An article in the January 2010 issue of Woman’s Day magazine described carpal tunnel syndrome- the diagnosis and treatment.  Near the end was a sentence that said that surgery should be considered a treatment of last resort.  I agree 100% with that assertion, but the author  neglected to mention many options.

My colleagues and I presented a paper at the American College of Rheumatology meeting in November 2009 describing a minimally invasive procedure using a small needle and ultrasound guidance.

This technique has prevented the need for surgery in many patients.  While not 100% effective for everybody, it sure beats the knife. Here it is…

Ultrasound-Guided Percutaneous Injection, Hydrodissection, and Fenestration for Carpal Tunnel Syndrome

Tuesday, October 20, 2009

Hall D (Pennsylvania Convention Center)

Daniel G. Malone, University of Wisconsin, Madison, WI, Thomas B. Clark, MSKUS, Vista, CA and Nathan Wei, Arthritis & Osteo Ctr of MD, Frederick, MD

Purpose: Carpal tunnel syndrome, caused by compression of the median nerve deep to the flexor retinaculum, is the most common entrapment neuropathy.  Most patients are initially treated with conservative measures such as splinting.   When conservative measures fail, interventional techniques are considered the next step.  Many studies have appeared comparing open surgical flexor retinaculum release to blind injections of corticosteroids into the carpal tunnel, but neither technique has proven superior to the other.  Advantages of injection are: lower level of invasiveness, faster recovery, and ease of the technique.  Occasional failures and complications occur with all techniques.
Method: We have been using an ultrasound-guided procedure of percutaneous hydrodissection of the median nerve away from the deep surface of the flexor retinaculum, followed by fenestration of the flexor retinaculum along a path parallel to the long axis of the arm, starting from the level of the distal palmar crease and progressing proximally to the level of the radio-lunate joint, the intent being to lower the pressure exerted by the flexor retinaculum on the nerve (panel 1).  We have treated a series of 39 wrists in 29 patients with electrically-proven carpal tunnel syndrome, using this technique of hydrodissection and fenestration, performed using standard injection equipment and a GE LogiQ e ultrasound system with a 12 MHz linear array probe.  All patients had typical carpal tunnel syndrome symptoms and presented to us for interventional treatment, conservative measures having failed.  No patient had had previous surgery, and 2 had had blind carpal tunnel steroid injections, without hydrodissection or fenestration.  Outcomes were defined as:
Excellent-all symptoms resolved,
Fair-some residual symptoms, or return of symptoms, but improved compared to prior to procedure,
Failure-required open surgical release.
Follow-up periods after procedure ranged from 5-64 weeks, averaging 38 weeks (as of late June 09).  Patients were contacted by telephone, or seen in follow-up in clinic, to determine outcomes.
Results:
Excellent—31 wrists
Fair—5 wrists
Failure—3 wrists
No complications were encountered.
Conclusion:
Ultrasound-guided hydrodissection and fenestration is a viable, easy, relatively non-invasive therapy for carpal tunnel syndrome that can result in prolonged symptom relief, and may be a way to postpone, or even obviate the need for, open release.

Keywords: carpal tunnel syndrome and ultrasound

Disclosure: D. G. Malone, General Electric, 5 ; T. B. Clark, General Electric, 5 ; N. Wei, None.