Minimally Invasive Surgery for Carpal Tunnel Syndrome: A New Cost-Effective Method

Carpal_Tunnel_SyndromeCarpal tunnel syndrome, also called “entrapment idiopathic median neuropathy,” is due to compression of the median nerve in the carpal tunnel, in the wrist. It is becoming more common these days and often requires surgical treatment. The increasing incidence is probably related to typing, sewing and use of vibratory tools. It causes numbness, weakness, pain and sometimes depression. Conservative treatment is often not effective, and traditionally, open surgical treatment has been the treatment of choice. Recently, minimally invasive surgery with special instruments has been described. We describe a minimally invasive surgery with the traditionally available instruments.

Methods

Regional or general anesthesia could be used. A 1.5 cm transverse incision is made along the skin crease (the wrist flexion crease between the tendons of palmaris longus and flexor carpi ulnaris) at the proximal end of the carpal tunnel in the midline. It is deepened to expose the transverse carpal ligament, or TCL . Haegar’s dilators are used to create a space under the ligament, pointing it towards the distal end of the TCL, at the junction of the third web space and distal part of the fully abducted thumb.surgery in progress 1 - dr g

The optical urethrotome with insufflation with air/carbon dioxide, instead of saline, is used to visualize the ligament and cut it with the cold knife of the urethrotome. The air/carbon dioxide is pressed out after removing the instrument. Next, the incision is closed, and the hand is elevated for 24 hours.
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Discussion

The incidence of carpal tunnel syndrome is on the increase. In addition to the factors mentioned earlier, genetic predisposition is also present. Tapping over the median nerve in the wrist causing shooting pain (Tinel’s sign) and bending the wrist forward for one minute causing numbness (Phalen’s test) are used for diagnosis. Conservative measures such as non-steroidal anti-inflammatory drugs and local steroid injections are not very effective (1). Open surgery is the gold standard, and techniques with two or single portals have been described for endoscopic surgery (2). However, they are not easily available, and the equipment is expensive.

Although a minimally invasive procedure might not seem to be a great option initially, when the post-operative pain is considered, it is of great benefit to the patient. They generally find the incision in the palm very painful, and this method avoids making an incision there. The commercially available endoscopic equipment, of course, is very expensive and not available in rural areas.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

Image: Carpal Tunnel Syndrome. Source/Author: BruceBlaus. Blausen.com staff. “Blausen gallery 2014”. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. 20 August 2013. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Carpal_Tunnel_Syndrome.png

References (click to show/hide)

  1. Orthopedic surgery for carpal tunnel syndrome treatment and management. David A Fuller, Harris Gellman. September 2010. http://emedicine.medscape.com/article/1243192-treatment#a1133
  2. Surgical treatment of carpal tunnel syndrome. Nadine Hollevoet. European Musculoskeltal review, 2010, 5 (1): 76 – 81.


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