Article
Is it worth operating severe, old carpal tunnel syndrome? Which technique?
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Authors
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Amina Shammat
- University Emergency County Clinical Hospital Pius Brinzeu, Timisoara, Romania
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Vladislav Gyebnar
- University Emergency County Clinical Hospital Pius Brinzeu, Timisoara, Romania
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Mihaela Mastacaneanu
- CHU Martinique, SOS Main, Hopital Pierre Zobda Quitman, Fort-de-France, Martinique
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Izabela Popa
- Office of Neurology Dr Izabela Popa, Timisoara, Romania
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Veronica Romanescu
- University Emergency County Clinical Hospital Pius Brinzeu, Timisoara, Romania
| Published: | February 6, 2020 |
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Outline
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Objectives/Interrogation: Nerve conduction studies (NCS) in carpal tunnel syndrome (CTS) stage 4 show sensory nerve action potential absent but motor response preserved, distal motor latency to abductor pollicis brevis 4.5 ms to 6.5 ms. After several years of disease evolution, median nerve fibrosis is always present.
We presume that median nerve epineurolysis (MNE) improves the result of the carpal tunnel release (CTR) in all cases of long lasting, stage 4 CTS (prospective study).
Methods: Inclusion criteria: stage 4 CTS (NCS), at least two years of evolution, nocturnal pain interfering with sleep, neurologist's recommendation for MNE.
All patients were operated by the same surgeon, using mini-invasive CTR. In all cases, the epineurium of the median nerve was visibly fibrosed and MNE was performed. Postoperatively: 5 days of AINS, 10 days compressive dressing, follow-up at 12-14 days.
All patients completed a questionnaire one day before and one year after surgery. Patient-reported outcomes regarded nocturnal pain and awakening, numbness resolution (measured on visual analogue scale VAS) and overall satisfaction. The NCS were performed by the same neurologist, 1-2 months preoperatively and one year after surgery, using the same device and technique.
Results and Conclusions: We included 208 patients (331 hands), 73 male, mean age 56,5 years. Twenty-two patients had more than 3 months of sick leave in the past year prior to surgery and 16 had to change their workplace.
Simple CTR led to median nerve hyperemia. Intraoperative fibrosis was assessed visually and tactilely. Following MNE, the nerve increased in volume.
The pain resolution was immediate (7.9 preoperatively to 1.4 VAS postoperatively). Numbness remission was noticed at 2-3 months (7.2 preoperatively to 2.3 VAS postoperatively). All patients were very satisfied with the results.
Electrophysiological findings: the distal latencies diminished by a mean of 0.5 ms and the compound muscle action potentials CMAP increased with around 1,5 mV.
No matter how old is a severe CTS, there was a definite improvement in all operated cases, mainly regarding the disparition of pain.
All patients with long-lasting evolution of CTS must undergo NCS to evaluate the severity of the disease and median nerve fibrosis (standard of care).
In stage 4 CTS surgical intervention is still indicated, but mini-invasive carpal tunnel release needs to be completed by epineurolysis.
Intraoperative NCS might be the next step in predicting the need for MNE.
