The authors have nothing to disclose. Indications for the procedure are failed conservative treatment of carpal tunnel syndrome, severe thenar muscle atrophy, or acute carpal tunnel syndrome. Contraindications are local or systemic infection. Expected outcomes after carpal tunnel release are relief of pain at night symptoms, potential return of painless sensation to the median nerve distribution, reinnervation of thenar muscles, and full range of motion of the wrist. Risks and benefits for the procedure were discussed with patients. Equipment needed for the procedure are a basic hand and foot set, a tourniquet, local anesthetic, a scalpel, a sliding release system, and nylon suture. The intersection of an imaginary line along the radial border of the ring finger with Kaplan's cardinal line marks the distal extent of the planned incision. Kaplan's cardinal line is drawn from the apex of the interdigital fold between the thumb and index finger toward the ulnar side of the hand, parallel with the middle crease of the hand. A 1.5 to 2 cm incision proximal to this is marked. 7 cc's of 1% lidocaine without epinephrine is injected at a 45 degree angle between the pisiform and the palmaris longus tendon, superficial and then deep to the transverse carpal ligament. The remaining 3 cc's is injected subcutaneously along the incision. An S mark is used and a tourniquet is then inflated to 250 mmHg. Incision is carried out by sharp dissection through the palmar fascia. Subtractors are placed radially, ulnarly, and proximally. Fibers of the palmaris preface are usually visible, overlying the transverse carpal ligament, and are swept aside. The transverse carpal ligament is then incised in line with the incision. The proximal tractor is then positioned to the distal aspect of the incision, for exposure of the distal aspect of the transverse carpal ligament. The distal transverse carpal ligament is then incised. The distal release is complete once fat is visualized distal to the ligament. Return retractor proximally. Closed scissors are directed towards the pisiform and used to develop a plane superficial and deep to the ligament. The guide is then slid deep to the ligament, aiming proximally and ulnarly, and being careful that no synovium is entrapped between the guide and the ligament. After removal of the proximal retractor, a blade is then slid along the guide to release the proximal portion of the transverse carpal ligament, as well as the palmar carpal ligament. Irrigation and closure with nylon sutures is then performed. A soft wrap is then applied and tourniquet let down. Six month post-op photograph reveals a well-healed incision. All of the patient's preoperative symptoms had been resolved. Lee and Strickland showed equivalent results compared to endoscopic. Wong conducted a prospective randomized study that showed limited and endoscopic had similar outcomes at 1-year follow-up, however limited had less scar tenderness at 2nd and 4th week. Also limited had less thenar and hyperthenar pain. More studies are needed with the specific sliding system we used, however, Attic had a cadaveric study that showed no injuries to adjacent neurovascular structures and complete transverse carpal ligament release. Bradley had 91% of patients satisfied, and when compared to a different core hope that had a traditional open carpal tunnel release, significant improvement in symptom severity and functional outcome. Key points are, the incision should be ulnar to thenar crease to avoid the palmar cutaneous nerve. The transverse carpal ligament is released along the ulnar side to avoid the recurrent motor branch. Release the transverse carpal ligament distal to the fat pad. Recurrence or incomplete relief of symptoms can occur with failure to release the proximal portion of the transverse carpal ligament or the palmar carpal ligament.

carpal tunnel release

carpal tunnel syndrome

pain relief

muscle reinnervation

postoperative results