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Open Carpal Tunnel Release with Use of a Nasal Turbinate Speculum
Raghuveer Muppavarapu, MD; David Ruchelsman, MD; Mark Belsky, MD; Newton Wellesley Hospital
Newton Wellesley Hospital, Newton, MA, USA

HYPOTHESIS

Incomplete release of the transverse carpal ligament (TCL) and median nerve injury are complications of carpal tunnel surgery (CTS). We describe a modified mini-open release using a fine nasal turbinate speculum to aid the proximal release with direct visualization of the proximal limb of the TCL and distal volar forearm fascia (DVFF). This technique ensures a safe and complete proximal release with optimal visualization and minimizes complications.

METHODS

Design: Retrospective cohort analysis of 101 consecutive modified mini-open CTRs (63R; 38L) performed in 88 patients (51F; 37M) over a 1-year period. The setting is a single center academic hand surgery practice with fellowship trained hand surgeons. CTRs performed in the setting of trauma and revision cases were excluded. Mean age at the time of surgery was 63 years (range, 28-92). Preoperatively, patients were graded as mild, moderate, or severe based on clinical and/or electro-diagnostic criteria.

Technique: 2.5cm palmar longitudinal incision and standard distal release of the TCL to the sentinel fat pad is completed. Proximally, the subcutaneous tissues above the proximal limb of the TCL and DVFF are mobilized to 2cm proximal to the distal wrist flexion crease. A fine nasal turbinate speculum is inserted into the plane above the proximal limb of the TCL and DVFF. Direct topside visualization of the DVFF and its confluence with the TCL is achieved. The ulnar neurovascular bundle is protected by the ulnar blade of the speculum. A long handle scalpel is used to incise the DVFF and TCL under direct visualization from proximal to distal in continuity with the previously completed distal release. Wide diastasis of the leaflets is visualized.

RESULTS

At latest follow-up, (mean 80 days, range 11-341) CTS symptoms were relieved in all patients with a high degree of satisfaction. There were no major complications such as infection, reoperation, or neurovascular injury or severe residual pain. Four patients (3 of which had severe CTS pre-operatively) had significant improvement compared to pre-op but reported residual numbness in their fingers at latest follow-up.

SUMMARY

Open release of the TCL remains the gold standard for symptomatic CTS. Modified mini-open release of the TCL using the nasal turbinate speculum to aid the proximal release allows direct visualization of the confluence of the DVFF and TCL and the completed release, and avoid risks of a “blind” proximal release. Additionally, there is no added economic cost. Results are reproducible with minimal complications.


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