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CTS: Postoperative Care and Complications

- Post Op Care:
     - following surgery, the wrist is splinted in neutral or slight extension;
           - this avoids anterior displacement of median nerve w/ entrapment between divided margins of the TCL;
                 - some believe early motion (with in days after surgery) actually may promote prolonged hypersensitivity;
           - keeping the wrist in a dorsiflexion night splint may prevent the median nerve from adhering to the anterior scar;
     - encourage digit motion to prevent adhesions, but do not allow simultaneous wrist and finger flexion;
           - consider prescribing vit B6 (50 mg PO tid) for 2-3 weeks postop;
     - post op splinting:
           - in the report by Finsen V, et al, the value of of postoperative splinting after open carpal tunnel surgery;
           - the authors randomly selected 82 wrists for 4 weeks of postop immobilization or no immobilization;
           - distributions of scar discomfort or pain and "pillar pain" were equal in the two groups both at 6 weeks and 6 months;
           - median sick leave was 6 weeks in both groups;
           - grip strength was reduced compared to preoperative values by about 20% and keypinch strength by about 10% in both groups at 6 weeks and had returned to normal by 6 months;
           - authors conclude that 4 weeks of postoperative immobilization confers no detectable benefit.
           - ref: No advantage from splinting the wrist after open carpal tunnel release. A randomized study of 82 wrists.   
     - expected return to work:
           - in the report by Agee, et al (1992) workers compensation was the major determinant for length of recovery;
                   - workers compensation patients: avg return to work was 71 days for endoscopic patients vs 78 days for open release;
                          - non compensation patients: avg return to work was 16.5 days for endoscopic patients and 45.5 days for open release;
                   - in the report by Brown, et al (1993), in non workers compensation patients the average return to work was 14 days in the endoscopic group vs 28 days in the open release group;
                          - in this study, more than half of the patients has signficant scar tenderness at 3 months;
           - in the report by Braun RM, et al (1999), 225 patients were studied retrospectively over a 10 year period;
                   - recovery to preoperative levels occurred at about 3-4 months;
                   - mean return to work was 20 weeks, and in patients represented by lawyers mean time to work was 24 weeks;
     - references:
           - Prediction of the outcome 24 hours after carpal tunnel decompression.
           - The effect of legal representation on functional recovery of the hand in injured workers following carpal tunnel release.
           - Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods.
           - Endoscopic release of the carpal tunnel: a randomized prospective multicenter study.

- Complications:
    - recurrent symptoms:
          - recurrent symptoms following open release may occur in up to 20% of patients;
          - most common cause of failure of surgery is the incomplete division of the proximal part of the ligament and scarring of the median nerve to the divided transverse carpal ligament;
          - appearance & presence of multiple flexion creases at wrist usually may indicate accessory ligaments at wrist, which if not relieved at time of sectioning of deep transverse carpal ligament, will secondarily produce at compression of median & or ulnar nerve at wrist and recurrent symptoms;
          - second most common cause of failure, is incomplete release of the distal edge of the transverse carpal ligament;
          - pillar pain: may result from division of the terminal branches of the palmar cutaneous nerve and/or scar between the divided TCL and skin;
          - in the study by Atroshi I, et al (1999), most patients showed large improvement in symtpoms (pain and sensory) and function at 6 weeks after surgery, and further moderate improvements may occur over 6 months (improvements in pain were delayed as compared to improvement in sensory symptoms);
                  - in contrast, sensibility and strength measures showed much smaller postoperative changes;                    
          - references:
                  - Symptoms, disability, and quality of life in patients with carpal tunnel syndrome.
                  - Prediction of the outcome 24 hours after carpal tunnel decompression.
                  - Year Book: Carpal Tunnel Decompression: 16 Second Look Operations.
                  - Factors that determine reexploration treatment of carpal tunnel syndrome.  
                  - Outcome for reoperation for carpal tunnel syndrome.  
                  - Recurrent carpal tunnel syndrome.  
                  - [Re-intervention after carpal tunnel release]
                  - [Reoperations for CTS because of recurrence or for correction]
                  - Revision surgery after carpal tunnel release--analysis of the pathology in 200 cases during a 2 year period
                  - Short-term electrophysiological conduction change in median nerve fibres after carpal tunnel release
                  - The effect of carpal tunnel release on median nerve flattening and nerve conduction
                  - Time course and predictors of median nerve conduction after carpal tunnel release
                  - Median nerve function in patients undergoing carpal tunnel release: pre- and post-op nerve conductions.
                  - Electromyographic changes after carpal tunnel release
                  - Changes in electrophysiological parameters after surgery for the carpal tunnel syndrome
                  - Median nerve compression by a radially inserted palmaris longus tendon after release of the antebrachial fascia: A complication of carpal tunnel release
                  - Severance of the thenar branch of the median nerve as a complication of carpal tunnel release
                  - The long-term post-operative electromyographic evaluation of patients who have undergone carpal tunnel decompression 

    - bowstringing of flexor tendons:
          - bowstringing of flexors tendons, and subluxation of the flexor tendons over the hook of the hamate may occassionally occur;
          - the former is treated w/ maintenece of the wrist in slght extension for the first post-operative week (upto 10 days);
          - the later is treated by excision of the hook of the hamate;
          - reference: The transverse carpal ligament. An important component of the digital flexor pulley system.
    - infection:
          - reference: Deep postoperative wound infection after carpal tunnel release.

- References:

Symptoms, disability, and quality of life in patients with carpal tunnel syndrome.

Comparing the outcome of a carpal tunnel decompression at 2 weeks and 6 months. 

A reliable and simple solution for recalcitrant carpal tunnel syndrome: the hypothenar fat pad flap.

Median nerve damage during two-portal endoscopic carpal tunnel release

A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression

Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? An analysis of published series.

[Surgical treatment of persisting and recurrent carpal tunnel syndrome from 1999 to 2003]

Complications of endoscopic and open carpal tunnel release