Preoperative Patient Care A 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 B Advanced Evaluation and Patient Management 1 Complex postop management worsening numbness worsening pain additional radiating symptoms C 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 Operative Techniques E 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 F Room Preparation 1 Surgical instrumentation Loupes recommended 2 Room setup and equipment standard operative table with hand table 3 Patient positioning supine position G Superficial Dissection 1 Make incision make an incision through the previous incision and extend it proximally and distally H 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 I 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 J 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 K Explore Nerve to Ensure Decompression 1 Check nerve palpate and visual any signs of compression on the nerve L 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 N Wound Closure 1 Use 3-0 nylon for skin closure Postoperative Patient Care O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds outpatient PT wound care schedule follow up in 2 weeks
A 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 B Advanced Evaluation and Patient Management 1 Complex postop management worsening numbness worsening pain additional radiating symptoms C 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
E 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 F Room Preparation 1 Surgical instrumentation Loupes recommended 2 Room setup and equipment standard operative table with hand table 3 Patient positioning supine position G Superficial Dissection 1 Make incision make an incision through the previous incision and extend it proximally and distally H 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 I 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 J 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 K Explore Nerve to Ensure Decompression 1 Check nerve palpate and visual any signs of compression on the nerve L 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 N Wound Closure 1 Use 3-0 nylon for skin closure
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds outpatient PT wound care schedule follow up in 2 weeks