Carpal tunnel decompression with transverse carpal ligament transection is a very successful treatment of carpal tunnel syndrome. The standard long-curved incision technique has become the best treatment for median nerve entrapment decompression. Here we introduce the metacarpal small incision carpal tunnel release (MSICTR) in the treatment of carpal tunnel syndrome (CTS).
Endoscopic carpal tunnel release (ECTR) techniques have been established as a successful treatment for carpal tunnel syndrome and have proven equally effective as traditional open carpal tunnel release (OCTR) techniques in relieving pain and numbness. However, patients who undergo OCTR are more likely to experience scar tenderness and pillar pain and take longer to return to work.
We present here a method of metacarpal small incision for carpal tunnel release (MSICTR) as a safe, reliable, cost-effective alternative surgical decompression of the median nerve of the wrist. This technique utilizes a metacarpal small incision and direct visualization of the median nerve and carpal tunnel contents, reducing the risk of permanent injury and neurasthenia when compared to traditional OCTR. MSICTR is also suitable for the examination of the median nerve, surrounding tendon sheath, or space-occupying lesions.
MSICTR is associated with shorter operation times, less postoperative pain, faster recovery, and improved cosmetic results when compared to traditional OCTR. Therefore, MSICTR is an effective surgical decompression of the median nerve for the treatment of carpal tunnel syndrome.
Carpal tunnel syndrome (CTS) is a common peripheral nerve entrapment disorder caused by the compression of the median nerve in the wrist region, especially in the carpal canal. The clinical manifestations of CTS are diverse and may include pain, numbness, weakness, and hand muscle atrophy1,2, which can significantly impact the quality of life of patients. The diagnosis of CTS is typically based on clinical manifestations and physical examination, supported by electrophysiological studies such as electrodiagnostic testing3,4. For patients with mild symptoms, conservative treatment may be sufficient, but for those with moderate to severe symptoms, surgical intervention is often necessary5.
Many surgical techniques6,7,8,9,10,11,12,13,14,15,16,17,
18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35 have been developed for the treatment of CTS, each with its advantages and disadvantages6,7,8. Open carpal tunnel decompression with a standard long palmar curved incision is a commonly used technique; however, it is associated with various complications such as scar tenderness, cosmetic dissatisfaction, and loss of hand grip and pinch strength3,7,9,10. Therefore, there is a need for a surgical technique that is effective in treating CTS but is also minimally invasive and associated with fewer complications.
The purpose of this study is to introduce a metacarpal small incision for carpal tunnel release (MSICTR) technique in the treatment of CTS and summarize our experience. This technique utilizes a small incision made at the base of the palm, over the carpal tunnel, allowing direct visualization of the median nerve and carpal tunnel contents (Figure 1). The advantages of MSICTR include shorter operation time, less postoperative pain, faster recovery, and improved cosmetic results when compared to traditional open carpal tunnel decompression techniques3.
Previous studies have shown that MSICTR is an effective and safe surgical technique for the treatment of CTS13,16,17,18,20,24,26,27,28. MSICTR has been associated with low rates of postoperative complications such as scar tenderness, infection, and median nerve damage17. Additionally, MSICTR can provide direct visualization of the median nerve and carpal tunnel contents, ensuring the complete release of the carpal tunnel and reducing the risk of residual compression18. The MSICTR technique is suitable for patients with CTS who have failed conservative management and are suitable for surgery. It can be used in patients with mild to severe symptoms of CTS and is particularly suitable for those who are concerned about cosmetic results and postoperative recovery time. However, MSICTR should not be used in patients with coagulation disorders or those who are not suitable for general anesthesia.
In summary, MSICTR is a safe and effective surgical technique for the treatment of CTS that has advantages over traditional open carpal tunnel decompression techniques. It is associated with shorter operation time, less postoperative pain, faster recovery, and improved cosmetic results. However, further randomized controlled trials are needed to compare MSICTR with other surgical techniques for CTS to establish its true efficacy and safety.
This study was approved by the ethics committee of our institution and all patients provided informed consent before participating in the study.
1. Preoperative steps
2. Initial surgical procedures
NOTE: Pay attention to the abnormal anatomy of nerves and blood vessels during the operation.
3. Postoperative care
It is important to discuss the recovery time with the patient before the operation to make the patient's expectation of the outcome of the operation realistic. The surgical marker simplifies the identification of surgical incisions (Figure 2A).
When the surgical approach is performed in accordance with the above steps, all the diseased sites of the transverse carpal ligament and adjacent metacarpal fascia can be touched without any problem (Figure 3A–D).
We have conducted a retrospective study comparing the outcomes of the MSICTR technique with those of traditional open carpal tunnel decompression in 100 patients with CTS. Additionally, MSICTR patients had shorter recovery times and lower rates of postoperative complications such as scar tenderness and infection.
The data were collected prospectively for all patients who underwent MSICTR or traditional open carpal tunnel decompression between 2018 and 2021. Patients were evaluated presurgery and at 6 months post surgery using the visual analog scale (VAS) for pain score, a dynamometer for grip and kneading strength, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire for functional outcome.
The results of the study are summarized in Table 1, which shows the mean changes in pain score, grip, and kneading strength, and the DASH score at 6 months post surgery for patients who underwent MSICTR and traditional open carpal tunnel decompression. It can be seen that patients who underwent MSICTR had significant improvement in all parameters compared to patients who underwent traditional open carpal tunnel decompression.
Additionally, MSICTR patients had shorter recovery times and lower rates of postoperative complications such as scar tenderness and infection. We believe that the MSICTR technique is a valuable option for the treatment of CTS and is superior to traditional open carpal tunnel decompression in several aspects.
Figure 1: Landmarks for the incision for carpel tunnel release. The green area is the area of the surgical incision. Please click here to view a larger version of this figure.
Figure 2: The surgical approach. (A) The incision is on the palmar side, ~3 cm. (B) The sutured incision is on the palmar side of the hand, ~ 3 cm. (C) Surgical separation of the subcutaneous fat layer. (D) Closed incision: covering the incision with loose, thick gauze. Please click here to view a larger version of this figure.
Figure 3: Metacarpal small incision carpal tunnel release in the treatment of carpal tunnel syndrome. (A–D) Release of the transverse carpal ligament. (A) Cutting the transverse carpal ligament with scissors along the ulnar side of the median nerve under direct vision through the incision. (B) Using a retractor to pull up the skin proximal to the incision and release the transverse carpal ligament to the level of the far flexion carpal crease. (C) Using fingers to check whether the median nerve is completely released. (D) The median nerve was not damaged; it was completely released. Please click here to view a larger version of this figure.
Outcome | MSICTR (n = 50) | Open Decompression (n = 50) |
Pain Score (VAS) | -2.8±1.1* | -2.0±1.3 |
Grip Strength (%) | 81±19* | 67±23 |
Kneading Strength (%) | 75±21* | 61±24 |
DASH Score (%) | 68±24* | 79±29 |
Table 1: Summary of outcomes at 6 months post surgery. *Statistically significant improvement compared to preoperative values (p < 0.05).
Carpal tunnel surgical decompression combined with transection of the transverse carpal ligament has been a very successful operation for the treatment of CTS11,12,13,14,15,16. Over the years, the carpal tunnel decompression procedure has been developed to reduce complications and side effects associated with the operation. All previously described surgical techniques11,12,13,14,15,16,17,18 have proven successful in relieving symptoms such as CTS numbness, but each technique has its advantages and disadvantages.
Until now, for many orthopedic surgeons, the standard long-curve incision technique has been considered the optimal treatment for surgical carpal tunnel decompression. The greatest advantage of this technique is that it allows visualization of all structures and lesions in the carpal tunnel19, but it can have technical complications associated with the procedure itself6,7. Because the procedure is performed under direct vision7,19, early complications are usually rare. However, the incidence of late complications is relatively high. These late complications include hypertrophic postoperative scarring, tenderness in the surgical scarring area, loss of grip strength, and localized sympathetic dystrophy, which may delay the recovery time and cause emotional distress3,7,19,20.
To reduce these complications, various improved surgical techniques21,22,23,24,25,26 have emerged, such as limited incision or endoscopic techniques. In particular, endoscopic techniques have been accepted and widely used by surgeons. However, the endoscopic technique has its limitations, such as the large size of the endoscope and the rather long learning curve27. However, the most common technical complications of these approaches are injury to the median nerve and its branches, tendon tears, and arterial injury, which is an undesirable outcome4,7,24,28.
Recently, a new method called ultrasound-guided needle release with corticosteroid injection has been developed for treating carpal tunnel syndrome29,30,31. This method provides several advantages over traditional open surgery. First, it requires a smaller incision, which means less damage to the surrounding tissues and faster recovery. Second, it is less costly than traditional surgery because it does not require expensive equipment or a large operating room. Finally, the procedure is faster and simpler to perform, which reduces the overall treatment time and improves patient satisfaction.
The advantages of ultrasound-guided ultra-minimally invasive surgery may be no incision and rapid recovery, but the recurrence rate may be higher30. There is no prospective study to compare various ultrasound-guided techniques. Compared with traditional open surgery, ultrasound-guided needle release with corticosteroid injection is a more suitable option for CTS patients who are concerned about cosmetic results and recovery time. This method is also suitable for patients who are not suitable for general anesthesia.
In this study, the MSICTR technique is safe and effective in visualizing the structure and lesions of the carpal tunnel during surgery. As a result, potential technical complications and the risk of nerve, artery, or tendon injury were minimized. Transverse carpal ligament transection and carpal tunnel surgical decompression are more easily performed under direct vision. The only surgical signs are small scars left by the procedure and less scar tenderness. In these surgical patients, there were no complications of nerve, vascular, or tendon injuries associated with surgical intervention. Therefore, our patients generally do not require physical therapy or anti-inflammatory medication, and after 6 months of follow-up, their symptoms have improved significantly. The procedure shortens the recovery time of patients and reduces social and medical costs.
The small metacarpal incision technique typically does not require physiotherapy. However, there is limited information available on the effectiveness of postoperative rehabilitation interventions in individuals who have undergone carpal tunnel surgery32. However, given the potential benefits, individuals who undergo carpal tunnel surgery may wish to consult with a physiotherapist to determine if postoperative physiotherapy is appropriate for them.
The differences between the metacarpal small incision technique described herein, the limited incision technique, and the mini-incision technique for carpal tunnel surgery mainly lie in the incision length and surgical approach13,16,17,18,20,24,26,27,28,33,35. Regarding the incision length, the metacarpal small incision technique requires a slightly longer incision, generally 3 cm in length, which is longer than that of the limited incision technique and mini-incision technique. The limited incision technique has an incision length of 2-2.5 cm, while the mini-incision technique has an incision length of 1.5-2.0 cm33. The specific incision length for each technique depends on the size of the patient's hand.
In terms of the surgical approach, the metacarpal small incision technique is performed entirely under direct visualization, which ensures a precise release of the transverse carpal ligament and avoids nerve damage. This is in contrast to the limited incision and mini-incision techniques, which may require more precision and caution to avoid damage to the surrounding nerves and tissues as they involve smaller incisions. Therefore, surgeons performing these techniques must possess a high level of expertise and experience to ensure successful outcomes.
Overall, the differences between these three techniques are relatively small but crucial in ensuring a successful surgical outcome with minimal risk of complications. The choice of which technique to use depends on the surgeon's preference and expertise as well as the patient's specific condition and needs. In our opinion, MSICTR median nerve release is a safe, low-cost procedure with a low-grade learning curve and short operative time, which can be accomplished with conventional surgical instruments. The tolerance of the patients is reasonably high, and the procedure is in line with the current trend toward minimally invasive surgery.
The authors have nothing to disclose.
This study was supported by a fund from the University-Industry Collaborative Education Program of the Ministry of Education in 2021 (project number: 202101312014) and a fund from the University-Industry Collaborative Education Program of the Ministry of Education in 2022 (project number: 220905634190447).
Absorbable suture | Shandong Boda Medical supplies Co., Ltd. | 01-1517-8817-2 | Absorbable suture in surgical suture, after implantation into human tissue, can be degraded and absorbed by the human body, and does not need to remove stitches, but to avoid the pain of suture removal of a new type of suture material. |
Disposable aseptic surgical blade | Huaiyin Medical equipment Co., Ltd. | yuxiezhuzhun20192150063 | It is used to cut soft tissue during surgery. |
Disposable aseptic surgical membrane | Zhejiang Chun'an Renhe Medical products Industry and Trade Co., Ltd. | zhechunxiebei20180017hao | It can be used to cover and protect the organs of surgical patients from bacterial infection in hospital operations. at the same time, it can be used for CT, nuclear magnetic resonance, organ B-ultrasound and other inspection imaging examination. |
Disposable infusion device | Shandong Weigao Group Medical Polymer products Co., Ltd. | 1401275143736 | Clinical intravenous infusion |
Disposable sterilized rubber surgical gloves | Shanghai Huaxin Medical Materials Co., Ltd. | huxiezhuzhun20172660706 | It is used in surgical procedures to protect patients and users, to avoid cross-infection, and is not suitable for examination gloves or procedural gloves. |
Hemostatic forceps | Hunan Kefu Medical Technology Development Co., Ltd. | xiangxiezhuzhun20192150038 | Hemostatic forceps is a kind of surgical instrument which can block blood by clamping blood vessels. |
LM bipolar drop hydrocoagulation forceps (hemostatic ablation electrode during surgery) | Jiangsu Yibo Leiming Medical Technology Co., Ltd. | 20222068536P | LM bipolar drop hydrocoagulation forceps (hemostatic ablation electrode during surgery) for electrocoagulation of tissue |
Medical forceps | Yangzhou Euro Science and Technology Development Co., Ltd. | 6803 | Medical forceps are used to hold human tissue. |
Medical gauze piece | Steady medical supplies co., Ltd. | 59400869174 | Medical gauze is a disposable item used in surgery and wound care. |
Medical surgical towel | Xuchang Zhende Medical dressing Co., Ltd. | yushiyaojianxiezhunzi2006di2640197hao | It is used for hemostasis and isolation in all kinds of operations. at the same time, it can be used to observe and protect the important parts of patients in bedside photography and fluoroscopic surgery. |
Needle holder | Shanghai Youqun Medical equipment Co., Ltd. | 91310113758584951A | The needle holder is mainly used to hold stitches and suture various tissues. |
Single-use suction connecting pipe | Suzhou Jingle Polymer Medical equipment Co., Ltd. | huxiezhuzhun20183100062 | It is used to attract, aspirate blood, lavage, and rinse during the operation and play an auxiliary role in the operation. |
Surgical hilt | Zhejiang Suichang Shuangjian Medical equipment Co., Ltd. | zhexiezhuzhun2020207162234 | The scalpel is divided into a blade and a handle. The blade is disposable, the handle is not. Other instruments are not disposable, but they are autoclaved each time they are used. |
Surgical scissors | Maichuang Medical Technology (Suzhou) Co., Ltd. | 91320509MA1MMLGX80 | For cutting dressings, human epidermis or soft tissue. Tissue scissors: used for cutting tissue. |
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