Outcomes of the surgical treatment of carpal tunnel syndrome under local anesthesia: comparison of the surgeries with and without tourniquet use

Year 2024, Volume: 17 Issue: 1, 41 - 50, 01.01.2024

Bilal Aykaç , Alper Türkkan

https://doi.org/10.31362/patd.1328303

Abstract

Purpose: Carpal tunnel syndrome is the most common upper limb entrapment neuropathy. The current study reviews outcomes in carpal tunnel syndrome surgeries performed with local anesthesia in a procedure room outside the operating room and compares the surgeries with and without tourniquet use.
Materials and methods: Patients who underwent carpal tunnel syndrome surgery between June 2019 and January 2023 were retrospectively analyzed. Patients were divided into two groups: with and without tourniquet use. Demographic characteristics, operative time, complications, and outcomes were compared. All patients
were examined preoperatively and at postoperative month 3 using the Quick Disabilities of the Arm, Shoulder and Hand scale (QDASH) questionnaire, which measures upper extremity activity and participation restrictions.
Results: The study included 119 patients. The operative time was longer in the nontourniquet group than in the tourniquet group, with a statistically significant difference (16.75±2.39 min and 14.47±1.88 min, p<0.001). Bipolar use was higher in the nontourniquet group, with a statistically significant difference (p<0.001). The preoperative QDASH score was statistically similar in both groups (62.58±6.67 and 63.86±6.04, p=0.229). The mean postoperative QDASH score was 4.79±7.65 in the nontourniquet group and 4.24±3.86 in the tourniquet group (p=0.799).
Conclusions: Tourniquet use may slightly shorten the operative time and may be more effective in controlling bleeding. However, there was no significant difference between the groups regarding postoperative results. The results indicate that operating with a local anesthesia alone is an effective alternative to tourniquet use and a
safe choice.

Keywords

Carpal tunnel syndrome, tourniquet, wide awake hand surgery

Karpal tünel sendromunun lokal anestezi ile yapılan cerrahi tedavisinin sonuçları: turnikeli ve turnikesiz yapılan ameliyatların karşılaştırılması

Abstract

Amaç: Karpal tünel sendromu en sık görülen üst ekstremite tuzak nöropatisidir. Bu çalışma, ameliyathane dışında bir işlem odasında lokal anestezi ile yapılan karpal tünel sendromu ameliyatlarının sonuçlarını gözden geçirmekte ve turnikeli ve turnikesiz ameliyatları karşılaştırmaktadır.
Giriş ve yöntem: Haziran 2019 ile Ocak 2023 tarihleri arasında karpal tünel sendromu ameliyatı geçiren hastalar retrospektif olarak incelendi. Hastalar turnikeli ve turnikesiz olmak üzere iki gruba ayrıldı. Demografik özellikler, operasyon süresi, komplikasyonlar ve sonuçlar karşılaştırıldı. Tüm hastalar ameliyat öncesi ve ameliyat sonrası
3. ayda, üst ekstremite aktivitesini ve katılım kısıtlamalarını ölçen Hızlı Kol, Omuz ve El Engelliliği ölçeği (QDASH) anketi kullanılarak değerlendirildi.
Bulgular: Çalışmaya 119 hasta dahil edildi. Ameliyat süresi turnike olmayan grupta istatistiksel olarak anlamlı derecede daha uzundu (16,75±2,39 dk ve 14,47±1,88 dk, p<0,001). Bipolar kullanımı turnike olmayan grupta istatistiksel olarak anlamlı derecede daha yüksekti (p<0.001). Preoperatif QDASH skoru her iki grupta istatistiksel
olarak benzerdi (62,58±6,67 ve 63,86±6,04, p=0,229). Ameliyat sonrası ortalama QDASH skoru turnikesiz grupta 4,79±7,65, turnikeli grupta 4,24±3,86 idi (p=0,799).
Sonuç: Turnike kullanımı ameliyat süresini biraz kısaltabilir ve kanama kontrolünde daha etkili olabilir. Ancak ameliyat sonrası sonuçlar açısından gruplar arasında anlamlı fark yoktu. Bu, tek başına lokal anestezik ile ameliyatın turnike kullanımına güvenli ve etkili bir alternatif olduğunu düşündürmektedir.

Keywords

Karpal tünel sendromu, turnike, uyanık el cerrahisi

References

• 1. Ralte P, Selvan D, Morapudi S, Kumar G, Waseem M. Haemostasis in open carpal tunnel release: tourniquet vs local anaesthetic and adrenaline. Open Orthop J 2010;4:234-236. https://doi.org/10.2174/1874325001004010234
• 2. Sasor SE, Cook JA, Duquette SP, et al. Tourniquet use in wide-awake carpal tunnel release. Hand 2020;15:59-63. https://doi.org/10.1177/1558944718787853
• 3. Kaplan SJ, Glickel SZ, Eaton RG. Predictive factors in the non-surgical treatment of carpal tunnel syndrome. J Hand Surg Br 1990;15:106-108. https://doi.org/10.1016/0266-7681-90-90061-8
• 4. Van Demark RE, Becker HA, Anderson MC, Smith VJS. Wide-awake anesthesia in the ın-office procedure room: lessons learned. Hand 2018;13:481-485. https://doi.org/10.1177/1558944717715120
• 5. LeBlanc M, Lalonde D, Thoma A, et al. Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery. Hand (N Y) 2011;6:60-63. https://doi.org/10.1007/S11552-010-9301-9
• 6. Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL. A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States. Ann Plast Surg 2011;66:245-248. https://doi.org/10.1097/SAP.0B013E3181DB7784
• 7. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg 2001;9:345-351. https://doi.org/10.5435/00124635-200109000-00008
• 8. Sraj S. Carpal tunnel release with wide awake local anesthesia and no tourniquet: with versus without epinephrine. Hand (N Y) 2021;16:592-594. https://doi.org/10.1177/1558944719890038
• 9. Bloc S, Squara P, Quemeneur C, et al. Wide awake local anesthesia no tourniquet (WALANT) technique improves the efficiency of distal nerve blocks for carpal tunnel release. Anaesth Crit Care Pain Med 2023;42:e101229. https://doi.org/10.1016/j.accpm.2023.101229
• 10. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 2013;131:811-814. https://doi.org/10.1097/PRS.0B013E3182818CED
• 11. Olaiya OR, Alagabi AM, Mbuagbaw L, McRae MH. Carpal tunnel release without a tourniquet: a systematic review and meta-analysis. Plast Reconstr Surg 2020;145:737-744. https://doi.org/10.1097/PRS.0000000000006549
• 12. Saleh E, Saleh J, Govshievich A, Ferland Caron G, Lin JC, Tremblay DM. Comparing minor hand procedures performed with or without the use of a tourniquet: a randomized controlled trial. Plast Reconstr Surg Glob Open 2021;9:e3513. https://doi.org/10.1097/GOX.0000000000003513
• 13. Iqbal HJ, Doorgakant A, Rehmetullah NNT, Ramavath AL, Pidikiti P, Lipscombe S. Pain and outcomes of carpal tunnel release under local anaesthetic with or without a tourniquet: a randomized controlled trial. J Hand Surg Eur Vol 2018;43:808-812 https://doi.org/10.1177/1753193418778999
• 14. Ki Lee S, Gul Kim S, Sik Choy W. A randomized controlled trial of minor hand surgeries comparing wide awake local anesthesia no tourniquet and local anesthesia with tourniquet. Orthopaedics and Traumatology: Surgery and Research 2020;106:1645-1651. https://doi.org/10.1016/j.otsr.2020.03.013
• 15. Chan V, Peng P, Kaszas Z, et al. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis. Anesth Analg 2001;93:1181-1184. https://doi.org/10.1097/00000539-200111000-00025
• 16. Gebhard RE, Al Samsam T, Greger J, Khan A, Chelly JE. Distal nerve blocks at the wrist for outpatient carpal tunnel surgery offer ıntraoperative cardiovascular stability and reduce discharge time. Anesth Analg 2002;95:351-355. https://doi.org/10.1097/00000539-200208000-00020
• 17. Harris AHS, Meerwijk EL, Kamal RN, et al. Variation in surgeons’ requests for general anesthesia when scheduling carpal tunnel release. Hand (N Y) 2020;15:608-614. https://doi.org/10.1177/1558944719828006
• 18. Derkash RS, Weaver JK, Berkeley ME, Dawson D. Office carpal tunnel release with wrist block and wrist tourniquet. Orthopedics 1996;19:589-592. https://doi.org/10.3928/0147-7447-19960701-07
• 19. Leblanc M, Lalonde J, Lalonde D. A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in canada. Hand (N Y) 2007;2:173-178. https://doi.org/10.1007/S11552-007-9043-5
• 20. Jagodzinski N, Ibish S, Furniss D. Surgical site infection after hand surgery outside the operating theatre: a systematic review. J Hand Surg Eur 2017;42:289-294. https://doi.org/10.1177/1753193416676408
• 21. Eroglu U, Ozgural O, Yakar F, Kahiloğulları G. Endoscopic carpal tunnel decompression: Comparison of mid- and long-term outcomes of 30 endoscopic and 30 standard procedure carpal tunnel decompression operations. Asian J Neurosurg 2017;12:534-536. https://doi.org/10.4103/1793-5482.210002
• 22. Williamson ERC, Vasquez MD, Melamed E. Multistate comparison of cost, trends, and complications in open versus endoscopic carpal tunnel release. Hand (N Y) 2021;16:25-31. https://doi.org/10.1177/1558944719837020
• 23. Braithwaite B, Robinson G, Burge P. Haemostasis during carpal tunnel release under local anaesthesia: a controlled comparison of a tourniquet and adrenaline infiltration. J Hand Surg Br 1993;18:184-186. https://doi.org/10.1016/0266-7681(93)90103-m
• 24. Leinberry CF, Rivlin M, Maltenfort M, et al. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective. J Hand Surg Am 2012;37:1997-2003. https://doi.org/10.1016/J.JHSA.2012.07.016
• 25. Kam PCA, Kavanaugh R, Yoong FFY. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia 2001;56:534-545. https://doi.org/10.1046/J.1365-2044.2001.01982.X
• 26. Lim E, Shukla L, Barker A, Trotter DJ. Randomized blinded control trial into tourniquet tolerance in awake volunteers. ANZ J Surg 2015;85:636-638. https://doi.org/10.1111/ans.12532
• 27. Maury AC, Roy WS. A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance. J Hand Surg 2002;27:359-360. https://doi.org/10.1054/jhsb.2002.0787
• 28. Segal KR, Debasitis A, Koehler SM. Optimization of carpal tunnel syndrome using walant method. J Clin Med 2022;11:3854. https://doi.org/10.3390/JCM11133854
• 29. Frank SG, Lalonde DH. How acidic is the lidocaine we are injecting, and how much bicarbonate should we add? Can J Plast Surg 2012;20:71-73. https://doi.org/10.1177/229255031202000207
• 30. Thurston A, Lam N. Results of open carpal tunnel release: a comprehensive, retrospective study of 188 hands. Aust N Z J Surg 1997;67:283-288. https://doi.org/10.1111/j.1445-2197.1997.tb01964.x
• 31. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). Am J Ind Med 1996;29:602-608. https://doi.org/10.1002/(SICI)1097-0274(199606)29:6<602::AID AJIM4>3.0.CO;2-L
• 32. Dogan SK, Ay S, Evcik D, Baser O. Adaptation of Turkish version of the questionnaire Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) in patients with carpal tunnel syndrome. Clin Rheumatol 2011;30:185-191. https://doi.org/10.1007/s10067-010-1470-y
• 33. Changulani M, Okonkwo U, Keswani T, Kalairajah Y. Outcome evaluation measures for wrist and hand: which one to choose? Int Orthop 2008;32:1-6. https://doi.org/10.1007/S00264-007-0368-Z
• 34. Gunes M, Ozeren E. Effect of age and body mass ındex on surgical treatment outcomes in patients with carpal tunnel syndrome. Turk Neurosurg 2021;31:83-87. https://doi.org/10.5137/1019-5149.JTN.29704-20.2
• 35. Tonga F, Bahadir S. The factors associated with carpal tunnel syndrome severity. Turk Neurosurg 2022;32:392-397. https://doi.org/10.5137/1019-5149.JTN.34519-21.2