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Revision Carpal Tunnel Release

Planning

B

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • Loupes recommended

2

Room setup and equipment

  • standard operative table with hand table

3

Patient positioning

  • supine position

Technique

D

Superficial Dissection

1

Make incision

  • make an incision through the previous incision and extend it proximally and distally
E

Expose TCL

1

Expose the TCL

  • use a scalpel or scissors to dissect through the subcutaneous fat and palmar tissue
  • the palmaris brevis muscle is often seen superficial to the TCL
  • incise and feather the palmaris brevis muscle from the TCL to allow adequate visualization
  • use a mosquito clamp or Carroll elevator into the carpal canal just deep to the TCL
  • this space defines the undersurface of the TCL and the hamate hook

2

Visualize the superficial surface of the TCL

  • place a right angle retractor
  • this is placed to protect the critical structures that are located between the skin and the ligament
F

Release TCL

1

Release the most ulnar aspect of the TCL

  • identify the most ulnar aspect of the TCL in the canal close to the hook of hamate
  • release the TCL under direct visualization
  • make sure to release proximally and distally
  • use scissors, scalpel or mini meniscotome type beaver blade
  • keep the radial leaflet of the TCL over the median nerve

2

Release the distal forearm fascia proximally

  • this is a common secondary site of compression

3

Confirm release of the TCL proximally and distally

G

Release Scarring and Check Integrity of Nerve

1

Separate the TCL from the median nerve

  • scarring is expected and puts the median nerve at risk during this entire procedure
  • completely release the TCL while protecting the motor branch of the median nerve

2

Perform external epineurotomy

  • perform an external epineurotomy to expose the bands of the fontana on the surface fascicles on the median nerve
H

Explore Nerve to Ensure Decompression

1

Check nerve

  • palpate and visual any signs of compression on the nerve
I

Hypothenar Fat Pad (optional)

1

Excise Fat Pad

  • dissect the fat pad to the level of the ulnar nerve and artery
  • advance the radial edge of the fat pad to cover the median nerve

2

Suture edge of the fat pad to the radial flap of the TCL

J

Wound Closure

1

Use 3-0 nylon for skin closure

Patient Care

K

Preoperative H & P

1

Perform basic history and physical exam

  • check neurovascular status
  • identify medical co-morbidities that might impact surgical treatment
  • screen medical studies to identify and contraindications for surgery

2

Perform operative consent

  • describe complications of surgery including
  • incomplete release
  • median nerve damage or scarring
  • ulnar nerve or ulnar artery damage
  • palmer arterial arch damage
  • RSD
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • wound care
  • schedule follow up in 2 weeks
M

Outpatient Evaluation and Patient Management

1

Obtain focused history and performs focused exam

  • night pain, paresthesias
  • Median nerve motor/ sensory evaluation
  • MN numbness
  • thumb abduction
  • provocative maneuvers
  • Tinel
  • tap the median nerve over the volar carpal tunnel
  • Phalen
  • wrist flexed with elbow extended for ~60 sec produces symptoms
  • less sensitive than Durkin compression test
  • Durkins compression test
  • is the most sensitive test to diagnose carpal tunnels syndrome
  • press thumbs over the carpal tunnel and hold pressure for 30 seconds.
  • onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.
  • evaluate other sites of MN compression
  • pronator syndrome
  • cervical radiculopathy

2

Orders and interprets required diagnostic studies

  • EMG and NCV
  • often the only objective evidence of a compressive neuropathy (valuable in work comp patients with secondary gain issues)
  • not needed to establish diagnosis (diagnosis is clinical)
  • NCV
  • increase latencies (slowing) of NCV
  • distal sensory latency of > 3.2 ms
  • motor latencies > 4.3 ms
  • decreased conduction velocities less specific than latencies
  • velocity of < 52 m/sec is abnormal
  • EMG
  • test the electrical activity of individual muscle fibers and motor units
  • detail insertional and spontaneous activity
  • potential pathologic findings
  • increased insertional activity
  • sharp waves
  • fibrillations
  • fasciculations
  • complex repetitive discharges

3

Prescribes and manages nonoperative treatment

  • night splints
  • steroid injections
  • attempts trial of physical therapy

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides simple post operative management and rehabilitation

  • postop: 2-3 Week postoperative visit
  • wound check
  • remove sutures
  • start hand therapy
  • diagnose and management of early complications
N

Advanced Evaluation and Patient Management

1

Complex postop management

  • worsening numbness
  • worsening pain
  • additional radiating symptoms
 

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