Comparison of Surgical Time and Clinical Outcomes for Intravenous Regional Anesthesia (IVRA) versus Wide-Awake Local Anesthesia No Tourniquet (WALANT) in Open Carpal Tunnel Release Surgery: A Comparative Study

Abstract

Background This study aimed to compare the efficacy and safety of two anesthetic techniques in patients undergoing carpal tunnel release surgery: intravenous regional anesthesia (IVRA) and the wide-awake local anesthesia no tourniquet (WALANT) technique.

Materials and Methods A retrospective observational dual-center study was conducted, including 102 patients diagnosed with moderate-to-severe carpal tunnel syndrome (CTS) unresponsive to conservative treatment. Outcomes were assessed using the visual analog scale (VAS) for pain and the Duruoz Hand Index (DHI) for hand functionality. Comparisons were made based on age, gender, preoperative VAS scores, incision length, and surgical procedure duration.

Results The outcomes of the WALANT (n = 51) and IVRA (n = 51) techniques in CTS surgery were compared. The IVRA group had a shorter operation time (2.49 ± 0.50 minutes) and faster return to daily activities (10.13 ± 9.50 days) compared with the WALANT group (operation time: 7.27 ± 1.35 minute, return to daily activities: 17.64 ± 2.52 days) (p < 0.05). Additionally, postoperative analgesic requirements were significantly lower in the IVRA group (8/51; 15.6%) than in the WALANT group (37/51; 72.5%) (p < 0.05). Both groups showed significant postoperative improvements in VAS and DHI scores (p < 0.05), with the IVRA group demonstrating a greater improvement in DHI scores (14.76 ± 0.43) compared with the WALANT group (12.76 ± 0.45) (p < 0.05).

Conclusion IVRA with small incisions demonstrated superior outcomes in CTS surgery compared with WALANT, including shorter operation times, faster recovery, and reduced postoperative analgesic requirements. These findings suggest that IVRA may be a more favorable option for both patients and surgeons in carpal tunnel release surgery.

Keywords

carpal tunnel syndrome - IVRA - regional anesthesia - WALANT - wide awake local anesthesia

Introduction

Carpal tunnel syndrome (CTS) is the most common median nerve entrapment neuropathy in humans and affects the quality of life in 1 to 5% of people.[1] [2] CTS occurs due to the compression of the median nerve within the carpal tunnel, an oval-shaped passage on the wrist's front side. This compression is related to several different etiologies, such as repetitive exposure to vibrations or forceful angular motions, genetic predisposition, injury, and specific conditions, such as diabetes, pregnancy, and morbid obesity.[3] CTS can result in considerable loss of work productivity and is prevalent in approximately 4 to 7% of the population, more commonly in those aged 40 to 60 years who frequently use their hands, especially in extension positions.[4] [5] Women are more likely than men to develop CTS, with the dominant hand being more commonly affected. Approximately 10% of cases involve both hands.[6]

There are two main approaches to treating CTS: surgical and nonsurgical or conservative.[7] Despite the high prevalence of CTS and the effectiveness of various treatment methods, more definitive treatment has yet to be established. Both conservative and surgical treatments are available, and surgery is considered for severe cases that do not respond to conservative approaches. Surgical treatment can be performed using different techniques, including open, miniopen, endoscopic-assisted, or ultrasound-guided carpal tunnel release.[8] [9] However, no universal surgical consensus has been reached.[6] The current literature focuses more on diagnostic methods and surgical and nonsurgical treatment strategies. Nevertheless, in cases where the primary complaints are pain and tingling, the choice of anesthesia technique is equally significant. Therefore, many questions remain regarding its cause and optimal treatment.

To address this gap, our study aimed to compare the effects of two commonly used anesthetic techniques, intravenous regional anesthesia (IVRA), widely known as Bier's block versus wide awake local anesthesia no tourniquet (WALANT), on postoperative outcomes, including visual analog scale (VAS) score, surgery-related complications, surgical procedure time, and surgical site complications. This comparative analysis aimed to provide valuable insights and a deeper understanding of each technique's advantages and disadvantages to guide clinicians in making well-informed decisions regarding anesthesia management in carpal tunnel surgery. The findings of this study may contribute to the development of best practice guidelines and standardized protocols for optimal patient care and improved clinical outcomes in CTS treatment.

Materials and Methods

This dual-center retrospective observational study was approved by the institutional review board of Ankara Bilkent City Hospital (Protocol number No. E1-22-3119). From January 4, 2018, to December 1, 2022, a comparative efficacy analysis was conducted retrospectively for those who underwent unilateral CTS surgery utilizing the IVRA technique at Ankara Bilkent City Hospital and Gazi Mustafa Kemal State Hospital neurosurgery clinics. This analysis compared patients who underwent unilateral surgery employing WALANT and IVRA.

Patient Selection

The study included patients classified in American Society of Anesthesiologists groups scoring 1 to 2, aged 18 years or older, diagnosed with at least moderate-to-severe CTS (≥ 4.0 ms distal motor latency) both clinically and electrophysiologically, unresponsive to conservative treatment for at least 3 months, and having at least one follow-up later postoperative period. We excluded patients who had previous CTS surgeries. Patients unwilling to complete the postoperative questionnaire were excluded from the study.

Preoperative and Postoperative Period

A total of 102 patients were included in the study, and informed consent was obtained from all participants. The same surgeon (A.G.) performed the surgical procedures for each group. In the WALANT group (n = 51), A solution of 1% lidocaine with 1:100,000 epinephrine is mixed in a ratio of 10 cc lidocaine to 1 cc of 8.4% sodium bicarbonate to reduce injection pain was directly infiltrated into the skin and subcutaneous tissues of the operative site. In the IVRA group (n = 51), the arm to be operated on was raised, and after ensuring venous drainage by wrapping the arm with an Esmarch bandage, a double-cuffed tourniquet was placed on the upper arm and inflated. Subsequently, 3 mg/kg of 2% lidocaine (Jetmonal 2% ampoule, Adeka, Türkiye) in a 40-mL volume, complemented with 0.9% NaCl to make a 40-mL solution, was administered through a venous cannula on the back of the hand, and the traditional IVRA method was performed. For the IVRA group, patients were monitored by an anesthesiologist, and intravenous catheters were placed in the contralateral extremity to manage potential complications. All patients were prophylactically administered with 1 g of cefazolin sodium preoperatively via intravenous infusion; no postoperative antibiotics were prescribed. All patients were discharged on the same day. A postoperative elastic bandage was used, and the arm was flexed 90 degrees from the elbow for the first 24 hours. The next day, the dressing was changed, a new dressing was applied to cover only the incision site and finger exercises were scheduled. Early finger mobilization was recommended for all patients postoperatively, and sutures were removed 10 to 14 days after the surgery. The surgeon subjectively reported blood loss as either present or absent during the surgery.

Outcomes

In all patients, intraoperative and postoperative blood pressure, heart rate, and peripheral oxygen saturation were monitored. VAS score was used to evaluate preoperative and postoperative pain and recorded symptom severity, complications, surgical duration, and incision length. The patients' data were reviewed for age, gender, preoperative VAS scores, incision length, and surgical procedure duration. The Duruoz Hand Index (DHI) survey was conducted preoperatively and in the third postoperative week to assess hand functionality.[10] VAS scores were checked on postoperative day 1 while changing the wound dressings. The time taken for the patients to return to daily activities/work and their postoperative analgesic needs were recorded.

Surgical Procedure

In the WALANT group, the surgical procedure was performed under local anesthesia without using a tourniquet and without emptying the arm veins using a pressure control system. The patient's arm was slightly flexed, and the median nerve pathway was identified between the palmaris longus and flexor carpi radialis tendons. While the patient was supine, a small silicone pad was placed under the wrist with the hand, wrist, and fingers slightly extended. Local anesthetic solution was infiltrated superficially from the distal wrist crease along the median nerve to the palm ([Fig. 1]). The sensory block of the median nerve was then tested by touching the nerve region with a needle tip. Subsequently, a skin incision was made approximately 5 cm long with a #15 scalpel, extending from 1.5 cm proximal to the distal wrist crease along the Kaplan oblique line. The tissues were further opened using a mini-automatic retractor. The proximal end of the flexor retinaculum (FR) and the transverse carpal ligament (TCL) were visualized. The FR was opened with a #15 scalpel to reveal the median nerve underneath. The proximal end of the TCL was observed, and its dorsal and ventral surfaces were dissected with a dissection clamp. First, the distal and proximal parts of the skin, subcutaneous tissue, and palmar aponeurosis were suspended with a hand retractor, and the ligament was cut using tissue scissors. The FR and TCL were cut using a clamp and tissue scissors, and the median nerve was decompressed. Adequate decompression was confirmed with the help of a clamp and dissector ([Fig. 2]). After hemostasis was achieved, the surgical area was irrigated with physiological saline and the skin was closed with 3/0 nonabsorbable sutures.

Fig. 1 Superficial infiltration of local anesthetic (10 mL prilocaine) was performed from the distal wrist crease toward the palm along the path of the median nerve.

Fig. 2 A clamp and tissue scissors were used to cut the flexor retinaculum (FR) and transverse carpal ligament (TCL), and decompression of the median nerve was performed (A). The adequacy of decompression was verified using a clamp and dissector. A 5-cm incision is closed by nonabsorbable sutures (B).

The surgical procedure was performed in the IVRA group using an upper arm tourniquet with a Bier block. A double tourniquet was placed on the upper arm of the extremity undergoing surgery. The arm was then elevated, and blood was drained by wrapping the arm with an Esmarch bandage. The proximal cuff was inflated to 300 mm Hg, and the Esmarch bandage was removed ([Fig. 3]). Circulation isolation of the arm was confirmed by examining the hand and the absence of a radial pulse. Regional anesthesia was achieved by injecting 3 mg/kg of 2% lidocaine in a 40-mL volume, complemented with 0.9% NaCl to make a 40-mL solution, through a venous cannula in the dorsum of the hand. After confirming the median nerve block, the hand was placed on the surgical arm table. A vertical incision of approximately 1 cm was made just above the median nerve pathway between the palmaris longus and flexor carpi radialis tendons near the distal wrist crease using a #15 scalpel. Mini-hand retractors were used to pull the skin and subcutaneous tissue to the sides. The FR was exposed using a dissection clamp, and a 0.3-cm incision was made with a #15 scalpel, revealing the underlying median nerve. First, the distal and proximal parts of the skin, subcutaneous tissue, and palmar aponeurosis were suspended with a retractor, and the TCL was cut using tissue scissors. Decompression of the median nerve was confirmed using a mini-dissector ([Fig. 4]).

Fig. 3 After the Esmarch bandage was applied, the proximal cuff was inflated to a pressure of 300 mm Hg, and the bandage was subsequently removed.

Fig. 4 The first step involved suspending the distal part of the skin, subcutaneous tissue, and palmar aponeurosis (A), followed by the proximal part using a retractor. Subsequently, the transverse carpal ligament (TCL) was cut using tissue scissors. The decompression of the median nerve was confirmed with the aid of a mini dissector. Smaller incisions were sutured with nonabsorbable sutures (B).

In both groups, a postoperative elastic bandage was used, and the arm was recommended to be kept elevated with the elbow at 90 degrees of flexion for the first 24 hours. The following day, the dressing was changed, and a new dressing was applied to cover only the wound area, with exercises planned for the fingers.

Statistical Methods

Descriptive statistics were used to calculate continuous variables' mean and standard deviation, including age, incision length, days to return to daily activities, operation time, and preoperative and postoperative VAS and DHI scores. Independent t-tests were employed to compare means between the two groups, while the chi-square test was used to compare categorical variables. In addition, paired t-tests were conducted to evaluate changes in pain and disability levels within each group. A p-value of less than 0.05 was considered statistically significant for all tests performed. A power analysis was performed using G Power v.3.1 software (to achieve a power of 0.80 with α = 0.05 and β [type II error] = 0.20) for mean differences between the two groups, a sample size of 102 (51:51) participants was required.[11]

Results

The mean ages in the WALANT and IVRA groups were 62.6 ± 8.6 and 62.8 ± 8.6 years, respectively. In the WALANT group, 40 patients were female (78.4%), while in the IVRA group, 43 were female (84.3%). The gender distribution was equal between the two groups. In the WALANT group, the affected side was the right hand for 38 patients (74.5%); in the IVRA group, the affected side was the right hand for 40 patients (78.4%).

The incision length in the WALANT group was 4.03 ± 0.72 cm, while in the IVRA group, it was 1.3 ± 0.1 cm. The number of days to return to daily activities postoperatively was 17.6 ± 2.5 days in the WALANT group and 10.1 ± 9.5 days in the IVRA group. The IVRA group showed statistically significant shorter times to return to daily activities (p-value < 0.05) ([Table 1]). The operation time in the WALANT group was 7.2 ± 1.3 minutes, while in the IVRA group, it was 2.4 ± 0.5 minutes. The operation time was statistically shorter in the IVRA group compared with the WALANT group (p-value < 0.05).

Table 1 Summary of treatment groups

	WALANT (n = 51)	IVRA (n = 51)	p-Value
Age (± SD)	62.66 ± 8.60	62.80 ± 8.63	0.582
Gender, female (n; %)	40 (78.4%)	43 (84.3%)	0.445
Effected extremity, right	38 (74,5%)	40 (78.4%)	0.641
Incision length (cm)	4.03 ± 0.72	1.3 ± 0.01	< 0.05
Return to daily activity (d)	17.64 ± 2.52	10.13 ± 9.50	< 0.05
Operation duration (min)	7.27 ± 1.35	2.49 ± 0.50	< 0.05
VAS preop	7.49 ± 0.83	7.43 ± 0.87	0.724
Complication	2	1	0.558
Need of postoperative analgesic	37	8	< 0.05

Abbreviations: IVRA, intravenous regional anesthesia; SD, standard deviation; VAS, visual analog scale; WALANT, wide-awake local anesthesia no tourniquet.

In the WALANT group, all the patients exhibited bleeding that required hemostasis, whereas in the IVRA group, no bleeding was observed. In the WALANT group, 2 of 51 patients (3.9%) had complications of wound dehiscence, while in the IVRA group, one patient had wound dehiscence (1.9%). The postoperative need for analgesia was observed in 37/51 (72.5%) patients in the WALANT group and 8/51 (15.6%) patients in the IVRA group (p-value < 0.05).

In the WALANT group, the preoperative VAS score was 7.4 ± 0.8, and the postoperative 24-hour VAS score was 1.9 ± 0.7. In the IVRA group, the preoperative VAS score was 7.43 ± 0.87, and the postoperative 24-hour VAS score was 1.82 ± 0.62. The change in VAS score within both groups was statistically significant (p-value < 0.05); however, there was no significant difference in the VAS score changes between the two groups ([Table 2]).

Table 2 Comparison of treatment groups

	WALANT	p-Value	IVRA	p-Value
VAS preoperative VAS postoperative, 24 h	7.49 ± 0.83 1.92 ± 0.71	< 0.05	7.43 ± 0.87 1.82 ± 0.62	< 0.05
DHI preoperative DHI postoperative, 3rd week	23.00 ± 3.94 10.23 ± 1.76	< 0.05	25.31 ± 3.93 10.54 ± 2.08	< 0.05
VAS difference	5.41 ± 0.29		5.53 ± 0.28	0.810
DHI difference	12.76 ± 0.45		14.76 ± 0.43	< 0.05

Abbreviations: DHI, Duruoz Hand Index; IVRA, intravenous regional anesthesia; VAS, visual analog scale; WALANT, wide-awake local anesthesia no tourniquet.

In the WALANT group, the preoperative DHI score was 23.0 ± 3.9, and the postoperative 3-week DHI score was 10.2 ± 0.7. In the IVRA group, the preoperative DHI score was 25.3 ± 3.9, and the postoperative 3-week DHI score was 10.5 ± 2.0. The change in DHI score pre- and postoperatively within both groups was statistically significant (p-value < 0.05). The DHI differences in the WALANT and IVRA groups were 12.76 ± 0.45 and 14.76 ± 0.43, respectively. This difference was statistically significant (p-value < 0.05).

Discussion

In this study, we compared the outcomes of carpal tunnel surgery using IVRA and WALANT techniques, considering factors such as operation time, postoperative pain, analgesia requirement, and functional recovery. Our study has significant results. First, the IVRA group displayed significantly shorter times for returning to daily activities than the WALANT group. Second, the IVRA group exhibited notably reduced operation time compared with the WALANT group. Lastly, the IVRA group demonstrated a significantly lower postoperative need for analgesia. However, our study showed no significant difference in the VAS score changes between the two groups.

The initial comparison of WALANT and IVRA revealed that they were similar in clinical and surgical outcomes.[12] However, the operation time in the IVRA group was significantly shorter than that in the WALANT group, probably due to the more extensive anesthesia provided by IVRA in the surgical area, potentially leading to a smoother and more efficient surgical procedure than that provided by WALANT. Furthermore, shorter operation times may reduce exposure to intraoperative complications and accelerate patient turnover in the operating room. Notably, Eroğlu et al reported that the surgical duration for WALANT was shorter than that for IVRA, which is inconsistent with the findings of our study.[13]

The most objective indicator of postoperative pain relief in CTS was electromyography (EMG) studies. Preoperative evaluation has indicated that high synovial vascularization and low nerve conduction velocity comprise significant factors that contribute to the decline of the quality of life of patients following surgery.[14] Herein, we did not conduct EMG prediction or preoperative ultrasound examinations; however, we observed significant improvements in postoperative pain, as measured via the VAS score, in both groups. Nonetheless, there was no significant difference between the groups regarding changes in the VAS scores. However, the IVRA group exhibited a significantly lower need for postoperative analgesia than the WALANT group. This could be due to the more extensive anesthesia provided by IVRA, which induced better pain control during the immediate postoperative period compared with WALANT. Reduced analgesic requirements may lower the risk of medication-associated side effects and improve patient satisfaction. A randomized controlled study comparing WALANT and local anesthetic techniques using a tourniquet reported that both techniques yielded similar clinical outcomes.[15] Our retrospective case series study utilized smaller incisions in the IVRA technique compared with previous clinical trials due to reduced bleeding. Therefore, the inconsistencies with the current literature may be attributed to our study methodology.[16] [17]

Another potential cause of postoperative pain is the presence of the tourniquet, which may contribute to discomfort in patients following surgery.[18] Herein, we considered this factor and attempted to shorten the tourniquet time as much as possible using the IVRA technique. We found that the IVRA group reduced postoperative pain and the requirement of analgesics by shortening the incision and minimizing the tourniquet time. A study also reported that monitoring during IVRA was a factor in reducing pain.[19] Despite the observed differences in incision length, operation time, analgesic requirements, and functional recovery, our study showed both IVRA and WALANT were effective anesthetic methods for carpal tunnel surgery. Thus, selecting the most appropriate anesthetic technique should be based on patient preference, surgeon experience, and resource availability.[20]

Our study used the DHI as the main parameter to compare functional outcomes between the two anesthetic techniques. Patients in the IVRA group demonstrated better functional outcomes, as evidenced by their improved DHI scores, than those in the WALANT group. This difference in outcomes can be attributed to the efficacy of the anesthetic techniques as well as the effect of the surgical approach on postoperative recovery. The improved functional outcomes in the IVRA group suggest that this technique may be more suitable for patients undergoing carpal tunnel surgery as it accelerates rehabilitation and returns to daily activities compared with WALANT.[21] However, further research is warranted to corroborate these findings and better understand the factors contributing to the observed differences in functional outcomes.

Our study had several limitations. First, the study's retrospective nature can lead to potential biases and inaccuracies in data collection, thereby affecting the study outcomes. Second, the absence of a standardized measurement for blood loss during surgery, which the surgeon subjectively reported, may introduce inconsistencies in assessing this parameter. Third, pain is a subjective sensation, making it challenging to objectively compare between groups. This inherent subjectivity may have introduced bias, as patients have varying pain tolerance levels. Finally, the study did not include long-term follow-up, which could have provided additional insights into the comparative efficacy and safety of the two anesthetic techniques. Further research with larger sample sizes and prospective designs is needed to validate and expand on the findings of this study.

Conclusion

Our study suggests that IVRA with small incisions may offer advantages over WALANT for carpal tunnel surgery, including smaller incision lengths, shorter operation times, reduced postoperative analgesic requirements, and better functional recovery. However, both methods can effectively manage postoperative pain and improve functionality. Further studies, including more extensive randomized controlled trials, are warranted to confirm these findings and provide more definitive guidance regarding the optimal anesthetic technique for carpal tunnel surgery.

Conflict of Interest

None declared.

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Publication History

Article published online:
16 April 2025