Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 237e243
Comparative analysis between minimal access versus traditional accesses in carpal tunnel syndrome: A perspective randomised study Mauro Tarallo, Pasquale Fino*, Valentina Sorvillo, Paola Parisi, ` Scuderi Nicolo Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome “Sapienza”, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy Received 3 June 2012; accepted 21 October 2013
KEYWORDS STC; Median nerve; Median release; MACTR; TOCTR; BCT
Summary Introduction: Carpal tunnel decompression with division of the transverse carpal ligament has been a highly successful procedure for the treatment of carpal tunnel syndrome. The standard longitudinal incision technique, with a long curvilinear incision, has been the optimal treatment procedure for surgical decompression of the median nerve, for many surgeons. The aim of this study was to compare the traditional open carpal tunnel release (TOCTR) technique with the minimal-access carpal tunnel release (MACTR) technique for the treatment of carpal tunnel syndrome (CTS), presenting our experience. Materials and methods: A total of 120 patients eligible for carpal tunnel decompression were recruited into the study. The patients were randomised for treatment allocation, at a 1:1 ratio, resulting in 60 patients in group A, treated by standard TOCTR, and 60 patients in group B, treated by MACTR. To evaluate patients’ outcomes we used the Boston Carpal Tunnel (BCT) questionnaire; the formed scar was evaluated according to the Vancouver scale and shortand long-term complications. Statistical analysis was performed by the chi-squared test and analysis of variance (ANOVA); Excel was the program used. Results: In our series, there was no complication related to the surgical intervention of any injury to nerve, artery or tendon structures. In each section of the BCT questionnaire, patients in group B had significantly better results than patients in group A at both 6 and 12 months’ follow-up (p < 0.001). For the Vancouver scar scale, there was a significant difference between two groups’ scores; group B patients had significant improvements compared with group A patients.
* Corresponding author. Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome “La Sapienza”, Policlinico Umberto I, Viz olei Quinzi, 5, Inferno21, 00175 Rome, Italy. Fax: þ39 06 491525. E-mail addresses: [email protected], [email protected] (P. Fino). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.033
238
M. Tarallo et al. Conclusions: In our perspective randomised study, MACTR showed statistically significant improvement compared to TOCTR. The patient tolerance is reasonably high and the procedure is compatible with the current minimal invasive trend in surgery. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies in clinical practice. It is caused by the compression of the median nerve at the wrist region, more precisely at the carpal tunnel. It affects the 1e5% of the general working population,1 mainly the middle-aged female population,2e4 accounting for 90% of all entrapment neuropathies.5e7 The general clinical presentation is of painful paraesthesias and/or burning pain in the lateral half of the hand, predominantly in the three first fingers. Typically, the paraesthesias are predominantly nocturnal. The patients may also complain of anaesthesia, loss of dexterity, weakness and, in more advanced cases, loss of motor function and thenar atrophy.8,9 The diagnosis is based on clinical presentation and physical examination, which may be confirmed by electrophysiological testing, specifically electroneuromyography (ENMG), based on sensory and motor latency, and the observation of conduction abnormalities.8,5,10,11 The conservative treatment for patients with mild symptoms of CTS consists of non-steroid anti-inflammatory drugs, vitamin B6, local steroid injections or hand braces.5,12 Surgical treatment is generally required in patients with moderate and severe symptoms.12 Various methods have been described for the surgical treatment of CTS. Standard open carpal tunnel release with a long palmar curvilinear incision still remains the preferred surgical procedure for many surgeons5,6,13; but, this procedure has many complications including pillar pain, scar tenderness, cosmetic dissatisfaction, loss of grip and pinch strength or time losses due to inability to work.2,5,10,14 The aim of this study was to compare the traditional open carpal tunnel release (TOCTR) technique with the minimalaccess carpal tunnel release (MACTR) technique for the treatment of CTS, presenting our experience.
Methods and patients A total of 120 patients eligible for carpal tunnel decompression were recruited into the study from January 2009 to January 2011, from a sample of patients scheduled for CTS selecting the same number of males and females by a random method. The study protocol conformed to the ethical guidelines of the Declaration of Helsinki. An informed consent was obtained from each patient. Inclusion criteria were diagnosis of CTS with moderateto-severe symptoms, based on the history of hand dysaesthesia, paraesthesia, numbness in the median nerve distribution, a positive Phalen’s flexion test finding and/or a positive Tinel’s sign. All patients also underwent nerve conduction tests and had positive electrodiagnostic study findings. Patients were randomised for treatment allocation, at a 1:1 ratio, resulting in 60 patients in group A, treated by
standard TOCTR, and 60 patients in group B, treated by MACTR. The two groups were homogeneous for sex, age and characteristics. There were 60 men and 60 women. The youngest patient was 54 years old and the oldest was 75 years old. Co-morbidities were evaluated. All patients underwent nerve conduction studies (NCS) before surgery. The TOCTR and the MACTR techniques were performed after local anaesthesia with an upper-arm pneumatic tourniquet by the same surgeon.
Surgical technique Patients in group A had carpal tunnel decompression by TOCTR. For the standard technique, a curved longitudinal incision was made parallel to the thenar crease, distally at Kaplan’s cardinal line, and was extended 2e4 cm proximally towards the wrist crease obliquely in an ulnar direction at a point in line with the long axis of the flexed ring finger or just on the ulnar side of the palmaris longus tendon (Figures 1e3). Patients in group B had carpal tunnel decompression by MACTR. A 2-cm-long incision was marked in the proximal palm over the transverse carpal ligament, beginning distally at the insertion of Kaplan’s cardinal line drawn with the thumb radially abducted and a line drawn along the radial border of the finger metacarpal (Figure 4). After the skin incision, the subcutaneous tissue was incised with a no. 15 blade and two Ragnel retractors were positioned to separate the edges of the incision. The palmar fascia was divided and the transverse carpal ligament was identified (Figure 5). A no. 15 scalpel was used to incise the carpal ligament and enter the carpal tunnel, for identification of the median nerve (Figure 6). A pop could be felt as a window was made over the transverse carpal ligament. Iris
Figure 1
(TOCTR) preoperative view.
Minimal access versus traditional accesses in CTS
Figure 2
Median nerve exposed by (TOCTR).
scissors were used to divide the transverse carpal ligament distally. Afterwards division became easier, with the slit forming a ‘V’ to guide division, under direct observation, including the distal aspects of the carpal ligament. The median nerve was then inspected, and the tourniquet was released. The incisions were closed with interrupted 4/ 0 nylon sutures and a pressure bandage was applied (Figure 7). No splint was used, and the patients were encouraged to move their hands and fingers in the immediate postoperative period. The original dressing was removed after 5 days, and the stitches were removed after 10 days. Postoperative follow-up was at 7 days and then at 1, 3, 6 and 12 months. We analysed early and late complications. To evaluate patient’s outcomes we used the Boston Carpal Tunnel (BCT) questionnaire, which is a patientoriented, self-administered, standardised instrument.15,16 It is divided into two sections; the first one concerns symptoms evaluation (Symptom Severity Scale) and includes 11 items, with each item score ranging from 1 (mild)
Figure 3
(TOCTR) postoperative outcome.
239 to 5 (severe). The second section of the questionnaire evaluates hand functions (Functional Status Scale), testing eight daily activities scored from 1 (no difficulty) to 5 (cannot perform the activity). An Italian modified version of this questionnaire has been validated.16 In particular, in order to evaluate the results of treatment 12 months after the surgery, the formed scar was evaluated (its pigmentation, colour, height, elasticity and scar hypertrophy). The pigmentation of the scar, its height and colour were evaluated on a scale from 0 to 3. Elasticity was evaluated on a scale from 0 to 5 according to the Vancouver scale. The cosmetic appearance of the scar was evaluated subjectively by the patients themselves, based on a scale from 1 to 4 (1, the cosmetic appearance is close to normal; 4, the cosmetic appearance is unsatisfactory). Moreover, in examining disorders of sensation, the discrimination of two points was evaluated using needles fixed by standard distances (two-point test). At the beginning of the examination, the preoperative mean static twopoint discrimination score ranged from 7.2 mm, in group A patients to 7.6 mm in group B patients. This examination was repeated three times, and the best result was recorded (Table 1).
Statistical analysis The chi-squared test was performed to compare discrete variables of the early and late complications of the two groups and analysis of variance (ANOVA) was performed to compare the cosmetic outcome of the two groups. For pvalues
Comparative analysis between minimal access versus traditional accesses in carpal tunnel syndrome: A perspective randomised study Mauro Tarallo, Pasquale Fino*, Valentina Sorvillo, Paola Parisi, ` Scuderi Nicolo Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome “Sapienza”, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy Received 3 June 2012; accepted 21 October 2013
KEYWORDS STC; Median nerve; Median release; MACTR; TOCTR; BCT
Summary Introduction: Carpal tunnel decompression with division of the transverse carpal ligament has been a highly successful procedure for the treatment of carpal tunnel syndrome. The standard longitudinal incision technique, with a long curvilinear incision, has been the optimal treatment procedure for surgical decompression of the median nerve, for many surgeons. The aim of this study was to compare the traditional open carpal tunnel release (TOCTR) technique with the minimal-access carpal tunnel release (MACTR) technique for the treatment of carpal tunnel syndrome (CTS), presenting our experience. Materials and methods: A total of 120 patients eligible for carpal tunnel decompression were recruited into the study. The patients were randomised for treatment allocation, at a 1:1 ratio, resulting in 60 patients in group A, treated by standard TOCTR, and 60 patients in group B, treated by MACTR. To evaluate patients’ outcomes we used the Boston Carpal Tunnel (BCT) questionnaire; the formed scar was evaluated according to the Vancouver scale and shortand long-term complications. Statistical analysis was performed by the chi-squared test and analysis of variance (ANOVA); Excel was the program used. Results: In our series, there was no complication related to the surgical intervention of any injury to nerve, artery or tendon structures. In each section of the BCT questionnaire, patients in group B had significantly better results than patients in group A at both 6 and 12 months’ follow-up (p < 0.001). For the Vancouver scar scale, there was a significant difference between two groups’ scores; group B patients had significant improvements compared with group A patients.
* Corresponding author. Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome “La Sapienza”, Policlinico Umberto I, Viz olei Quinzi, 5, Inferno21, 00175 Rome, Italy. Fax: þ39 06 491525. E-mail addresses: [email protected], [email protected] (P. Fino). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.033
238
M. Tarallo et al. Conclusions: In our perspective randomised study, MACTR showed statistically significant improvement compared to TOCTR. The patient tolerance is reasonably high and the procedure is compatible with the current minimal invasive trend in surgery. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies in clinical practice. It is caused by the compression of the median nerve at the wrist region, more precisely at the carpal tunnel. It affects the 1e5% of the general working population,1 mainly the middle-aged female population,2e4 accounting for 90% of all entrapment neuropathies.5e7 The general clinical presentation is of painful paraesthesias and/or burning pain in the lateral half of the hand, predominantly in the three first fingers. Typically, the paraesthesias are predominantly nocturnal. The patients may also complain of anaesthesia, loss of dexterity, weakness and, in more advanced cases, loss of motor function and thenar atrophy.8,9 The diagnosis is based on clinical presentation and physical examination, which may be confirmed by electrophysiological testing, specifically electroneuromyography (ENMG), based on sensory and motor latency, and the observation of conduction abnormalities.8,5,10,11 The conservative treatment for patients with mild symptoms of CTS consists of non-steroid anti-inflammatory drugs, vitamin B6, local steroid injections or hand braces.5,12 Surgical treatment is generally required in patients with moderate and severe symptoms.12 Various methods have been described for the surgical treatment of CTS. Standard open carpal tunnel release with a long palmar curvilinear incision still remains the preferred surgical procedure for many surgeons5,6,13; but, this procedure has many complications including pillar pain, scar tenderness, cosmetic dissatisfaction, loss of grip and pinch strength or time losses due to inability to work.2,5,10,14 The aim of this study was to compare the traditional open carpal tunnel release (TOCTR) technique with the minimalaccess carpal tunnel release (MACTR) technique for the treatment of CTS, presenting our experience.
Methods and patients A total of 120 patients eligible for carpal tunnel decompression were recruited into the study from January 2009 to January 2011, from a sample of patients scheduled for CTS selecting the same number of males and females by a random method. The study protocol conformed to the ethical guidelines of the Declaration of Helsinki. An informed consent was obtained from each patient. Inclusion criteria were diagnosis of CTS with moderateto-severe symptoms, based on the history of hand dysaesthesia, paraesthesia, numbness in the median nerve distribution, a positive Phalen’s flexion test finding and/or a positive Tinel’s sign. All patients also underwent nerve conduction tests and had positive electrodiagnostic study findings. Patients were randomised for treatment allocation, at a 1:1 ratio, resulting in 60 patients in group A, treated by
standard TOCTR, and 60 patients in group B, treated by MACTR. The two groups were homogeneous for sex, age and characteristics. There were 60 men and 60 women. The youngest patient was 54 years old and the oldest was 75 years old. Co-morbidities were evaluated. All patients underwent nerve conduction studies (NCS) before surgery. The TOCTR and the MACTR techniques were performed after local anaesthesia with an upper-arm pneumatic tourniquet by the same surgeon.
Surgical technique Patients in group A had carpal tunnel decompression by TOCTR. For the standard technique, a curved longitudinal incision was made parallel to the thenar crease, distally at Kaplan’s cardinal line, and was extended 2e4 cm proximally towards the wrist crease obliquely in an ulnar direction at a point in line with the long axis of the flexed ring finger or just on the ulnar side of the palmaris longus tendon (Figures 1e3). Patients in group B had carpal tunnel decompression by MACTR. A 2-cm-long incision was marked in the proximal palm over the transverse carpal ligament, beginning distally at the insertion of Kaplan’s cardinal line drawn with the thumb radially abducted and a line drawn along the radial border of the finger metacarpal (Figure 4). After the skin incision, the subcutaneous tissue was incised with a no. 15 blade and two Ragnel retractors were positioned to separate the edges of the incision. The palmar fascia was divided and the transverse carpal ligament was identified (Figure 5). A no. 15 scalpel was used to incise the carpal ligament and enter the carpal tunnel, for identification of the median nerve (Figure 6). A pop could be felt as a window was made over the transverse carpal ligament. Iris
Figure 1
(TOCTR) preoperative view.
Minimal access versus traditional accesses in CTS
Figure 2
Median nerve exposed by (TOCTR).
scissors were used to divide the transverse carpal ligament distally. Afterwards division became easier, with the slit forming a ‘V’ to guide division, under direct observation, including the distal aspects of the carpal ligament. The median nerve was then inspected, and the tourniquet was released. The incisions were closed with interrupted 4/ 0 nylon sutures and a pressure bandage was applied (Figure 7). No splint was used, and the patients were encouraged to move their hands and fingers in the immediate postoperative period. The original dressing was removed after 5 days, and the stitches were removed after 10 days. Postoperative follow-up was at 7 days and then at 1, 3, 6 and 12 months. We analysed early and late complications. To evaluate patient’s outcomes we used the Boston Carpal Tunnel (BCT) questionnaire, which is a patientoriented, self-administered, standardised instrument.15,16 It is divided into two sections; the first one concerns symptoms evaluation (Symptom Severity Scale) and includes 11 items, with each item score ranging from 1 (mild)
Figure 3
(TOCTR) postoperative outcome.
239 to 5 (severe). The second section of the questionnaire evaluates hand functions (Functional Status Scale), testing eight daily activities scored from 1 (no difficulty) to 5 (cannot perform the activity). An Italian modified version of this questionnaire has been validated.16 In particular, in order to evaluate the results of treatment 12 months after the surgery, the formed scar was evaluated (its pigmentation, colour, height, elasticity and scar hypertrophy). The pigmentation of the scar, its height and colour were evaluated on a scale from 0 to 3. Elasticity was evaluated on a scale from 0 to 5 according to the Vancouver scale. The cosmetic appearance of the scar was evaluated subjectively by the patients themselves, based on a scale from 1 to 4 (1, the cosmetic appearance is close to normal; 4, the cosmetic appearance is unsatisfactory). Moreover, in examining disorders of sensation, the discrimination of two points was evaluated using needles fixed by standard distances (two-point test). At the beginning of the examination, the preoperative mean static twopoint discrimination score ranged from 7.2 mm, in group A patients to 7.6 mm in group B patients. This examination was repeated three times, and the best result was recorded (Table 1).
Statistical analysis The chi-squared test was performed to compare discrete variables of the early and late complications of the two groups and analysis of variance (ANOVA) was performed to compare the cosmetic outcome of the two groups. For pvalues
