Comparing a Modified Mini-incision Approach Versus the Conventional Approach for Carpal Tunnel Release
Condition: Carpal Tunnel Syndrome; Incision
MeSH terms: Carpal Tunnel Syndrome; Surgical Wound
Study type: Interventional

Summary: 
      Carpal tunnel syndrome (CTS) is the commonest nerve compression syndrome in the upper limbs,
      and carpal tunnel decompression is one of the most prevalent upper limb surgical
      interventions. Surgeries for CTS may be more effective compared to conservative measures in
      reducing symptoms and improving hand function, particularly in patients with severe CTS.

      The etiology of CTS is multifactorial and includes occupational and personal factors.
      Physical workload factors play an important role in CTS but the role of some personal factors
      is less clear. Obesity is a well-documented risk factor for CTS. Hypothyroidism, diabetes
      mellitus, rheumatoid arthritis and osteoarthritis are possible risk factors for CTS. Finally,
      the role of smoking in CTS is uncertain.

      Traditional approach makes use of a longitudinal skin incision from the palm toward the wrist
      and across the transverse carpal ligament. Though this approach offers excellent
      visualization, reliable release of the full retinaculum, and ability to identify anatomic
      variations, it is associated with some intractable complications, including wound pain, scar
      tenderness, flexor tendon entrapment and thenar as well as hypothenar (pillar) pain, which
      are difficult to recovery.

      The attempt to perform CTR without extra complications leads to the development of different
      techniques and several mini-incision approaches.

      These techniques help to reduce incisional discomfort after surgery, but it can lead to
      frequent incidence of blood vessel injury or incomplete release. The mini-incision approaches
      have the advantage of leaving a smaller scar, less scar pain, and lower grade of pillar pain.
      Though several methods have been proposed, there were still some disadvantages in them.
      Though CTR can be safely accomplished by them, incomplete release still occurred in several
      cases for some reasons.

      After intensive research in the current literature, there is a paucity of studies evaluating
      the efficacy and safety of mini-incision approaches in achieving CTR in Egyptian patients.
      That is why we conducted the present study to present our experience with the modified
      mini-incision technique and compare its outcomes to the conventional open approach.
    

Detailed description: 
      All selected cases with primary CTS will be submitted to:

      I) Preoperative evaluation:

      A- Careful history taking: Brief history based on the characteristics of pain, sensory
      disturbances including numbness, tingling, and/or weakness involving the median nerve
      distribution. Patients were additionally inquired about their functional status, normal
      activities, ability to work, family history of diabetes and the use of medications.

      B- The visual analogue scale (VAS) (0= no pain to 10= worst possible pain), will be used to
      assess the severity of diabetic neuropathic pain.

      C- Neurosensory examination mainly included percussion over a distribution of the affected
      peripheral nerve (Tinel sign) and two-point discrimination (2-PD) using the Disk-Criminator.

      D- Nerve conduction velocity (NCV).

      II) Surgical Technique:

      All patients are positioned on the operating table in supine position and anesthetized with
      local anaesthesia.

      A) For the conventional approach: a palmar longitudinal incision began at the axis of the
      ring finger, passed between the thenar and hypothenar eminences, and continued proximally to
      the proximal flexor crease of the wrist. After exposing the underlying transverse carpal
      ligament, its ulnar side was cut longitudinally. The median nerve was identified and
      protected, and then the wound was closed in routine manner.

      B) For the new mini-incision approach: a special metal guide with a groove at the center is
      used. The incision is started above the proximal flexor crease of the wrist and is advanced
      proximally for 1.5-2.0 cm. After opening the superficial fascia, blunt dissection with a
      mosquito clamp is performed till the median nerve appears and the guide is inserted into the
      carpal tunnel, then a scissor is inserted along the groove in the guide and the transverse
      carpal ligament is cut proximally and distally.

      III) Postoperative follow up:

      The follow-up was conducted mainly on an outpatient basis comparing the postoperative outcome
      in both groups as regard improvement of symptoms, postoperative complications, scar effect
      and recurrence of symptoms. Patients will be followed up at 2 weeks, 1 month, 3 months, and 6
      months post decompression.
    

Intervention name(s): carpal tunnel release mini-incision; carpal tunnel release conventional incision
Intervention type(s): Procedure; Procedure
Intervention description(s): Patients were subjected to a longitudinal mini-incision started just above the proximal flexor wrist crease and then extended for 1.5 - 2 cm in a proximal direction; Patients were subjected a longitudinal incision which was created between the thenar and hypothenar eminences along the longitudinal axis of the ring finger. Then, it was extended to the proximal flexor wrist crease.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment