Perioperative management - Carpal tunnel syndrome – open carpal roof division

• persistent sensory and/or motor deficits (hypoesthesia, impairment of stereognosis/2-point discrimination) in D1-D4 with/without thenar atrophy
• significant and patient-impairing painful paresthesias in D1-D4 (not improved by conservative measures)
• in pregnant patients with existing deficits and in postpartum persistent CTS

• local or general diseases that contraindicate an elective operation surgically or anesthesiologically, or are improvable preoperatively
• no specific contraindications for open carpal roof splitting

• History of the typical clinic:
  • Nocturnal burning/discomfort/tingling paresthesias of fingers D1-4
  • Nocturnal/exertion-dependent numbness of fingers D1-4
  • Improvement by shaking/changing the position of the hand
• Clinical examination:
  • Inspection/palpation of the radial thenar (M. abductor pollicis brevis, M. opponens pollicis, M. flexor pollicis brevis Caput profundum) in side comparison, sweat production
  • Testing surface sensitivity by, for example, touching with a cotton ball
  • Testing stereognosis by two-point discrimination, recognizing coins or paper clips
  • Testing motor skills with abduction (90° to the plane of the hand) and opposition, positive bottle sign
  • Provocation tests: Phalen's test, Hoffmann-Tinel sign
• Electrophysiological diagnostics (always N. medianus and N. ulnaris on both sides)
  • The leading finding is the reduced nerve conduction velocity of the N. medianus in the carpal tunnel as a result of demyelination: pathological distal motor latency (DML) of the N. medianus > 4.2 ms (here DML of the N. ulnaris < 3.3 ms)
  • pathological sensory nerve conduction velocity (NCV) of the N. medianus < 46.9 m/s, as well as a difference in NCV of > 8 m/s compared to the N. ulnaris (limit value 44.6 m/s)
    reduced amplitude of the stimulus response as a result of axonal damage
• Optional additional diagnostics:
  • Imaging diagnostics (X-ray, ultrasound, MRI) only if there is evidence of concomitant diseases (e.g., carpal/tumor)

• no special preparation of the patient necessary
• generally an outpatient procedure
• clarification of contraindication for bloodlessness (e.g., existing shunt in dialysis)

Information about:

• Surgical methods open vs. endoscopic
  • Complication rate for open surgery 2.8%, for endoscopic surgery 5.6%
• Additional procedures such as accompanying tenosynovectomy
• General surgical risks (wound healing disorder)
• Specific surgical risks:
  • Injury to the median nerve (risk of complete transection < 0.3%) with neuropathic
  • pain prolonged scar pain (usually subsides after 6 months)
  • persistent symptoms, revision surgery
  • lack of regression of a sensorimotor deficit
  • risk of recurrence (increased in patients with rheumatic synovitis and dialysis patients)
  • wound infection (deep infections < 0.5%)
  • tendon/vascular injury (extremely rare < 0.1%)
  • functional deficit of the wrist/hand
  • CRPS (extremely rare)

• local infiltration anesthesia with a fine needle
• intravenous regional anesthesia
• plexus anesthesia
• general anesthesia

• Supine position
• Positioning the hand on a hand table
• Recommended: Application of upper arm tourniquet

• the surgeon should sit on the side where the leading hand points distally with the scissor tip
• an assistant may sit opposite
• the scrub nurse positions themselves at the head of the hand table

• the use of a hand holder such as a lead hand or similar is advisable
• the application of an upper arm tourniquet is recommended
• the use of magnifying optics such as loupes is recommended
• a hand instrument set is used
• special instruments are not necessary for the open method

Postoperative Analgesia

• Non-steroidal anti-inflammatory drugs are generally sufficient; if necessary, an increase with opioid-containing analgesics can be considered. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management).
• Follow the link to the current guideline Treatment of acute perioperative and peritraumatic pain.

Medical Follow-up Treatment

• Consistent elevation of the surgically treated extremity above heart level to counteract swelling
• If necessary, application of cold packs as a local physical measure
• If necessary, drainage removal on the 1st or 2nd postoperative day
• Regular wound inspection, elastic compressive bandage for a few days (Caution: constriction!); a wrist splint is generally not necessary (consider due to pain)
• Suture removal after 14 days
• If necessary, use of fatty ointment for scar care (special scar ointment not necessary)
• Release of load after 14 days
• Neurological follow-up examination after 3 - 6 months

Thrombosis Prophylaxis

• Not required

Mobilization

• Immediate

Physical Therapy

• Active exercise treatment with possible physiotherapeutic support with full extension and fist closure of the fingers from the 1st postoperative day (prevents hand edema and finger stiffness)

Dietary Build-up

• Not required

Bowel Regulation

• Not required

Incapacity for Work

• Generally 14-21 days depending on manual activity (maximum 6 weeks)