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Minimally invasive approaches dominate latest carpal tunnel syndrome advances
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In 2017, hand surgeons have a variety of techniques to achieve what should be the goals of every type of treatment for patients with carpal tunnel syndrome: decompress the median nerve within the carpal tunnel, allow better movement of or release the transverse carpal ligament, reduce pain and restore wrist function.
Orthopaedics Today Europe spoke with international experts about newer treatments for carpal tunnel syndrome (CTS) that are in clinical or experimental use worldwide or just now being researched. They agreed ultrasound guidance is being used more regularly during the part of CTS surgery performed to section the transverse carpal ligament (TCL). It is also reportedly being used to more effectively diagnose CTS and guide injection of steroids to treat it or manage the pain associated with CTS.
Sources said some novel methods to section the TCL and different surgical devices are among the newer CTS treatment options, including a forward-facing knife for endoscopic releases. However, they cautioned that the evidence available about the effectiveness and safety of some of these newer methods is often weak and, in some instances, nonexistent. Furthermore, they said meta-analyses of CTS studies are hard to do because CTS presents differently in every patient. Severity may depend on the patient’s occupation, whether he or she is healthy, or has diabetes and other factors.
Release, but do not injure median nerve
Regardless of whether a CTS technique used is new or old, orthopaedic surgeons should ideally select a treatment that releases the TCL completely, Grey Giddins, FRCS(Orth), EDHS, of The Hand Clinic, in Bath, United Kingdom, told Orthopaedics Today Europe.
Giddins’ preferred CTS treatment is a standard, open release.
“Researchers are looking at how many discreet moves it takes to do it; that may improve the technique and be a measure of progress in training,” Giddins said.
But, Giddins said the anatomy can be surprising and the canal very tight, so there is a risk of the median nerve being injured with incisions that are too small. Therefore, surgeons must take whatever steps they can to avoid such an injury, which is disproportionate to any small gain from a small incision, he said.
Classic vs short incisions
Lars B. Dahlin, MD, PhD, of the Department of Translational Medicine – Hand Surgery, Lund University, Skane University Hospital in Malmö, Sweden, said the skin incision in CTS surgery is not as much a concern as how well the CTL is managed.
“You have to divide the ligament, which has the physiological task to keep the tendons in the carpal tunnel in place during gripping and give strength and so on. This type of ligament has to be divided and then the ligament heals with a lengthening,” Dahlin told Orthopaedics Today Europe.
Because it takes a while for the divided TCL to heal, he said time is the key to successful CTS surgery in his patients rather than other factors, such as the length of the incision or surgical instrument used.
“That is why I am not convinced that a lot of the minimal techniques will improve things,” Dahlin said.
Supraretinacular release
Some surgeons who treat CTS open or endoscopically now perform a superficial release carpal tunnel release. Giddins said the technique is among the newer, but not yet established methods of which he is aware.
He mentioned a recent study by Ecker and colleagues in which they reported results with a supraretinacular endoscopic carpal tunnel release, which is different than the infraretincular approach some hand surgeons currently use.
“Because the endoscope is inserted superficial to the flexor retinaculum, the median nerve is not compressed before division of the retinaculum and, as a result, we have observed no cases of the transient median nerve deficits that have been reported using infraretinacular endoscopic techniques” Ecker and colleagues wrote.
Results of comparative study
In 2013, Larsen and colleagues found no advantage to CTS surgery done with a short incision in their randomized comparison of classic and short incision open and endoscopic surgical techniques which included 90 patients with 24 weeks of follow-up.
“The results indicate that the endoscopic procedure is safe and has the benefit of faster rehabilitation and return to work,” Larsen and colleagues wrote in the study’s abstract.
Giddins said that based on his experience the indications for endoscopic releases are by and large the same as for open releases.
Special knife for endoscopic release
Investigators from Seoul, Korea reported results with their endoscopic surgical experience using a forward-facing knife in 657 patients (1,000 hands) with CTS proven by electrodiagnostic testing. They found 97% of patients were satisfied with their results in 30 hands at 3 months postoperatively. However, the transverse carpal ligament release was incomplete in 12 hands among the dissatisfied patients.
“Nine hands with severe thenar muscle atrophies and severe electrodiagnostic abnormalities were not improved after [endoscopic carpal tunnel release] ECTR. In addition, 2 hands associated with cervical disc disease, 1 hand with motor neuron disease, and 1 hand with fibrolipomartous hamartoma of median nerve were not improved,” Hyung Sik Hwang, MD, and colleagues wrote.
They noted there are few descriptions in the literature of results with the forward-facing knife, and wrote, “ECTR surgery using a forward-facing knife is an effective, minimally invasive surgical technique with a low complication rate with cost-effectiveness.”
TCL cutting variations
“There is little that could be called ‘new and effective’ treatment for CTS in the last few years,” Jeremy D.P. Bland, MB ChB, FRCP, a consultant in clinical neurophysiology at East Kent Hospitals University NHS Foundation Trust, told Orthopaedics Today Europe. “Some interesting variations on ways to cut the TCL have been devised, of which the most ingenious is probably ultrasound-guided division with a thread.”
The thread is used like a Gigli saw, Bland said.
“Endoscopic, two-incision limited incision technique and ultrasound guided carpal tunnel release are newer techniques. Published literature suggests results of these techniques are comparable with open/mini-open carpal tunnel release in primary CTS,” Sudhir Kumar Garg, MS-Orth, ODTS(UK), FUICC(USA), FIMSA, of Chandigarh, India, told Orthopaedics Today Europe.
Devices, ultrasound
Various devices have been introduced during the years for minimally invasive approaches to surgical CTR that aid with the release or better illuminate the procedure, such as the Knifelight (Stryker).
“Newer devices include the Manos CTR system (Thayer Intellectual Property Inc.),” Garg said. It is a manual orthopaedic instrument for release of the TCL in patients who failed conservative therapy for CTS.
Concerning noninvasive or minimally invasive CTS treatment, Giddins said, “Steroid injection is an evolving field.”
However, ultrasound to guide either the surgical release or injections “has not taken off,” he said.
Dahlin, who has no experience with ultrasound or ultrasound-assisted CTS treatment, said, “I think it is extremely important that the resolution is good [so] that you can see all the parts, that you could divide the ligament.”
He is hesitant about adopting this treatment approach because of the possibility some small fibers of the distal, deeper part of the TCL may remain afterward because these may not be seen as well by the surgeon as the fibers are seen in conventional, open CTS surgery.
“You have to be familiar with [its] use to use ultrasound” and its use requires extra care on the part of the surgeon, Dahlin said.
“If you leave some of these fibers, there might be an even more severe compression afterward because if you leave them it will be more like a constriction,” he said.
Steroids injection to avoid surgery
The problem with steroid injections is these only address the soft tissue in the affected area and previous studies have shown a limited long-term benefit. But, these are a possible solution in some patients. Injections may be indicated for women with CTS who are pregnant and cannot undergo the surgery or can be a diagnostic aid, according to Giddins.
In a study by Bland and his colleague A. Hameso, less than half of 254 patients with CTS who had corticosteroid injections into their carpal canal in 2007 needed surgery by 2015.
“This seems to suggest a role for steroid injections in long-term treatment, avoiding the need for surgery in some patients,” Giddins said.
Garg said triamcinolone acetonide, methylprednisolone acetate and betamethasone sodium phosphate and betamethasone acetate injectable suspension, USP (Celestone Soluspan; Merck Sharp & Dohme Corp.) are among the steroid preparations for local injection to treat CTS. This can be useful when symptoms are mild to moderate symptoms or it may help delay surgery in patients who failed conservative care and whose symptoms are confined to paresthesia.
“In our experience, duration of relief in patients, when symptoms are restricted to nocturnal or work-related paresthesia, is long-lasting,” Garg said.
“Personally, I do not think we make the most of treatment by local corticosteroid injection, resorting far too easily to surgery in many places, but that is an old treatment, not a new one,” Bland said.
Diuretics, botulinum toxin as CTS treatment
Other non-surgical, medical treatments of CTS are also being studied. Garg and Giddins noted gabapentin, a nerve medication, is being explored as an adjunct to other methods, in patients with diabetes, or in patients who cannot undergo surgery. It appears to mitigate the nerve pain, but mainly local, rather than systemic treatments, are best for such a localized condition, Giddins noted.
Thus, diuretics have also been used to treat nerve pain associated with CTS, but would be recommended by few, if any, hand surgeons, he said.
Bland noted randomized placebo-controlled trials of gabapentin have so far failed to show it to be superior to placebo in CTS.
However, he said some bizarre CTS treatments have been and continue to be proposed, such as herbal treatment, as well as injection of lidocaine, insulin or autologous blood.
“But, none of these off-the-wall ideas have been adequately replicated and most of the studies are of dubious quality,” Bland said.
Magnetic therapy and dermal patches that release capsaicin, which is essentially chili pepper, also have been proposed as CTS treatment. A company has developed PHYSTRAC (Contex BV), which is a traction apparatus designed to treat CTS.
A randomized double-blind clinical trial underway at the University of Minnesota, in Minneapolis, is comparing the results of a single injection into the carpal tunnel of 40 mg corticosteroid with 1 mL 1% lidocaine with injection of 45 units botulinum toxin in terms of pain relief and duration of symptom relief. – by Susan M. Rapp
- References:
- www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRes/res.cfm?ID=150962; Accessed January 24, 2017.
- Bland JD, et al. Muscle Nerve. 2014;doi:10.1002/mus.24058.
- www.carpal-tunnel.net
- Ecker J, et al. J Hand Surg Eur Vol. 2015;doi:10.1177/1753193414524688.
- Hameso A, et al. J Hand Surg Eur Vol. 2016;doi:10.1177/1753193416671102. [Epub ahead of print]
- Hwang HS, et al. Neurosurgery. 2014;doi:10.1227/01.neu.0000452428.06799.6c.
- Larsen MB, et al. J Hand Surg Eur Vol. 2013;doi:10.1177/1753193412475247.
- Petrover D., et al. Cardiovasc Intervent Radiol. 2016;doi:10.1007/s00270-016-1545-5. [Epub ahead of print].
- For more information:
- Jeremy D.P. Bland, MB ChB, FRCP, can be reached at Ethelbert Rd., Canterbury CT1 3NG, United Kingdom; email: jeremy.bland@nhs.net.
- Lars B. Dahlin, MD, PhD, can be reached at Jan Waldenstrõms gata 5, SE-205 02 Malmö, Sweden; email: lars.dahlin@med.lu.se.
- Sudhir Kumar Garg, MS-Orth, ODTS(UK), FUICC(USA), FIMSA, can be reached at Department. of Orthopaedic Surgery, Government Medical College & Hospital, Sector 32 B, Chandigarh 160030, India; email: sudhir_ortho@yahoo.com.
- Grey Giddins, FRCS(Orth), EDHS, can be reached at The Hand Clinic and the Orthopaedic Department, Royal United Hospital, Bath, United Kingdom; email: greygiddins@thehandclinic.co.uk.
Disclosures: Bland, Dahlin, Garg and Giddins report no relevant financial disclosures.