Carpal Tunnel Release
Patient Selection
Indications
Failed nonsurgical treatment (activity modification, wrist splint, corticosteroid injection)
Carpal tunnel release (CTR) produces good to excellent results in 95% of cases
Contraindications
Consider delaying surgery until other local diagnoses/conditions (eg, tendinitis of wrist, forearm, or elbow) improve
Discuss with patient in advance how these conditions may affect surgical outcomes
Electrodiagnostic Testing
Helps support diagnosis or eliminate secondary diagnoses
Interpret in context of clinical signs and symptoms
Carpal tunnel syndrome is a constellation of symptoms
Median neuropathy at the wrist (an electrodiagnostic diagnosis) is sometimes seen in the absence of carpal tunnel syndrome (and vice versa)
Median motor latency of >4.5 ms and or sensory study >3.5 ms generally indicative of median neuropathy at the level of the wrist
Nerve conduction velocity—Change from normal (50 to 60 m/s) to 30 m/s is highly suggestive of peripheral neuropathy
Electromyography or EMG portion may reveal denervation patterns can be seen in median nerve–innervated thenar muscles
Procedure
Patient Positioning
Supine position with arm on hand table
Generally, local or local anesthesia with sedation is most commonly used
Nonsterile tourniquet may be applied to the forearm or upper arm or may be avoided especially with the use of local anesthesia with epinephrine
Special Equipment
Loupe magnification may be helpful
Specialized equipment may be required for endoscopic techniques
Surgical Technique
Goal of CTR surgery is decompression of median nerve by complete division of transverse carpal ligament (TCL)
 | Video 37.1 Carpal Tunnel Release. Edward Diao, MD (3 min) |
Open Carpal Tunnel Release
Figure 1Illustration shows surface landmarks and critical deep structures to be considered when contemplating surgical release of the median nerve. FCR = flexor carpi radialis, FCU = flexor carpi ulnaris, TCL = transverse carpal ligament.
The intended incision may be represented by the intersection of the Kaplan cardinal line and line along radial border of fourth ray, ending at wrist flexion crease; alternatively, the incision may be parallel or on the thenar crease in line with the radial aspect of the fourth ray (Figure 1)
If the wrist crease is crossed, it should be crossed in an oblique fashion
Incise skin, and then dissect through subcutaneous fat. The palmar fascia is then incised, exposing the transverse fibers of the TCL
If palmaris brevis muscle is present superficial to TCL, incise and release from ligament
Incise TCL over a small segment, avoiding injury to deep structures
One may place a small hemostat or Freer elevator into canal to define undersurface of ligament and direction of release. It is helpful to use a right-angle or Meyerding loupe retractor superficially from the radial and ulnar sides to expose the TCL and (on the ulnar side) to protect the ulnar neurovascular bundle
Release TCL leaving a radially based TCL leaflet over median nerve
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