism, and renal failure. Compression may also result from space-occupying lesions within the canal such as proliferative tenosynovitis, hematoma, tumors, or ganglion cysts. Displaced distal radius or carpal injuries may also diminish canal volume. Patients predominantly complain of paraesthesias and numbness, in the distribution of median nerve. The paraesthesias may be aggravated on wrist movement or prolonged wrist posture in a flexed position, such as holding a baby or driving a car. With progression of the disease, patients may complain of weakness of grasp and pinch and later thenar muscle atrophy may also develop.

 

The diagnosis is primarily clinical based on a combination of symptoms and characteristic physical signs. The Phalen test (wrist flexion test) and Tinel sign (nerve percussion test) are frequently positive. Nerve conduction studies (NCV) may demonstrate; increased distal median nerve sensory latency (>3.5 msec), increased distal median nerve motor latency (>4.5 msec), and decreased conduction velocity (demyelination) or amplitude (axonal loss). Denervation of thenar muscles on EMG (fibrillation potentials, sharp waves, increased insertional activity) will predict post operative recovery in advanced disease. MRI is a sensitive tool but rarely used, ultrasound is easy to perform and frequently used as a first-line tool to assist diagnosis.

 

Carpal tunnel release (CTR) is one of the most frequently performed hand surgery worldwide (2). The traditional open technique requires a longitudinal incision extending between the distal end of the transverse carpal ligament (TCL) and distal wrist flexion crease. Whereas this access provides a complete exposure of the median nerve, it carries the risk of scar tissue and scar sensitivity, along with a possible flexion contracture in the wrist. All these conditions can significantly delay a complete functional recovery (3,4,5). To avoid such complications, less invasive techniques have been proposed, such as the endoscopic-assisted release or mini-palmar incision surgery, sometimes by using innovative surgical instruments. CTR surgery with a single limited or small incision is becoming more widely accepted. A better recovery, less pillar pain, less scarring, and an earlier return to work are the key benefits of single limited incision (6,7).

 

Despite these premises, all the techniques mentioned above could result in several complications, such as vascular, nerve, and tendon damages, or the incomplete release of the transverse ligament, leading to recurrence (7).

 

When adopting a less invasive procedure, the final aim is to reduce surgical time and possible complications (including the extent of the incision and post-operative scar), providing faster recovery and an earlier return to work and daily activities. This study describes our surgical technique and outcome of single limited incision (1cm) minimally invasive carpal tunnel release for CTS, with easily available, routinely used instruments. This technique has all the advantages of ECTR and has significantly overcome all the disadvantages of major open surgical techniques (Classical open technique, Palmar crease approach, mini open single incision palmar approach and minimally invasive Distal wrist crease approach (13,14,15). We describe a minimally invasive surgery for carpal tunnel release with the traditionally available instruments

METHODS

The study was conducted in the department of Plastic and Reconstructive surgery GMC Srinagar. The patients who underwent treatment for carpal tunnel syndrome from March -2018 to Feb -2022 were the subjects of study.

 

Surgical Technique

Minimally invasive (Mini Open) surgical technique using routine instruments (Mushtaq’s Technique). The technique is performed under regional anesthesia, under tourniquet control.

 

Step 1: Incision

A 1cm transverse skin incision is made in the proximal wrist flexion crease, medial to Palmaris Longus tendon (Fig 1).

 

Double blunt Senn retractors are used to retract the skin.

 

Step 2: Identification and Incision of antebrachial fascia

 

After dissection of subcutaneous tissues, antebrachial fascia is identified and incised (Fig 2).

 

Step 3: Delineation of the distal edge of antebrachial fascia

 

Delineation of distal edge of antebrachial fascia, which is distally continuous with TCL (Fig 3).