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Chirurgie de la main 33 (2014) 75–94

Recent advance
Carpal tunnel syndrome
Le syndrome du canal carpien
M. Chammas
Service de chirurgie de la main et du membre supérieur, chirurgie des nerfs périphériques, hôpital Lapeyronie,
CHU de Montpellier, avenue Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
Received 27 August 2013; received in revised form 31 October 2013; accepted 11 November 2013
Available online 15 February 2014

Abstract
Carpal tunnel syndrome is the commonest entrapment neuropathy and is due to combined compression and traction on the median nerve at the
wrist. It is often idiopathic. Although spontaneous resolution is possible, the usual natural evolution is slow progression. Diagnosis is mainly
clinical depending on symptoms and provocative tests. An electromyogram is recommended preoperatively and in cases of work-related disease.
Medical treatment is indicated early on or in cases with no deficit and consists of steroid injection in the canal or a night splint in neutral wrist
position. Surgical treatment is by section of the flexor retinaculum and is indicated in resistance to medical treatment, in deficit or acute cases. Mini-
invasive techniques such as endoscopic and mini-open approaches to carpal tunnel release with higher learning curves are justified by the shorter
functional recovery time compared to classical surgery, but with identical long-term results. The choice depends on the surgeon’s preference,
patient information, stage of severity, etiology and availability of material. Results are satisfactory in 90% of cases. Nerve recovery depends on the
stage of severity as well as general patient factors. Recovery of force takes about 2–3 months after the disappearance of ‘pillar pain’. This operation
has a benign reputation with a 0.2–0.5% reported neurovascular complication rate.
# 2014 Elsevier Masson SAS. All rights reserved.

Keywords: Carpal tunnel syndrome; Median nerve compression; Surgery; Endoscopy

Résumé
Le syndrome du canal carpien, le plus fréquent des syndromes canalaires, est dû à des mécanismes combinés de compression et traction du nerf
médian au poignet. Il est le plus souvent idiopathique. Bien que des régressions spontanées soient possibles, une aggravation lente est observée le
plus souvent. Le diagnostic est avant tout clinique, reposant sur les symptômes et les tests de provocation. Un examen électroneuromyographique
est recommandé en période préopératoire ou en cas de maladie professionnelle. Le traitement médical est indiqué de première intention dans les
formes non déficitaires et repose sur l’infiltration intracanalaire de corticoïdes et/ou une orthèse d’immobilisation nocturne en rectitude du poignet.
Le traitement chirurgical qui comprend la section du rétinaculum des fléchisseurs, est licite en cas de résistance au traitement médical, dans les
formes déficitaires ou dans les formes aiguës. Les techniques mini-invasives (endoscopie, mini-open) aux courbes d’apprentissage plus longues
semblent créditées d’une récupération fonctionnelle plus précoce par rapport à la chirurgie classique, mais avec des résultats identiques à long
terme. Le choix dépend du chirurgien, de l’information du patient, du stade de gravité, de son étiologie et de la disponibilité du matériel. Les
résultats sont satisfaisants dans près de 90 % des cas. Rapidité et importance de la récupération neurologique dépendent du stade de gravité et du
terrain. La récupération de force demande deux ou trois mois après régression des douleurs de type pillar pain. Cette chirurgie à la réputation de
bénignité a 0,2 à 0,5 % de complications majeures neurovasculaires.
# 2014 Elsevier Masson SAS. Tous droits réservés.

Mots clés : Syndrome du canal carpien ; Compression du nerf médian ; Chirurgie ; Endoscopie

1. Introduction

Carpal tunnel syndrome (CTS) is the commonest entrap-

E-mail address: [email protected]. ment neuropathy and is due to combined compression and

1297-3203/$ – see front matter # 2014 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.main.2013.11.010
76 M. Chammas / Chirurgie de la main 33 (2014) 75–94

traction on the median nerve at the wrist. It was first described

by James Paget in 1853. In 1913, Marie and Foix published the
first description of a neuroma proximal to the flexor
retinaculum (FR). The first surgical release of the FR is
attributed to Galloway in 1924 [1].
The prevalence of CTS is estimated between 4 and 5% of the
population especially between ages 40 and 60 [2]. In 2008,
127,269 people over 20 years were operated for CTS in France,
i.e. an incidence of 2.7/1000 (women 3.6/1000, men 1.7/1000)
[3]. There were two peaks of frequency, the first and highest
between ages 45 and 59 including 75% women, and the second
between ages 75 and 84 including 64% women. Since 1999,
when 101,900 were operated, an annual rise of 2.8% has been
reported. The cost of surgery supported by the social security in
2008 was 108 million Euros. For people aged 18 to 85 with
primary operation the global cost of time off work was 81
million Euros, 42 of which were for work-related disease. The
duration of leave exceeded 56 days for 38.9% of cases after Fig. 1. The three portions of the FR as described by Cobb [5]. 1. Proximal part
open surgery, and 71.2% exceeded 28 days after endoscopic thickening of the deep layer of the antebrachial fascia at the distal
release (32.8% of which exceeded 56 days). radius. 2. Intermediate part, characterized by its bony insertions: the pisiform
and the hook of hamate on the ulnar side, the scaphoid tubercle and the tubercle
2. Anatomy of the trapezium on the radial side. 3. Distal fascial part extending between
thenar and hypothenar muscles.
Les trois portions du RF d’après Cobb [5]. 1. Partie proximale, épaississement
2.1. Flexor retinaculum du feuillet profond du fascia antébrachial en regard de la partie distale du
radius. 2. Partie intermédiaire ou LTC, caractérisée par ses insertions
The carpal tunnel is an osteofibrous outlet [4], which is not osseuses : du côté ulnaire le pisiforme et l’hamulus de l’hamatum ; du côté
extensible and defined as the space between the FR, which forms radial, le tubercule du scaphoïde et le tubercule du trapèze. 3. Partie distale
aponévrotique tendue entre muscles thénariens et hypothénariens.
its ceiling, and the carpus its floor. It is medially limited by the
hook of hamate, triquetrum, pisiform and laterally by the
scaphoid, trapezium and the septum of the flexor carpi radialis
(FCR) tunnel. The floor is formed by the capsule and the anterior
radiocarpal ligaments covering the adjacent parts of the scaphoid,
lunate, capitate, hamate and trapezium. The FR is composed
mainly of transverse fibers and has three parts [5] (Fig. 1):

 the proximal part is a thickening of the deep layer of the

antebrachial fascia at the distal radius. This leaflet is
prolonged deep to the FCR, flexor carpi ulnaris (FCU) and
the ulnar bundle to surround only the 9 flexor tendons and the
median nerve;
 the intermediate part or transverse carpal ligament (TCL) is
characterized by its bony insertions: medially to pisiform and
hook of hamate and laterally to the tubercles of the scaphoid
and the trapezium;
 the distal aponeurotic part extends between the thenar and
hypothenar muscles. These two last portions represent the
‘classic’ part of the carpal tunnel.

The surface landmark of the proximal border of the TCL

corresponds to the wrist crease. According to Cobb [5], the TCL
starts about 11 mm proximal to the capitolunate interval and the
carpal tunnel ends about 10 mm proximal to the 3rd
carpometacarpal interval (Fig. 2). The mean width of the
carpal tunnel from the TCL is 25  1.5 mm distally. This gives
Fig. 2. Radiographic projection of the three areas of FR described by Cobb [5];
an hourglass shape. The mean thickness of the flexor its hourglass shape.
retinaculum is 0.6 to 2 mm proximally and 1.6 to 3.6 mm at Projection radiographique des trois zones du RF d’après Cobb [5] ; sa forme en
the level of the hamate. sablier.
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 77

The flexor retinaculum has four functions: accentuated by wrist extension risking error of approach in
endoscopic surgery or direct injury in open surgery.
 it represents the first pulley of reflection for the flexor
tendons. Its section causes palmar displacement of the flexor 2.2. The contents of the carpal tunnel
tendons at 20–308 wrist flexion and an increase in their
excursion of 15 to 25% [6]; The median nerve is accompanied by the four tendons of the
 mechanical protection of the contents; flexor digitorum superficialis muscle (FDS), the four tendons of
 base for proximal insertion of thenar and hypothenar the flexor digitorum profundus (FDP) and the flexor pollicis
muscles; longus (FPL) tendon. The FPL tendon is the most radial
 minor role in transverse stabilization of the carpal arch. element, the median nerve most palmar.
Proximal to the canal, the median nerve is located either just
Superficial to the FR, there are the longitudinal connective dorsal to PL or between FCR and PL. In neutral position of the
fibers of the palmar aponeurosis – a prolongation of the wrist, the median nerve is either superficial to the FDS tendon
palmaris longus (PL) tendon if present, radial fibers of the FCU of the index, or between FPL and FDS of the index or palmar to
and the superficial part of the antebrachial fascia surrounding the FDS tendon of the middle finger. At the distal part of the
FCR, FCU and the ulnar neurovascular bundle [5]. canal, the median nerve divides into six branches: the thenar
Guyon’s canal is superficial on the ulnar side and partially (recurrent) motor branch, the three proper palmar digital nerves
covers the ulnar border of the TCL (Fig. 3). More distally, the (radial and ulnar to the thumb and radial to the index) and the
ulnar neurovascular bundle is found medial to the hook of common palmar digital nerves to the 2nd and 3rd spaces.
hamate. In some cases, it can be more lateral, which can be The flexor tendons are surrounded by synovial sheaths:

 a common synovial sheath of the long finger flexor tendons

which extends beyond the upper border of the FR and often
communicates with the synovial sheath of the little finger
flexor;
 a radial digito-carpal synovial sheath surrounds the FPL.

2.3. Anatomical variations

These may explain variations in symptoms and present a risk

of iatrogenic injury during surgery.

2.3.1. Anatomical variations in nerve

2.3.1.1. Bifid median nerve with high division. Bifid median
nerve with high division (1 to 3.3% of cases) may be present
alone or associated with a persistent median artery [7].

2.3.1.2. Thenar (recurrent) motor branch. Lanz has described

five types [8] (Fig. 4): the commonest is the extra-ligamentous
form (46%), under the ligament (31%), the transligamentous
form (23%) and two rare forms: one where the thenar branch
arises from the ulnar side of the median nerve and crosses it at
the thenar muscles, and the other (9%) where the thenar branch
is superficial to the FR. Kozin found in 4% of cases there were
multiple motor branches with one of them crossing the FR
every time [9]. The fascicles making up the thenar branch are
located in the radial portion of the median nerve in 60% of
cases, palmar in 20% and central in 18% of cases [10]. The
thenar branch passes through a separate tunnel before entering
the thenar muscles in 56% of cases. These variations may
explain the variable motor deficit in severe compression of the
median nerve [10].
Fig. 3. Position of Guyon’s canal in relation to the FR. At the pisiform, the
Guyon’s canal partly covers the FR (A). More distally, it lies medial to the hook
2.3.1.3. Palmar branch of median nerve. Usually the palmar
of hamate (B).
Position de la loge de Guyon par rapport au RF. Au niveau du pisiforme, la loge branch arises 4–7 cm proximal to the flexion crease of the wrist
de Guyon recouvre en partie le RF (A). Plus distalement, elle se situe and travels for 16 to 25 mm beside the median nerve, then
médialement à l’hamulus de l’hamatum (B). enters a tunnel formed by the fascia on the medial edge of the
78 M. Chammas / Chirurgie de la main 33 (2014) 75–94

Fig. 4. Variations of thenar (recurrent) motor branch of the median nerve according to Lanz [8]. Extra-ligamentous form (A). Subligamentous form
(B). Transligamentous form (C). Origin at the ulnar side of the median nerve and crossing the nerve at the thenar muscles (D). Course superficial to FR (E).
Variations du rameau moteur thénarien du nerf médian d’après Lanz [8]. Forme extra-ligamentaire (A). Forme sous-ligamentaire (B). Forme transligamentaire (C).
Naissance du côté ulnaire du nerf médian et croisement de celui-ci en regard des muscles thénariens (D). Trajet superficiel par rapport au RF (E).

FCR to emerge 8 mm proximal to the flexion crease of the wrist 2.3.2. Vascular anatomical variations: Persistent median
and innervate the skin over the thenar eminence. The palmar artery
branch can cross the TCL or travel ulnar to the median nerve. This embryonic remnant is observed in 1–16% of dissections
or operations [14]. A persistent median artery of at least 3 mm
2.3.1.4. Median nerve territory in the hand. The median in diameter was noted by Doppler in 26% of asymptomatic
nerve provides sensory innervation to the palmar aspects of the patients (6% cases were bilateral) [15]. A bifid median nerve
three radial fingers and the radial half of the ring finger. may be associated.
Dorsally, it supplies the last two phalanges of the index and
middle fingers and the radial half of the ring finger. The origin 2.3.3. Muscle and tendon variations [16]
of the palmar branch proximal to the FR explains why the 2.3.3.1. Palmaris longus muscle variation. The PL may run
thenar area is spared in CTS. inside the carpal tunnel to insert on its deep surface, is called
The median nerve innervates the muscles of opposition: the palmaris longus profundus, and can cause a constriction of the
abductor pollicis brevis (APB), opponens pollicis, the superfi- median nerve. A reversed PL with an intracanalicular muscle
cial head of flexor pollicis brevis (FPB) and the first two body may be present, called palmaris longus inversus.
lumbricals.

2.3.1.5. Communicating branches 2.3.3.2. Flexor digitorum superficialis. The extension of the
Sensory and motor communicating branches (CB) with the muscle belly within the carpal tunnel is the most common
ulnar nerve exist. variation, estimated by Holtzhausen to be 46% in women and
2.3.1.5.1. Palmar communicating branch of Berreti- 7.8% in men [17].
ni. This sensory CB is found in 67–92% of cases deep to
the superficial palmar arch and is responsible for changes in the 2.3.3.3. Lumbricals. The insertion can extend inside the
sensory territory at the ulnar side of the middle and ring fingers carpal tunnel, with no proven incrimination for median nerve
and the radial side of the little finger between the median and compression [7].
ulnar nerves [11–13] (Fig. 5). In some cases, this branch is just
distal to the FR, where it may be injured in carpal tunnel 2.4. Cutaneous innervation of the palm of the hand
release.
2.3.1.5.2. Communicating branch of Riché and Can- Four nerve branches involved in the innervation of the palm
nieu. This CB is very common (77% to 100%) [12] and is at the thenar and hypothenar eminences are considered at risk in
responsible for the distribution of thenar muscles between carpal tunnel surgery [12] (Fig. 6). Some of their branches may
median and ulnar nerves and can take any of various forms: cross the radial border of the ring finger:

 the commonest form is a communicating branch between  the palmar branch of the median nerve;
thenar branch of the median nerve and deep branch of the  the palmar branch of the ulnar nerve which is inconstant,
ulnar nerve to the FPB; arising 4.6 cm proximal to the pisiform bone;
 CB in the adductor pollicis;  the nerve of Henle, nervus vasorum of the ulnar artery, which
 CB between thenar branch and deep branch of the ulnar nerve contributes to the innervation of the hypothenar eminence in
at the first lumbrical; 40% of cases;
 CB between a palmar digital nerve of the thumb and the deep  the transverse palmar branches of the ulnar nerve arising
branch of the ulnar nerve. in Guyon’s canal and innervating the skin of the hypothenar
eminence and the palm of the hand, distal to the territory
Note that the innervation of lumbricals is similar to that of the of the palmar branch of the ulnar nerve and the nerve of
FDP. Henle.
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 79

Fig. 5. Variations of communicating branch between the ulnar and median nerves in the palm of the hand and implications on territories of sensory innervation
described by Don Griot [13]. Type 1: ulnar nerve connections to the median nerve (most frequent): radial digital nerve to the ring finger (42–62%) (A), to the radial
digital nerve of the ring finger and ulnar digital nerve of the middle (4–10%) (B), to the third common digital nerve (0–5%) (C), to the radial digital nerve to the ring
finger and radial digital nerve to middle (0–7%) (F). Type 2: connections of the median nerve to the ulnar nerve: towards the ulnar digital nerve of the ring finger (0–
4%) (D), to the ulnar digital nerve of the ring and the radial digital nerve of the little finger (0–4%) (G). Type 3: perpendicular connections with unknown destination
(0–8%) (E). Crossing of fibers (0–4%) (H).
Variations du rameau communicant entre nerf médian et nerf ulnaire à la paume de la main et conséquences sur les territoires d’innervation sensitive d’après Don
Griot [13]. Type 1 : connexions nerf ulnaire vers nerf médian (les plus fréquentes) : vers le nerf digital radial du 4e doigt (42–62 %) (A) ; vers le nerf digital radial du
4e doigt et le nerf digital ulnaire du 3e (4–10 %) (B) ; vers le nerf 3e nerf digital commun (0–5 %) (C) ; vers le nerf digital radial du 4e doigt et le nerf digital radial du
3e (0–7 %) (F). Type 2 : connexions du nerf médian vers le nerf ulnaire : vers le nerf digital ulnaire du 4e doigt (0–4 %) (D) ; vers le nerf digital ulnaire du 4e doigt et le
nerf digital radial du 5e (0–4 %) (G). Type 3 : connexions perpendiculaire, destination non connue (0–8 %) (E). Croisements de fibres (0–4 %) (H).

2.5. Surface anatomy 3. Pathophysiology and etiology

The proximal border of the FR corresponds to the wrist 3.1. Structural nerve abnormalities and clinical
flexion crease and the median nerve is at the middle of the wrist. correlations
Distally, there are two methods to mark the surface anatomy of
the superficial palmar arch and the thenar branch: The entrapment neuropathy combines phenomena of
compression and traction. Anatomically, there are two sites
 the cardinal line of Kaplan (Fig. 7) from the deepest point of of median nerve compression:
the first web and towards the ulnar border of the hand parallel
to the proximal palmar crease. The superficial palmar arch is  at the proximal edge of the carpal tunnel, caused by wrist
at least 7 mm distal to the line of Kaplan along the axis of the flexion and due to the change in thickness and rigidity
radial border of the ring finger [18]. The point where the between the antebrachial fascia and the proximal portion of
thenar branch penetrates the muscle is between 1 and 15 mm the FR;
proximally, along the radial border of the middle finger;  at the narrowest portion at the hook of hamate [12] (Figs. 1
 Cobb’s landmarks [19] (Fig. 7): they better locate the hook of and 2).
hamate [20] because they are not affected by any trapezio-
metacarpal thumb stiffness. The hook lies at the intersection of The longitudinal movement of the median nerve in the
two lines: one from the pisiform to the proximal palmar crease carpal tunnel was found to be 9.6 mm during flexion [21], 0.7 to
along the axis of the index, the other joining the middle of the 1.4 cm in wrist extension [22]. It can vary from 2.5 to 19.6 mm
base of the ring finger and the junction middle to medial thirds depending on the position of the shoulder, elbow, wrist and
of the wrist flexion crease. The superficial palmar arch is on fingers [23]. The median nerve tension varies from 8%
average 2.7 cm (1.8 to 4.5 cm) distal to the hook of hamate. depending on the position of the shoulder and 19% depending
80 M. Chammas / Chirurgie de la main 33 (2014) 75–94

the axon, as well as alterations in the supporting connective

tissue. Lundborg proposed an anatomo-clinical classification
useful in clinic [25] (Table 1). In so-called idiopathic CTS,
several factors are behind the nocturnal increase in intracana-
licular pressure:

 redistribution of the upper limb fluids in supine position;

 lack of muscle pump mechanism that contributes to the
drainage of interstitial fluid in the carpal tunnel;
 tendency to place the wrist in flexion thereby increasing
intracanalicular pressure;
 increased blood pressure in the second half of the night;
 fall of cortisol levels.

This classification, is simple, but lacks sensitivity. After

compression, not all nerve fibers within the same nerve are at
the same level of damage, the peripheral fibers are affected
before the more central ones, large myelinated ones before
smaller ones, and sensory fibers before motor fibers.
In chronic CTS, degradation occurs over months or years.

3.2. Associated pathology

Fig. 6. Distribution of cutaneous nerve branches to the palm of the hand.
Distribution des branches cutanées innervant la paume de la main. 3.2.1. Polyneuropathy
Any polyneuropathy, especially diabetes mellitus, can
on the position of the fingers. In addition to the longitudinal promote CTS by structural and functional alterations of the
movement, a transverse movement of the median nerve occurs median nerve, making it more sensitive to any compression [26].
with wrist position or during finger flexion against resistance
[24]. In compression and epineural adhesions, mobility is 3.2.2. Staged nerve compression syndrome ‘‘Double crush
hindered, creating lesions due to repeated traction on the nerve syndrome’’
during wrist movements [21]. The concept of staged nerve compression described by
Nerve compression and traction may cause disorders of the Upton and Mac Comas [27] is based on the fact that proximal
intraneural microcirculation, lesions in the myelin sheath and compression of a nerve makes it more sensitive to another more

Fig. 7. Cardinal line of Kaplan and Cobb’s surface landmarks from Cobb [19]. H: hamate; FCR: flexor carpi radialis; FCU: flexor carpi ulnaris; P: pisiform; TB:
thenar (recurrent) branch of the median nerve.
Ligne cardinale de Kaplan et repères de Cobb d’après Cobb [19]. H : hamatum ; FCR : flexor carpi radialis ; FCU : flexor carpi ulnaris ; P : pisiforme ; RT : rameau
thénarien du nerf médian.
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 81

Table 1
Anatomo-clinical classification of Lundborg [25] for staging the severity of CTS.
Classification anatomo-clinique de Lundborg [25] pour l’appréciation du stade de gravité du SCC.
Symptoms Histopathology Recovery after decompression
Early stage Nocturnal Venous stasis, epineural endoneural edema Immediate
Slowing of axonal transports
Intermediate stage Nocturnal + diurnal Permanent anomalies of microcirculation Rapid symptom relief (microcirculation is re-established)
Permanent interstitial edema Repair of myelin sheath (weeks or months) ! persistence
Connective tissue thickening of intermittent symptoms some weeks  persistent
Destruction of myelin sheath and ENMG abnormalities
nodes of Ranvier
Advanced stage Permanent sensory Wallerian degeneration Recovery depends on potential of nerve regeneration
trouble  deficit of Reactionary fibrous thickening of Several months delay
thumb opposition surrounding connective tissue May be incomplete, persistent ENMG abnormalities

distal compression by cumulative effects on anterograde axonal and/or carpal shortening), infection, basal thumb arthritis,
transport. Likewise, a distal compression, by alterations in villonodular synovitis;
retrograde axonal transport, can promote the emergence of a  acromegaly.
more proximal entrapment syndrome (‘‘Reversed double crush
syndrome’’). This can occur in practice in radicular compres- 3.3.2.2. Abnormalities of content. The abnormalities are:
sion or thoracic outlet syndrome (TOS) associated with a CTS
distally.  synovial hypertrophy;
 abnormal or supernumerary muscle: palmaris profundus
3.3. Etiology muscle, intracanalicular position of the belly of FDS muscle
or a lumbrical;
In most cases, CTS is said to be idiopathic. Secondary CTS  intracanalicular tumor: lipoma, synovial tumor (cyst,
may be related to abnormalities of the container or the contents. synovial sarcoma), nerve tumor (schwannoma, neurofibroma,
Dynamic CTS is frequently encountered in occupational lipofibroma);
pathology.  obesity;
 enlargement of a persistent median artery can cause CTS on
3.3.1. Idiopathic carpal tunnel syndrome effort,
It occurs most often in women (65 to 80% of cases) between  inflammatory tenosynovitis: inflammatory (rheumatoid
40 and 60 years, bilateral in 50% to 60% of cases [28]. arthritis, lupus) or infectious arthritis,
Bilaterality increases with the duration of symptoms. It is  metabolic tenosynovitis: diabetes mellitus (abnormal
related to a fibrous hypertrophy of synovial flexor sheath related collagen turnover), primary or secondary amyloidosis
to connective tissue degeneration with vascular sclerosis, (chronic hemodialysis with Beta 2 microglobulin deposits),
synovial edema and collagen fragmentation [29]. Meta- gout, chondrocalcinosis;
analyses [30] showed that sex, age, genetic and anthropometric  abnormal fluid distribution;
factors (size of the carpal tunnel) are the most important – during pregnancy [31,32] CTS occurs in 0.34 to 25% of
predisposing factors. Repetitive manual work, exposure to cases, especially in the 3rd trimester, with deficit in 37–
vibration, and cold exposure are minor predisposing factors. 52% of cases, with spontaneous resolution before the 3rd
Other minor predisposing factors have been identified such as postpartum month in 85% of cases,
obesity and tobacco. – hypothyroidism is a common etiology,
– an arteriovenous fistula in the context of chronic renal
3.3.2. Secondary CTS failure.
3.3.2.1. Abnormalities of the container. Any condition affect-
ing the walls of the carpal tunnel can cause compression of the 3.3.3. CTS and occupational pathology
median nerve: The French Table 57c of the general social security scheme
and Table 39c of the agricultural security scheme for the
 abnormal shape or position of the carpal bones due to recognition of CTS and compression of the ulnar nerve at
malunion, carpus or radiocarpal subluxation; Guyon’s canal state that: ‘‘Work in the usual way, repeated
 abnormal shape of the distal radius due to fracture with movements or prolonged wrist extension or hand grip, a carpal
translation of more than 35%, or malunion of the distal stress or prolonged or repeated pressure on the pillar of the hand’’.
radius, metalwork on the anterior surface of the radius; In 2007, with 40,537 cases, Table 57 of the general scheme
 pathology of the wrist joint such as osteoarthritis, inflamma- of occupational diseases accounted for 75% of reported
tory arthritis (due to synovial hypertrophy, bone deformity occupational diseases [33]. CTS is responsible for 37% of
82 M. Chammas / Chirurgie de la main 33 (2014) 75–94

recognized cases under Table 57 and 27% of all recognized 4.1. Diagnosis, associated pathology and differential
occupational diseases. In addition to the criteria in Table 57c, diagnosis
exposure to cold must be considered as another predisposing
factor. 4.1.1. Symptoms [38]
The condition may be unilateral or bilateral. Paresthesias in
3.3.3.1. Dynamic CTS. The pressure within the carpal tunnel median nerve territory are described as needles, burning
increases in extension and flexion of the wrist. Repetitive sensation, tingling, heaviness, or electric impulses usually
movements of the wrist in flexion and extension, finger flexion accompanied by pain radiating to the forearm, elbow or
and forearm supination have been implicated [34]. An shoulder. Of insidious onset, these symptoms are predomi-
entrapment of FDS and FDP muscle mass during extension nantly nocturnal or appear on waking up in the morning, they
of the wrist and fingers was found in 50% of cases [35]. can also be triggered by unusual daytime activity, or by
maintaining a prolonged position of the hand or wrist such as
3.3.3.2. CTS and computer work. No increased prevalence of holding a newspaper or telephone or driving. Shaking the hand
CTS was found in case of computer work more than 15 hours ( flick sign of Pryse-Phillips) [39] or changing the position
per week, an increased tendency has been shown beyond relieves the symptoms. At the limits of median nerve territory,
20 hours per week [36]. the little finger is sometimes involved due to median-ulnar CB,
after eliminating ulnar nerve compression at the elbow or
3.3.3.3. Vibration [34]. Exposure to vibration is a minor proximal cause of compression such as TOS, cervical or spinal
contributing factor [30] with histological effects similar to cord causes. A decrease of force, morning edema and cold
those related to compression. intolerance may be noted. As the compression progresses,
paresthesias become permanent leading to clumsiness and
3.3.4. Acute CTS dropping objects. In severe forms, sensory deficit perturbs fine
3.3.4.1. Posttraumatic. This is most common with distal radius movements and thenar atrophy can be observed at this stage,
fractures, especially with anterior displacement or wrist disloca- sometimes accompanied by weak opposition of the thumb if
tion. Increased intracanalicular pressure causing acute CTS may substitution by the ulnar does not exist.
also be due to immobilization of the wrist in flexion, excessive
distraction by external fixator, or due to crush syndrome [37].
4.1.2. Provocation tests
The median nerve is felt just distal to the flexion crease deep
3.3.4.2. Non-traumatic [37]. These are rarer:
to the PL tendon or midpoint of the wrist:
 infection and tenosynovitis, flexor sheath infection, abscess
 Tinel’s test is positive if the patient experiences paresthesias
or septic arthritis;
with manual percussion of the palmar aspect of the wrist over
 hemorrhage with hematoma under pressure by anticoagulant
the median nerve. The sensitivity is 26% to 79% and
overdose, hemophilia, or von Willebrand disease;
specificity is 40 to 100% [40];
 arthropathy, microcrystalline synovitis, tophi;
 Phalen’s test (Fig. 8) is positive if paresthesias appear in
 high pressure injection;
median nerve territory on maximum flexion of the wrist with
 acute thrombosis of a persistent median artery;
elbow extended for a whole minute. The time taken for the
 burn causing increased compartmental and carpal tunnel
symptoms to appear is noted in seconds. Sensitivity is 67% to
pressure.
83% and specificity is 47 to 100% [40,41];
4. Diagnosis

Clinical approach of a patient complaining of acropares-

thesia of the hand consists of five steps:

 diagnosis by examination, provocative tests, associated

pathology and differential diagnosis;
 determine the etiology;
 assess the severity of the compression by assessing sensory
discrimination using the Weber test and the strength of thenar
muscles innervated by the median nerve;
 additional tests especially electroneuromyographic examina-
tion (ENMG);
 propose the appropriate treatment according to severity,
etiology, general condition and activity.
Fig. 8. Phalen’s test.
There is no ‘‘gold standard’’ for diagnosis of CTS. Test de Phalen.
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 83

At the end of this diagnosis, differential diagnosis and

associated pathology are considered, the possibilities being:

 high clinical suspicion of CTS;

 CTS is suspected but accompanied by another pathology:
associated compression syndrome such as ulnar nerve at the
elbow (rarely at the wrist) may be suspected, or multiple
nerve compression syndromes with cervical arthritis;
 symptoms evoke another cause such as TOS, cervico-brachial
neuralgia or neurological disease.

4.2. Determining severity: anatomo-clinical classification

of Lundborg

This is determined by the timing of symptoms and

neurological deficit using the Weber test of static 2-point
discrimination for the pulp, and detection of thenar atrophy
(Table 1).

4.3. Determining etiology

Despite frequent ‘idiopathic’ forms of CTS, systematic

search for etiology is mandatory (Section 3).

Fig. 9. McMurthry’s and Paley’s tests. 4.4. When to request investigations?

Test de McMurthry et Paley.
4.4.1. Electroneuromyography (ENMG)
The ENMG consists of a stimulation phase and a detection
phase. The stimulodetection shows sensory and motor
 test of McMurthry and Paley [42] (Fig. 9) is positive if conduction of the median nerve and highlights any slowing
manual pressure on the median nerve 1 to 2 cm proximal to down during the passage through the carpal tunnel. It measures
the flexor crease causes pain or paresthesia. Sensitivity is amplitude and duration of motor and sensory evoked potentials.
89% and specificity is 45% [40]. Durkan described a variation Nerve conduction of the ipsilateral ulnar nerve and contralateral
with compression over the FR [43], which is more difficult to median nerve is also measured.
illicit; The earliest and most sensitive electrical abnormality is a
 test of compression in wrist flexion [44] where pressure is slower sensory conduction (possibly shown by measuring the
exerted on the median nerve over the carpal tunnel using two distance between the palm and/or fingers and wrist). We can
fingers with wrist flexed at 608, elbow flexed and forearm consider that a median nerve conduction velocity of less than
supination. The test is positive if paresthesias appear in the 45 m/s in the carpal tunnel is pathological, normal velocity
median nerve territory. Sensitivity is 82% and specificity is being at least 50 m/s [45,46].
99% [44]. At an advanced stage, there is prolonged distal motor latency
between wrist and APB; thus the time between nerve
According to Szabo, nocturnal acroparesthesia is the most stimulation at the wrist and the onset of a motor potential
sensitive symptom (96%), the most sensitive test is the direct recorded over APB is greater than 4 to 10 ms for a normal of
compression test (McMurtry et Paley) (89%) followed by  3.6 ms, and the muscle shows signs of denervation [46].
Phalen’s test and the monofilaments of Semmes Weinstein Motor latency can be altered without abnormal sensory
(83%) then the score of Katz and Stirrat (76%) in the typical conduction (3.9% of cases [47]). This isolated motor
form with tingling, burning, heaviness or hypoesthesia with or impairment may be due to a motor branch passing through a
without pain involving at least two of the three radial fingers separate tunnel in the FR.
excluding the palm and back of the hand. Spontaneous wrist This examination is operator dependent. Skin temperature
pain or radiating in the direction of the wrist can exist. The and age influence the results. The ENMG may be positive in 0–
combination of four abnormal tests: compression, monofi- 46% of asymptomatic subjects and negative in 16–24% of
laments, Katz and Stirrat scores and nocturnal symptoms is patients with a clinical diagnosis of CTS [48]. In an isolated
correlated with the diagnosis of CTS by a probability of 0.86. If motor distal latency study, Seror [49] found a sensitivity of 54%
the four tests are normal the probability of CTS is 0.0068. The and a specificity of 97.5%. In an isolated study of sensory
author thus concludes that ENMG is not often useful is conduction velocity, he found a significantly greater sensitivity
diagnosing moderate or severe CTS. of 75–92% and a specificity of 97.5%.
84 M. Chammas / Chirurgie de la main 33 (2014) 75–94

Thus, the false negative rate is not negligible especially in the content, e.g. diagnosis of a persistent median artery
early disease, where only nerve fibers of small caliber are thrombosis using Doppler US.
affected. The addition of ENMG study to clinical provocation
tests does not provide significant and reliable contribution to the 4.4.2.3. Magnetic resonance imaging. MRI is rarely indicated
diagnosis to be recommended in practice [50]. In case of but may be useful:
dynamic CTS, ENMG is positive only when the compression
reaches a certain degree of severity. Again, the ENMG will not  in secondary tenosynovitis;
detect early forms. However, normal ENMG almost certainly  in CTS of the child or young adult to detect intracanalicular
excludes a severe or moderate form. The ENMG does not return muscle abnormality, particularly in cases of CTS upon effort,
to normal in intermediate and severe forms, despite symptom or an intracanalicular tumor.
relief.
ENMG does not provide any additional evidence to the 5. Clinical forms
diagnosis of SCC compared to clinical assessment when the
clinical diagnosis is obvious [51]. 5.1. Evolving forms
Anatomical variations like Martin-Gruber and Riché-
Cannieu can interfere with the interpretation of electro- 5.1.1. Regression of CTS
myographic studies. The natural evolution of CTS has not been studied in detail
However, the ENMG examination remains a reference in the and is not an always progression. Changes may be intermittent
exploration of CTS. In addition to its medicolegal value, with periods of calm. In one third of patients symptoms regress
ENMG can confirm the diagnosis, eliminate another disease spontaneously [54]. According to Padua [55], at 1 year, 34% of
(cervico-brachial neuropathy or TOS), detect associated patients improved, and 45% were unchanged. Recent onset and
polyneuropathy, specify single or multiple compression sites young age are favorable prognostic factors. Persistent forms
and assess the severity of nerve damage thus guiding the evolve to affect quality of life and can cause irreversible nerve
treatment plan. damage [56].
The Working Group ANAES [52] concluded that:
5.1.2. Acute CTS
 ENMG should follow clinical examination; Acute CTS often presents with a sensory deficit, possibly
 ENMG is not essential for the diagnosis of a typical form of hyperesthesia.
CTS; Posttraumatic forms are the most common. A patient with
 ENMG is not necessary before steroid injection; chronic intermittent CTS may develop acute CTS following
 it is recommended in cases of doubt, it is an aid in the trauma with further increase in intracanalicular pressure. CTS
differential diagnosis; can also develop de novo. We must distinguish acute
 it is recommended prior to surgery; compression where treatment is often surgical, from contusion
 it is required to establish occupational disease recognition. where medical treatment is preferred [37]. In acute compres-
sion, the aggravation and deficit are gradual; in case of a
4.4.2. Imaging fracture or joint displacement, the soft tissue structures increase
4.4.2.1. Wrist X-rays and carpal tunnel view. Radiology is no in volume. In contusion, the neurological deficit is present
longer routinely indicated to diagnose etiology of CTS. PA, immediately, there is no or little displacement and no volume
lateral or carpal tunnel views of the wrist are useful: increase of soft tissue structures. A pressure recording
apparatus may be used [37].
 when there is wrist pain, limited mobility, deformity or flexor Diagnosis of the rarer non-traumatic acute CTS may be
tendon rupture; obscured by etiology. Acute thrombosis of a persistent median
 when the medical or history of trauma suggests abnormal artery causing CTS is evoked by the absence of etiological
tunnel or contents. context; spontaneous acute CTS in a young or middle-aged
adult suggests this diagnosis. Sometimes a bruise, manual
4.4.2.2. Ultrasonography. This is an operator- and material- exertion or exposure to vibration is present. Spontaneous acute
dependent study. In early disease, the median nerve maintains pain on the palmar aspect of the wrist radiating to the radial
normal morphology: a normal aspect of the nerve does not fingers and sensory deficit in median nerve territory are
eliminate CTS. A meta-analysis of 28 series published in 2012 reported. A Doppler US – if tolerated – shows a persistent
[53] showed an increase in cross-sectional area of the median median artery thrombosis often associated with a bifid median
nerve  10 mm2, reflecting that increased volume proximal to nerve. The diagnosis is usually made during urgent surgical
stenosis was the best diagnostic test with sensitivity 87.3% and exploration.
specificity 83.3%. The ratio (index) of flattening of the median
nerve facing the hamate is a reliable criterion. Other signs are 5.2. Associated forms
notching, nerve edema proximal to the stenosis, decreased
mobility during flexion-extension, and the FR bulge. Ultra- Another entrapment syndrome of the upper limb may be
sound can help diagnose etiology by morphological analysis of associated with CTS. Acroparesthesia of the fifth finger may
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 85

create confusion. We must distinguish anatomical variation of Prevention in recreational activities such as sports and crafts
compression of the ulnar nerve at the elbow, or more rarely in should also be considered.
Guyon’s canal, from TOS or cervical neuropathy.
It is important to check the cervical spine and TOS for a
6.2. Conservative treatment
multiple nerve compression syndrome which may explain
persistent postoperative acroparesthesia.
There is currently a sufficient level of evidence regarding the
Trigger fingers resulting from increased synovial volume
effectiveness of steroid injections, splinting and oral corticos-
must be sought; they can decompensate postoperatively.
teroids. Other treatment modalities such as ultrasound, laser,
Basal thumb arthritis – with inconstant symptoms – is fairly
diuretics, vitamin B6, weight loss are controversial.
common after 60 years.
The coexistence of CTS and Raynaud’s phenomenon is not
rare. The differential diagnosis may be tricky since sympathetic 6.2.1. Corticosteroid infiltration
signs are sometimes associated with CTS. It acts by reduction of synovial volume and by direct effect
on the median nerve. The main risk is injury to the median
5.3. Age-related forms nerve, with acutely painful sensation of electric shock, risk of
neurological deficit and persistent pain. The other complication
In elderly patients, a sensory deficit is often associated with a is tendon rupture.
thenar atrophy, which usually affects patient autonomy. Our injection point is 4 cm proximal to the wrist flexion
In the young patient, we must look for microtrauma or crease halfway between the PL tendon and the FCU, which
intracanalicular muscle abnormality, which gives symptoms corresponds to the axis of the fourth finger (Fig. 10). Prior local
only when using the hand. anesthesia is not necessary. After topical antisepsis, the needle
In children, the causes are usually genetic [57] in is slowly pushed obliquely at 458 to the carpal tunnel. There
mucopolysaccharidosis and mucolipidosis. Other non-genetic should be no abnormal resistance. The other hand passively
causes include macrodactyly and tumors. mobilizes the fingers to ensure that the needle is not stuck in a
CTS is rare in adolescents and sports are a contributing tendon then injection is performed slowly after aspiration. A
factor [58]. transient painful reaction can occur for some hours after
injection.
6. Treatment Injection between FCR and PL may cause median nerve
injury given the position of the median nerve. Dreano [59]
6.1. Prophylaxis injects ulnar to PL. Dubert [60] reports the measured location of
the median nerve in relation to PL, FCR and FCU, 1 cm
It is essential in occupational pathology and includes the proximal to the wrist flexion crease and identified a risk zone
modification of the workplace (height) and tools (gloves, located 1 cm on either side of the PL tendon. He recommends
weight, friction, temperature, shape), automation of certain injecting through the FCR 458 medially and 458 distally. There
tasks, slowing down the pace, the introduction of rest periods, is no difference at 1 year between injections at the wrist flexion
and diversification of manual activities (job rotation). crease and one 4 cm proximal to it [61].

Fig. 10. Carpal tunnel injection.

Infiltration du canal carpien.
86 M. Chammas / Chirurgie de la main 33 (2014) 75–94

Relief occurs within a few days to 2–3 weeks. Local steroid 6.3. Surgical treatment
injection is more effective than placebo injection at 1 month
and more prolonged than oral corticosteroids at 2 and 3 months The principle of surgical treatment is to obtain a reduction in
[62]. Temporary relief after local corticosteroid injection is a intracanalicular pressure by increasing the volume of the carpal
good prognosis for surgery [63]. Two injections are not more tunnel due to the section of the FR. This is usually performed as
efficient than one. More than three injections are not day case surgery using a tourniquet. The operation is usually
recommended. The minimum recommended time between unilateral. Three techniques are currently used: open;
two injections is one month. Diabetes mellitus is a techniques known as ‘‘mini-open’’; and endoscopic techniques.
contraindication especially if uncontrolled. Surgery with ultrasound guidance is under development and
In intermittent CTS with no deficit, Agarwal et al. [64] found evaluation [69]. Whatever the technique, the procedure must be
93.7% improvement clinically and on ENMG at 3 months, 79% atraumatic and care must be taken not to place the median nerve
at 16 months with 50% ENMG normalization. In a series of in the extension of the scar incision to minimize postoperative
patients with or without deficit treated by infiltration and splint epineural adhesions.
for three weeks, Gelbermann et al. [65] reported only 22% were
asymptomatic at maximum follow-up of 26 months. The 6.3.1. Anesthesia and carpal tunnel surgery
criteria for good prognosis are: symptoms for less than one year, Carpal tunnel surgery can be done under local, locoregional or
no motor or sensory deficit. Otherwise, failure and recurrence general anesthesia. In distal anesthesia, tourniquet tolerance is
were observed. the main limiting factor. Regional median, ulnar and musculo-
cutaneous block is poorly tolerated compared to wrist block.
6.2.2. Night splint in neutral wrist position Local anesthesia infiltration into the carpal tunnel associated
The tendency to place the wrist in flexion during sleep with subcutaneous injection at the incision (Altissimi and
increasing the intracanalicular pressure has been implicated in Mancini technique [70]) gives more postoperative relief than
the occurrence of nocturnal symptoms. The position of the wrist the subcutaneous infiltration alone [71]. The tourniquet is
splint must be in strict neutral position to decrease this pressure. inflated after injection. Local anesthesia does not cover flexor
A splint can be tailored to coexisting pathologies (basal thumb tendon synovectomy. Local vasoconstriction by epinephrine in
osteoarthritis). Results are similar to those of corticosteroid the local anesthetic avoids use of a tourniquet.
injection [66]. Stutzmann and Foucher [67] found improvement For endoscopic surgery, distal median, ulnar and musculo-
in moderate CTS in 81% of cases at three years. The duration of cutaneous nerve blocks when done 6 cm proximal to the wrist
treatment is three weeks to three months and can be done while flexion crease, avoid soft tissue infiltration, which is a nuisance
awaiting surgery. The splint may be associated with an for endoscopy. According to Delaunay [72], after 10 min, 9%
injection. and 32% of patients required additional anesthesia to the
median and ulnar nerves respectively. No postoperative
6.2.3. Modification of mechanical and ergonomic measures neurological deficit was found. If used, local anesthesia should
Even temporary reduction of activity often provides relief, be injected 20 minutes prior to endoscopic surgery to avoid soft
especially in CTS after manual overuse. tissue infiltration.
Very few studies have analyzed the ergonomic measures.
No significant improvement in symptoms and ENMG findings 6.3.2. The open technique
was found with the use of ergonomic computer keyboards 6.3.2.1. Basic procedure. This is the oldest technique. An
compared with conventional keyboards in patients with proved incision 3 to 4 cm long from the wrist crease is made in the axis
CTS [68]. of the radial border of the ring finger (Fig. 11) down to the

Fig. 11. Surgical approaches for conventional open surgery (A) and distal mini-open (B).
Voies d’abord chirurgie à ciel ouvert classique (A) et mini-open distal (B).
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 87

cardinal line of Kaplan. The medial fat pad is retracted and later Various techniques have been proposed [77]: Z-plasty, VY,
repositioned [73] to separate the skin from the FR after surgery. zigzag incision with suture of the angles, radial border flap with
The palmar fascia is then either incised or retracted laterally. proximal pedicle or the Jakab plasty, preferred by Foucher [78]
Subcutaneous dissection to preserve the sensory branches may where the apices of a distal radially based flap and a proximal
create postoperative pain and has not been proven superior to a flap with ulnar pedicle are sutured, double breasting of the FR.
direct incision of the FR [74]. Hemostasis using bipolar Most of these interventions are not used and their superiority
coagulation is performed if needed. has not been proven (series with methodological bias). One
FR is exposed using retractors. The hook of the hamate is methodologically satisfactory publication of patients with
identified. FR is incised in its ulnar middle portion in the axis of bilateral CTS, where one side was operated conventionally and
the fourth finger thus providing an ulnar border to limit the other with FR prolongation, showed no difference [79].
subluxation of the flexor tendons. The section of FR is More recently, a silicone implant and polyethylene tereph-
cautiously continued distally, guided by the separation of the thalate sutured to the edges of the FR has been proposed; the
edges up to the fat that protects the superficial palmar arch and authors compared two groups of 400 patients, and found faster
the communicating branch of Berretini. Proximally, the FR is recovery of force in the implant group [80], with five implants
dissected from flexor synovium using scissors, and a grooved having had to be removed.
probe is introduced along the axis of the fourth finger and that of 6.3.2.2.3. Transfer of thumb opposition. In atrophic forms
the forearm to protect carpal tunnel contents. Superficially, the with deficit of opposition, the release of the median nerve is
FR and the distal forearm fascia are separated from the associated with opposition transfer. It is rarely indicated
subcutaneous tissue along the groove. The skin is retracted. because the FPB receives ulnar innervation, which provides
Dissecting scissors are pushed slightly open, under vision, sufficient opposition despite an obvious thenar atrophy. If the
guided by the groove to incise the remaining proximal portion opposition is weak, the palmaris longus, prolonged by a part of
of the FR and the adjacent part of the antebrachial fascia. the palmar fascia, can be used as transfer onto the APB using
Complete section is checked by pushing the probe up against the Camitz technique [81].
the skin while withdrawing it. The radial flap of the FR must be
carefully lifted with a hook to see the median nerve, which is 6.3.3. The ‘‘mini-open’’ technique
the most superficial and radial structure. The content of the These techniques employ incision in the safety zone
carpal tunnel is checked for muscle abnormality and aspect of regarding sensory branches of the median nerve and the ulnar
the synovium. The flexor tendons are retracted laterally to nerve. Various techniques have been proposed:
check the floor of the tunnel. Skin is closed without drainage,
unless necessary. Comfortable dressing is placed.  mini-open incision over the FR [82,83]: A 1 to 1.5 cm skin
incision is made at the distal part of the FR from the cardinal
6.3.2.2. Associated procedures line of Kaplan in the axis of the radial border of the ring finger
Flexor synovectomy is no longer systematic. A biopsy is (Fig. 11). The FR is then incised from distal to proximal using
justified if secondary synovitis is suspected. If extensive scissors under retraction. A series published in 2003 reported
synovectomy is needed, the incision is extended proximally to results that were no better than those with other techniques,
the distal forearm with a hook in the wrist flexion crease. with no reported complications [82];
Epineurotomy of the median nerve is no longer recom-  mini-open with a single incision in the wrist flexion crease:
mended even in cases with deficit. It can be a source of FR is not seen and the absence of interposition bears the risk
postoperative adhesions. A primary endoneurolysis is not of iatrogenic damage and/or the incomplete section of the FR.
recommended because of the risk of adhesions and devascu- Paine [84] uses a ‘‘retinaculotome’’ to protect the contents of
larization. the carpal tunnel. Durandeau uses a grooved probe, making
6.3.2.2.1. Exploration of the thenar branch. In primary this his preferred technique [85];
surgery this is justified only in extensive synovectomy, looking  mini-open with a double approach, with a distal incision to
for anatomical variations, or isolated or predominant motor protect the neurovascular elements: again, the FR is not seen
deficit where rare specific compression of this branch is during its section. These include the techniques of Chaise
suspected. [86] and Bowers cited by Beckenbaugh [87], with an
Guyon’s canal release in acroparesthesia of the 5th finger is additional proximal incision, a distal incision 1 cm down-
not recommended in the absence of clinical and ENMG proven stream of the hook of hamate using a retractor for protection.
ulnar nerve compression at the wrist. Sensory median-ulnar Lee and Strickland [88] use a special knife with transillumi-
branches may be implicated if there is no compression of the nation.
ulnar nerve at the elbow or proximal disease (cervical spine,
TOS, spinal cord). Carpal tunnel surgery gives relief of 6.3.4. Endoscopic carpal tunnel surgery
symptoms [75]; after open or endoscopic surgery, the pressure This surgery was introduced in Japan by Okutsu [89] and in
in the Guyon’s canal decreases by two-thirds [76]. the United States by Chow [90]. The Chow technique includes
6.3.2.2.2. Reconstruction of the FR. The objective is to two surgical incisions. Complications inherent to the distal
reduce the duration of postoperative loss of strength, the risk of approach have limited its use in favor of the single approach
subluxation of the finger flexor tendons and ‘‘pillar pain’’. Agee technique [91] (MicroAire), Centerline1 (Arthrex).
88 M. Chammas / Chirurgie de la main 33 (2014) 75–94

6.3.5. Postoperative
Whatever the technique, digital mobilization is possible
immediately postoperatively. The stitches are removed from the
15th day. Strength activities are reintroduced after three weeks
and fully resumed at 6 to 8 weeks. Some authors recommend a
postoperative splint for two or three weeks to decrease ‘‘pillar
pain’’ [92] and improve FR healing. On the other hand,
immobilization may promote postoperative epineural adhe-
sions and limit mobility of the median nerve at the wrist.
Contrary to Chaise [93], no superiority to splinting has been
demonstrated by Finsen [94] and Bury [95].

6.3.6. Results of carpal tunnel surgery

6.3.6.1. Good outcome. In most cases, the outcome is good
with disappearance of pain crises and nocturnal paresthesias
immediately postoperative (early stage of Lundborg). In case of
Fig. 12. Endoscopic surgery through a single incision (Agee technique). myelin sheath alterations (intermediate stage), intermittent
Chirurgie endoscopique à une voie d’abord (technique d’Agee). paresthesia may persist a few days during the period of repair of
the sheath. If there was a preoperative deficit (advanced stage),
Furthermore, placing the wrist in hyperextension in the Chow the discriminative sensitivity takes a few weeks to a few months
technique increases intraductal pressure, which can cause acute to recover depending on the severity, whereas pulp dysesthesia
intraoperative compression of the median nerve. Endoscopic with contact persists throughout this recovery period. Motor
techniques require a longer learning curve and meticulous and atrophy recovery is random and usually absent in elderly
technique compared to open surgery. patients.
Technique of Agee: most often under regional anesthesia, a During FR healing, pain and edema in the area facing the FR
1 cm incision is made 0.5 to 1 cm proximal to the wrist flexion section regresses over 4 to 8 weeks and force is recovered in two
crease on the ulnar side of the PL or the middle of the wrist or three months. The discomfort is even more marked when the
(Fig. 12). The subcutaneous dissection toggles between veins to patient performs manual forceful labor.
expose the forearm fascia using two skin hooks. Care is taken The time off work varies according to the type of activity and
not to breach the fascia so as not to injure the median nerve. the surgical technique. In 2001, Chaise [86] evaluated the time
Dissecting scissors are placed under the fascia and the proximal off work after carpal tunnel surgery using two incisions without
portion of the FR area. The scissors are spread and a distaly endoscopy and postoperative immobilization of 21 days. For
pedicled flap from the FR of rectangular shape is elevated. A non-employed, the average was 17 days, for those in the private
skin hook applied on this flap is used to facilitate exposure and sector 35 days, for public sector 56 days. For patients with sick
show that the approach is not in the Guyon’s canal. The deep leave, time off work was 32 days and for those diagnosed as
surface of FR is rasped to its ulnar half. Care must be taken to be occupational diseases 49 days. Manual workers had 29 days off
extrabursal. The protuberance of the hook of hamate is felt in if non-employed, 42 days for the private sector and 63 days for
the tunnel and the transverse striations of FR are identified. The the public sector.
distal edge of the FR is rasped. Increasing dilators are
introduced into the carpal tunnel. The disposable knife is 6.3.6.2. Prognostic factors. From an analysis of the literature,
mounted. Sterile anti-fog product can be placed on the Turner et al. [96] concluded that the worst results were observed
endoscope. The knife is lubricated on its deep surface to in case of:
facilitate its entry. During the slow progress under endoscopic
control, the knife is pressed against the deep surface of FR  diabetes mellitus including polyneuropathy and impaired
characterized by its striations – used to confirm good position. general condition;
Rasping should be repeated until there is no interposition. If  alcohol and tobacco;
viewing is not good or the introduction of instrument is  normal preoperative ENMG;
difficult, the procedure must be converted to open, and the  occupational disease;
patient must be informed of this possibility before the surgery.  thenar atrophy;
Forward progression stops when the distal adipose tissue is  multiple nerve compression;
visible. The FR section starts distally close to the adipose tissue.  length of symptoms.
When both edges of FR recede, the proximal FR flap is cut. The
knife is withdrawn and a retractor may be used to lift the fat that Age is not considered a poor prognostic factor but rather
invaginates between the edges of the FR, which must be associated with slow evolution.
parallel. The FR flap is resected. Wash out, and skin is closed
using suture or Steristrip1 without drainage. Comfortable 6.3.6.3. Comparing open, mini-open and endoscopic surger-
dressing is placed. y. Open or endoscopic surgery is widely used. The volume
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 89

favor of mini-open [106]. The risk of incomplete section of FR

is higher in the mini-open [109].
The choice of open, mini-open or endoscopic surgery
therefore depends on the choices and preferences of the surgeon
[110], the information of the patient, the type of CTS, its
etiology and availability of equipment.

6.3.7. Complications of surgical treatment of CTS

6.3.7.1. Minor complications
6.3.7.1.1. Neuropathic scar pain. The four nerve branches
involved in the innervation of the palm (palmar branch of the
median nerve, palmar branch of the ulnar nerve, nerve of Henle,
palmar transverse branches of the ulnar nerve) (Fig. 6) may be
adversely affected by the incision, resulting in scar pain or a
neuroma formation. This is not observed after endoscopic
surgery. For open surgery, even for the classic recommended
extension of the incision along the radial side of the 4th finger,
there is no zone of absolute safety, given the overlap of nerve
territories [12,111]. Ozcanli justifies the mini-open with a distal
incision between the superficial palmar arch and the distal
territory of the palmar branch of the median nerve, which
presents less risk of damage to the superficial nerve branches
[112]. However, it has not been demonstrated that the incision
for mini-open is free of such complications [82].
6.3.7.1.2. Pillar pain [92]. Postoperative pain in the
hypothenar eminence and thenar is the rule in the initial
phase. There is concomitant edema around the FR. Persistent
loss of strength is fortunately less common (1% to 36%)
Fig. 13. CT view of retraction of the edges of the FR after endoscopic carpal [92,113] and may occur regardless of the type of surgery
tunnel release.
[82,113]. It is related to pain on forced manual activities at the
Vue tomodensitométrique de l’augmentation de distance des berges du canal
carpien après chirurgie endoscopique. insertions of hypothenar and thenar muscles, the edges of FR
and/or at the piso-triquetral joint. Resolution of edema at the cut
FR coincides with relief of pillar pain. It has not been
increase in the carpal tunnel is noted regardless of the technique demonstrated that postoperative immobilization prevents this
used to cut the FR. After open surgery, an increase in volume of complication [94,95]. Treatment includes immobilization,
24.2  11.6% was noted with palmar displacement of contents reduced activities and symptomatic treatment or corticosteroid
3.5  1.9 mm [97]. After endoscopic surgery, increased cross- injection.
sectional area was measured at 33  15% [98] (Fig. 13). 6.3.7.1.3. Complex regional pain syndrome type 1. It is
Safety, efficacy, morbidity, cost, and time to return to less common because of progress in anesthetic and analgesic
preoperative activities were compared. The learning curve is techniques. The severest forms can be seen after contusion or
longer for endoscopic surgery. No difference was found acute intraoperative compression of the median nerve.
between the two techniques at one year postoperatively [99]. 6.3.7.1.4. Instability of ulnar flexor tendons through the cut
However, a number of studies have shown that endoscopic FR. This is manifested by a sharp pain in the ulnar tunnel
surgery allowed earlier functional recovery especially in the radiating to the forearm along the ulnar flexor tendons. A tab of
first three months [78,100–103]. Local pain was less noted after the RF may be left on the hook of the hamate to reduce the
endoscopy [104,105]. Eight of 14 studies showed a faster return frequency. Persistence is rare. It is exceptionally observed after
to work after endoscopy with a difference between 6 and 25 endoscopic surgery because of the size of the endoscope which
days [106]. However, this remains controversial, other studies leaves an ulnar edge of the FR. FR reconstruction theoretically
having shown no superiority for either technique [107]. avoids this and may be the treatment if confirmed on imaging.
Few studies compared endoscopy to mini-open surgery;
results were either identical or favored endoscopic surgery 6.3.7.2. Major complications
regarding postoperative pain [106]. To Wong [108], the These are rare but serious, and even more so since this
technique of Lee and Strickland [88] seems to be associated surgery is common and credited with very satisfactory results in
with less postoperative pain than the endoscopic technique of the minds of the general public. In a review of the literature
Chow. from 1966 to 2001 for open surgery and 1989–2001 for
Conventional and mini-open surgery also show very little endoscopic surgery Benson et al. [114] reported 0.49% serious
difference in results with occasional short-term differences in complications for open surgery and 0.19% for endoscopic
90 M. Chammas / Chirurgie de la main 33 (2014) 75–94

surgery. Prevention should be emphasized, particularly in thrombosis of a persistent median artery, the artery is excised
endoscopic or mini-open surgery. after release of an often bifid median nerve.
6.3.7.2.1. Nerve complications. Transient neurapraxia
may occur (1.45% after endoscopy and 0.5% after open), after 6.4.2. Subacute or chronic CTS
partial or total median or ulnar nerve section (0.14% for Medical treatment is the first line in early forms.
endoscopy and 0.11 for open) or their branches (0.03% for It is less effective in intermediate forms with nocturnal and
endoscopy and 0.39% for open) [114]. The common palmar diurnal acroparesthesia with risk of development of a deficit. It
digital nerve of the 3rd space and the cutaneous branches of the can be tried first or immediate surgical treatment can be offered
common palmar digital nerves of the 3rd and 4th spaces may be depending on the context.
affected especially in the double approach endoscopic surgery or Surgery is indicated for resistant forms and advanced forms
the mini-open. This cutaneous branch is between 2.3 and 10 mm with deficit.
from the distal edge of the FR [115]. In case of total or partial The contra-indications for endoscopic surgery include
nerve section, the results of surgical repair – which must be [118]:
early – are incomplete, sometimes with residual permanent
severe pain.  isolated motor form;
6.3.7.2.2. Injury to the superficial palmar arch. It is  acute CTS;
reported in 0.02% of cases [114]. The superficial palmar arch  hypertrophic synovial pathology requiring extensive syno-
is close to the distal edge of the FR. This may be associated with vectomy;
injury of communicating branch of Berretini or common  intracanalicular tumor;
palmar digital nerve of the 3rd space. The Cobb or the Kaplan  poor visibility;
method may be used for its identification (Fig. 7).  secondary surgery;
6.3.7.2.3. Section of the flexor tendons of the fingers. These  small wrist with deficit (risk of intraoperative compression).
have been reported only after endoscopic surgery (0.008%)
[114]. 6.5. Persistence of symptoms, recurrence or new symptoms

6.3.8. Information for patients In a recent analysis of the causes of secondary surgery for
Preoperative information is a legal necessity, even if it is not 200 cases operated over a period of 26 months, Stütz et al. [119]
well registered by the patient. This may be oral, but difficult to found incomplete section of FR in 54% of cases and perineural
verify, so the best is oral and a written form supplying fibrosis in 32% of cases (anterior scar adhesion in 23% and
information and informed consent and including even exceptio- circumferential fibrosis in 9%) and iatrogenic nerve injury in
nal complications. A summary of the key elements to include was 6% of cases.
proposed by Goubier in 2006 [116]. In the absence of a proximal cause, reoperation is indicated
Julliard [117], in his expert experience, noted that nearly in three clinical pictures with a frequency varying from 0.3 to
three quarters of trials were due to unmeditated, passionate or 12% [120] (Fig. 14):
inappropriate comments amongst colleagues or mismanage-
ment of a crisis situation with the patient. A quarter of  persistence of symptoms. This is the commonest complica-
procedures were barely justified by technical faults: section of tion after CTS surgery, mainly due to an incomplete section
the nerve, infection, unnecessary procedure. . . of FR, most often in the distal portion. The absence of a
symptom-free interval, the persistence of symptoms and
6.4. Therapeutic indications in CTS positive provocation tests are suggestive. ENMG abnormali-
ties may persist despite effective release. However, a normal
ENMG eliminates persistent compression. Open revision
6.4.1. Acute CTS surgery is justified without the need for modification of
median nerve surroundings;
6.4.1.1. Posttraumatic CTS. A progressive compression fol-  recurrence of symptoms. After a free interval of three months,
lowing contusion with symptoms at onset and little edema, is symptoms may recur due to a progressive entrapment after
not in principle surgical and must be distinguished. In case of FR scarring with fibrous perineural adhesions, causing a
compression without deficit the urgent, simple reduction is ‘‘traction neuropathy’’ (Hunter’s syndrome) [121]. Recur-
often enough to relieve symptoms, to be verified by a careful rence of symptoms and a positive clinical examination
clinical monitoring with limb elevation. In case of compression suggest a syndrome of epineural adhesions. Again ENMG
with deficit or significant edema without deficit, emergency may be faulty. Procedures to restore gliding between the
open surgery is necessary. Shorter operating time is associated median nerve and its surroundings are often required;
with faster recovery [37]. examples are synovial flap [122], hypothenar fat flap [123],
pedicle flaps [124], biomaterials [80] or anti-adhesions gel
6.4.1.2. Non-traumatic CTS. Urgent open surgical decom- [120];
pression is required, with an incision that may be extended to  appearance of new symptoms. These are mostly secondary to
the forearm, and treatment of etiology. In case of acute intraoperative iatrogenic lesions of the median nerve trunk,
 M. Chammas / Chirurgie de la main 33 (2014) 75–94 91

Abnormal symptoms aer carpal tunnel release

Symptom-free interval
No symptom-free interval

Proximal signs (++) or Postoperave adhesion with True recurrence

signs in other Local signs (++) epineural +/- interfascicular fibrosis -Inial recovery
nervousterritory aer abusive neurolysis -Posive provocaon tests
-Negave provocaon -Short free interval -Abnormal ENMG
tests -Provocaon tests +/-
-Negave ENMG -Pain and acroparesthesias while wrist
flexion-extension
-ENMG +/-

Persistence of
symptoms New symptoms
-Posive -New or impaired
provocaon neurologic deficit
tests -Symptoms of neuroma
-Posive -Provocaon tests +/-
ENMG -ENMG +/-

-Mulple crush syndrome Incomplete Operave lesion of median

-Diagnosc mistake: other secon of nerve or its branch(es)
neuropathy involving flexor (contusion, secon)
spinal, radicular or
renaculum
truncular structure

Fig. 14. Treatment algorithm in cases of recurrence, persistence, or appearance of new symptoms after carpal tunnel surgery.
Algorithme décisionnel dans les cas de récidive, persistance ou nouveaux symptômes après chirurgie du canal carpien.

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