Carpal tunnel release: Surgical considerations

Entrapment of the median nerve at the carpal tunnel is the most common entrapment neuropathy. Although nocturnal paresthesias are the most common initial manifestation of carpal tunnel syndrome, the patient may also note hand numbness, clumsiness, pain radiating up the arm, and weakness or atrophy of thenar eminence muscles. The most important step in treating carpal tunnel syndrome is the diagnosis. A thorough knowledge of the normal and aberrant anatomy of the structures surrounding the carpal canal and uncompromised visualization of the transverse ligament are crucial to avoiding complications during the surgical release. Since Sir James Learmonth first described the surgical release of the transverse carpal ligament in 1933, several variations of the technique have been described. Most recently, several innovative procedures involving the endoscope have been introduced in the literature. Endoscopic methods include the two-portal techniques of Chow, Resnick, and Brown; the proximal uniportal techniques of Okutsu, Agee, and Menon; and the distal uniportal approach of Mirza. Proponents of endoscopic carpal tunnel release claim a decrease in postoperative palmar tenderness, a more rapid restoration of grip strength, and an earlier return to work as the major advantages of those techniques. These benefits of endoscopic carpal tunnel release must be weighed against the limited surgical exposure with concomitant risks of incomplete ligament release and inadvertent neurovascular or tendon injury. This review discusses the details of the various surgical procedures, both open and endoscopic, as well as discuss the potential benefits and complications associated with each.