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DOI: 10.1055/s-0044-1786179
USG-Guided Percutaneous Thread Carpal Tunnel Release
Abstract
Ultrasonography (USG) is utilized for the diagnostic and interventional management of patients with carpal tunnel syndrome (CTS). The management of patients with severe and/or refractory CTS includes the surgical (open/endoscopic) release of transverse carpal ligament. With the advancements in the resolution of USG, the release of transverse carpal ligament can be done safely with the help of transecting/cutting devices. We discuss the technical report on the principle of percutaneous thread carpal tunnel release with the help of surgical grade thread.
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Introduction
The main indication for the release of the transverse carpal ligament in carpal tunnel syndrome (CTS) is severe CTS (cross-sectional area > 15 mm2) with absent sensation or motor weakness/thenar muscle atrophy.[1] Surgical release has the demerits of scar tissue and longer time to return to work. Ultrasonography (USG)-guided release of carpal tunnel allows for the continuous assessment of the anatomy of carpal tunnel including the safe zone making it a safe procedure.[2] It has two needle punctures with no scar tissue and earliest return to work. The main advantage of using the thread is its universal availability and being economical.
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Technique
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USG to evaluate the safe zones of carpal tunnel which is devoid of neurovascular bundles. The transverse safe zone is between the median nerve and the ulnar artery ([Fig. 1A, B]). The longitudinal safe zone is the space between the distal extent of the transverse carpal ligament and the superficial palmar arch ([Fig. 2A, B]). Longitudinal safe zone of less than 2 mm or transverse safe zone of 0 mm is contraindication for the procedure.[2]
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Under aseptic precaution, a curved spinal needle is passed through longitudinal safe zone deep to the transverse carpal ligament after hydrodissection with 1% lignocaine. The curved needle is taken out 2 cm proximal to distal palmar crease. Threading the curved needle with medical grade suture leaving sufficient length of suture at both entry and exit points ([Fig. 3A–C]). The spinal needle is removed and the suture left inside.
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Reentry at palm with straight needle superficial to transverse carpal ligament. The needle is maneuvered to exit at the same exit point in the wrist ([Fig. 4A, B]). The free end of the thread from the wrist end is passed through the straight needle and taken out from the palm ([Fig. 4C]).
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The straight needle is removed and the loop of the thread one part superficial and another deep to the ligament remains in situ ([Fig. 5A, B]). USG scan to confirm the position of the thread loop in the safe zone and its relationship with the median nerve and ulnar artery is confirmed prior to initiating the release procedure ([Fig. 5C]).
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Manual release of the transverse carpal ligament by alternate pulling of both ends of the thread under continuous USG monitoring. Postprocedure USG to confirm the transection of the transverse carpal ligament ([Fig. 6A, B]).
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Postprocedure care includes resting the affected wrist with wrist brace for 2 days, avoiding driving/machinery work on the day of intervention as the hand is anesthetized, and symptomatic treatment for analgesia if required.
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Discussion
Surgical management of CTS involves transection of the transverse carpal ligament by either open or endoscopic technique.
USG-guided thread carpal tunnel release (TCTR) is performed by looping of the ligament by medical grade suture in the safe zone. Advantages of using the thread includes no scar, control of the transaction under USG guidance, and thus, avoiding transaction of the nontargeted tissue.[3] [4]
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Conclusion
USG-guided TCTR can be a safe and effective alternative to the open and endoscopic release of the transverse carpal ligament in patients with severe CTS or CTS with thenar muscles weakness/atrophy. TCTR has a significant learning curve and this technical note will help the readers in understanding the steps of the procedure.
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Conflict of Interest
None declared.
Acknowledgment
The authors thank Mr. Shashikant Kumar for the paramedical support for all the cases.
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References
- 1 Kamel SI, Freid B, Pomeranz C, Halpern EJ, Nazarian LN. Minimally invasive ultrasound-guided carpal tunnel release improves long-term clinical outcomes in carpal tunnel syndrome. Am J Roentgenol 2021; 217 (02) 460-468
- 2 Kang BH, Woo SR, Park HJ. et al. Ultrasonographic assessment of the safe zone for carpal tunnel intervention: a comparison between healthy individuals and patients with carpal tunnel syndrome. Ann Rehabil Med 2022; 46 (06) 284-291
- 3 Rojo-Manaute JM, Capa-Grasa A, Chana-Rodríguez F. et al. Ultra-minimally invasive ultrasound-guided carpal tunnel release: a randomized clinical trial. J Ultrasound Med 2016; 35 (06) 1149-1157
- 4 Guo D, Tang Y, Ji Y, Sun T, Guo J, Guo D. A non-scalpel technique for minimally invasive surgery: percutaneously looped thread transection of the transverse carpal ligament. Hand (N Y) 2015; 10 (01) 40-48
Address for correspondence
Publikationsverlauf
Artikel online veröffentlicht:
25. April 2024
© 2024. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Kamel SI, Freid B, Pomeranz C, Halpern EJ, Nazarian LN. Minimally invasive ultrasound-guided carpal tunnel release improves long-term clinical outcomes in carpal tunnel syndrome. Am J Roentgenol 2021; 217 (02) 460-468
- 2 Kang BH, Woo SR, Park HJ. et al. Ultrasonographic assessment of the safe zone for carpal tunnel intervention: a comparison between healthy individuals and patients with carpal tunnel syndrome. Ann Rehabil Med 2022; 46 (06) 284-291
- 3 Rojo-Manaute JM, Capa-Grasa A, Chana-Rodríguez F. et al. Ultra-minimally invasive ultrasound-guided carpal tunnel release: a randomized clinical trial. J Ultrasound Med 2016; 35 (06) 1149-1157
- 4 Guo D, Tang Y, Ji Y, Sun T, Guo J, Guo D. A non-scalpel technique for minimally invasive surgery: percutaneously looped thread transection of the transverse carpal ligament. Hand (N Y) 2015; 10 (01) 40-48