The Reliability of Successful Carpal Tunnel Release Surgery

Endoscopic or open, it’s all about efficiency.

A patient experiences numbness, tingling or pain in their hand, and seeks answers on the cause from a provider. Chances are they’re suffering from carpal tunnel syndrome — caused by the swelling of the tendons within the carpal tunnel that control the movement of the fingers and the median nerve that runs from the forearm to the palm of the hand — a condition that’s often synonymous with the symptoms described.

The most common cause

“Carpal tunnel syndrome is the most common condition that causes numbness, tingling and pain in the hand, but it’s also a condition for which surgery offers extremely good results,” says Linda Cendales, MD, a hand surgeon and professor of surgery for Duke Health in Durham, N.C.

Carpal tunnel surgery can be performed endoscopically by way of a two-centimeter incision at the base of the wrist or through an open procedure where a one- to two-inch incision is made on the palm. Both techniques are safe and provide reliable positive outcomes. But both surgeons and patients have preferences, and that leaves facility leaders wondering, Which option is best for our facility? Unlike a carpal tunnel diagnosis itself, the answer isn’t always so clear-cut.

• Endoscopic. From the patient’s perspective, there are two compelling reasons for surgeons to employ the endoscopic approach to carpal tunnel release surgery; one is practical and one cosmetic. With the endoscopic release, a small incision is made at the base of the inside part of the wrist. Surgeons enter through one end of the tunnel with the guidance of an endoscopic camera and deploy a knife that, under direct visualization, cuts the ligament.

The annual reimbursement per patient for endoscopic is probably going to be a little higher than it is for open.
Linda Cendales, MD

“One of the pros to endoscopic carpal tunnel release surgery is that studies have shown patients return to work sooner,” says Dr. Cendales. “Another advantage is the incisions are smaller.” Lana Kang, MD, a hand and upper extremity surgeon at Hospital for Special Surgery (HSS) in New York, also cites research suggesting a faster recovery from endoscopic cases could help get patients back to work more quickly. She also cited a major advantage to endoscopic procedures from the surgeon’s perspective. “You have the ability to see the nerve completely during the release, as opposed to what we call mini-open procedures where a lot of the relief of the nerve can be performed subcutaneously or under the skin,” says Dr. Kang.

The ability to visualize and avoid that extra incision is a big part of Dr. Kang’s preference for endoscopic procedures, which are aided by the endoscopic camera and the improved visualization. “It’s really easy,” she says. “It’s just the scope, and you attach the device to it and then you do your thing.”

Dr. Kang stresses the importance of a surgeon’s comfort with the devices they use. There was a time in her career when she wasn’t particularly satisfied with the endoscopic device — and that dissatisfaction was a factor. Now, however, she’s happy with the equipment, and certain key details play a role. “I like that the current device that I’m using has a clear cannula, so you can really visualize the structures and you’re not limited to see,” says Dr. Kang.

From a financial standpoint, there are also some benefits to the endoscopic approach. “The reimbursement is higher for endoscopic than it is for open,” says Dr. Cendales. The annual reimbursement per patient for endoscopic is probably going to be a little higher than it is for open.”

• Open. Like the endoscopic release, open carpal tunnel surgery — a technique that involves the surgeon making an incision at the base of the palm and cutting the transverse carpal ligament to release pressure on the median nerve — is a safe, dependable option with a long, proven track record of positive outcomes. While the research does suggest there’s a slightly faster recovery among endoscopic patients, there’s not a major gap. Carpal tunnel release, says Dr. Cendales, is a very common procedure and whether it’s done endoscopic or open, after several weeks the outcomes aren’t very different.

What’s more, the majority of Dr. Cendales’ cases are open carpal tunnel release surgeries performed in an office-based setting or clinic using wide awake local anesthesia, which she says is a major patient satisfier in and of itself because they can avoid going into an operating room and having additional anesthesia if it’s not necessary. “Some patients really prefer the office because they can just walk in, have the short procedure and walk out without having to stop eating the night before or getting someone to drive them to surgery.”

Ideally, Dr. Cendales believes facilities should be able to accommodate any type of patient and perform both open and endoscopic procedures seamlessly. Regardless of the technique, carpal tunnel release is all about efficiency. “It’s a short procedure, so it’s got to be so protocolized that when one case is being turned over, anesthesia is being administered for the next patient,” she says. “You want to be able to give your patients the most accurate possible estimate of what happens when they get there, and how long they can expect to stay — and stick to it.” OSM

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