Small Incision, Big Results

Angela Francois couldn’t sleep. The painful numbness in her hands was waking her up in the middle of the night on a more consistent basis. She had been experiencing the symptoms of carpal tunnel syndrome for more than 15 years and had put off undergoing surgery, but the restless nights were becoming too much to bear and the condition began to impact her work as a certified surgical tech.

“My hands would go numb during the day and that impeded my ability to assist during surgery,” says Ms. Francois. “The braces I wore at night to alleviate the numbness and pain were no longer effective. I was waking up constantly and that was hurting all aspects of my life.”

She didn’t need convincing that an endoscopic carpal tunnel release was her best treatment option or to look far for a surgeon who would perform the procedure. For 18 years, Ms. Francois has been working in the practice of Anthony J. Berni, MD, a board-certified orthopedic surgeon in O’Fallon, Mo. She’s seen countless examples of patients who responded exceedingly well after having carpal tunnel syndrome treated endoscopically by Dr. Berni, including her own husband.

During the pandemic, Ms. Francois worked long hours at a local surgery center, holding retractors in a static position for hours on end. Her symptoms became unbearable. It was finally time for her to go under the knife.

Ms. Francois saw her opportunity on the Friday before last Memorial Day weekend, which would give her an extra day off work to recover. 

She assisted during surgeries throughout the day and, while still in her scrubs, had an IV placed and was wheeled back to the OR in the late afternoon. Dr. Berni performed an endoscopic release on both wrists in minutes and sent Ms. Francois home to recover.

That night, she experienced minor soreness in her palms, but didn’t take pain medications to manage the discomfort. She didn’t have enough grip strength to grasp doorknobs, but the strength in her wrists and hands began to return on Saturday morning and she could open doors by noon. By the end of the day, Ms. Francois felt close to 100% and was cooking, carrying water glasses and toileting without assistance. The soreness in her palms persisted for about three weeks, but she was able to work five cases without issue the Tuesday after the long weekend — and was even back to bucking bales of hay on her family’s farm.

Not all patients will be ready for agricultural work soon after surgery, but most are discharged with a soft dressing over the incision and are back to routine life activities in about a week. Dr. Berni advises his patients to remove the dressing three days after surgery and shower as normal, compared with waiting a week to 10 days after open surgery.

The endoscopic procedure involves making a single incision about a centimeter long at the base of the wrist, proximal to the palmar skin. Surgeons enter the carpal tunnel and release the transverse carpal ligament under direct visualization with a retractable knife at the end of an endoscopic device. Dr. Berni places a tourniquet on the patient’s arm to limit blood flow in the surgical field and performs the procedure in about 10 minutes with the patient under light sedation.

Patients who undergo the endoscopic release avoid having an incision made to the palmar skin, which carries some risk of associated morbidity. “The skin is often calloused and doesn’t always heal properly. When that happens, the patient will feel some discomfort when they grasp an object or push against a surface,” says Dr. Berni. “The less invasive the surgery, the easier it is on patients.”

He resorts to performing the open technique on individuals with previous wrist trauma or for revisions of previous releases, both of which could change the anatomy of the carpal tunnel or result in residual scar tissue — factors that might distort the endoscopic view inside the tunnel or impede his access to the transverse carpal ligament.

Some surgeons don’t learn the endoscopic approach because patients do well with the open technique, according to Dr. Berni. He also points out that most of the early studies conducted to analyze the effectiveness of endoscopic carpal tunnel release involved the two-incision technique, which involves making an additional cut in the mid-palm. Dr. Berni says this method can prove problematic if surgeons make the wrist incision too proximal, leading to an incomplete release that doesn’t relieve patients of their symptoms. That potential for failure led many surgeons to question the effectiveness of the endoscopic approach and push back against adopting it. The single-incision technique, he says, is more effective and produces excellent outcomes. 

Dr. Berni continues to build his case volume on word-of-mouth referrals from patients who tout the effectiveness of the endoscopic procedure and the relatively easy recovery from it. Patients who had an open procedure performed on one hand before undergoing an endoscopic release on the other tell him they wish they knew about the minimally invasive approach the first time around.

Patients like Ms. Francois who experience such positive results will continue to drive demand for endoscopic releases. Her experience has also improved the care she provides patients. She lets them know that she underwent the same procedure, reassures them that the recovery will be smooth and shows them the lack of scars on her wrists. “The procedure was a life-changing treatment that I put off for far too long and for no good reason,” she says. “Getting relief from nerve pain and numbness and regaining full strength in my hands has been incredible. I wish I’d done it sooner.”
Not to mention the sweet relief of finally getting a full night’s sleep. “That’s made me a better mom, wife and employee,” says Ms. Francois. OSM

Note: This three-part article series is supported by Hand Biomechanics Lab.