Wiki source code of Moossy Carpal Tunnel Release

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1 = Anatomy =
2
3 The incision is linear, between the thenar and hypothenar eminences at about the level of the space between the 3rd and 4th fingers. The proximal end is at the wrist crease and it extends 4 cm distally.
4
5 [[image:1707519585861-623.png||height="307" width="268"]]
6
7 The recurrent branch of the median nerve innervates the thenar eminence. It branches off the lateral median nerve distal to the carpal tunnel.
8
9 [[image:https://cdn-images-1.medium.com/max/1200/1*vduy5PvLzE3P96QWfE5N4A.png||alt="Ganglion Cyst Pressure Motor Branch of the Median Nerve" height="269" width="203"]]
10
11 The transverse carpal ligament inserts on four carpals: on the ulnar side it inserts on the hamate distally and the pisiform proximally and on the radial side on the trapezium distally and the scaphoid proximally.
12
13 In addition to the median nerve, the carpal tunnel contains the eight tendons of the flexor digitorum profundus (4) and flexor digitorum superficialis (4) as well as the single tendon of flexor pollicis longus.
14
15 [[image:https://th.bing.com/th/id/R.29372fb97b9101fd39739afb932741e9?rik=nINRZiADDtTH%2fw&riu=http%3a%2f%2fepomedicine.com%2fwp-content%2fuploads%2f2014%2f05%2fcarpal-tunnel.png&ehk=jC%2bx1Phi9NPNEYLlPuwKpjNrW8TDZRGTfxaEe1gjYjk%3d&risl=&pid=ImgRaw&r=0||alt="Muscle connecting hip and leg exercises, very sore hips thyroid, flexor ..."]]
16
17 = Positioning =
18
19 Supine on a regular table, relevant arm extended at a 90-degree angle. Bed is turned such that the arm is away from anesthesia.
20
21 = Prep =
22
23 Prep before the patient goes to sleep. Ask the patient to raise their arm, then prep from the fingertips to the shoulder.
24
25 = Draping =
26
27 1. Unroll a stockinette over the hand and down the forearm and arm
28 1. Place a drape on the armboard followed by a blue towel nearest the patient's axilla
29 1. Ask the patient to let the arm rest on the arm board
30 1. Place another blue towel on top the shoulder
31 1. Secure the top blue towel to the one under the arm with towel clips above and below
32 1. Pass the arm through the arm-hole of the carpal tunnel drape and pass the "up" part to anesthesia
33
34 [[image:1707519163981-329.png||height="484" width="555"]][[image:1707519367833-125.png]]
35
36 [[image:1707519453911-181.png||height="391" width="554"]][[image:1707519475317-712.png||height="389" width="330"]]
37
38
39 = Medications =
40
41 Cut through the stockinette with scissors to expose the arm. Infiltrate the planned incision with lidocaine. Moossy does not like epi.
42
43 = Procedure =
44
45 The procedure is done sitting on a stool. Moossy prefers if you sit on the radial side (i.e. the side of the thumb).
46
47 Be sure to supinate the hand.
48
49 Make the skin incision with a 15 blade, going through the skin to the subcutaneous tissue.
50
51 Place a self-retaining retractor.
52
53 You will next encounter the palmar fascia, the insertion of the palmaris longus tendon. The fibers of the palmaris fascia are radially oriented from an origin point at the base of the palm. Continue to incise this with the 15 blade, along the same line as the skin incision.
54
55 Next, the transversely-oriented fibers of the transverse carpal ligament are encountered. Continue incision with the 15 blade until you are through it and can see the median nerve in the carpal tunnel.
56
57 Re-orient your body such that you are seated at the end of the arm board, furthest from the patient, with your line of sight going down the arm. Use the non-toothed end (i.e. not the rake) of a Sen retractor to retract the skin and soft tissue of the proximal corner of the incision (i.e. nearest the wrist). Pull up on the Sen retractor towards the ceiling. This both widens your view and causes the median nerve to pull deep, away from the flexor retinaculum.
58
59 Use Metzenbaum scissors. With the tips closed, dissect the space between the flexor retinaculum and median nerve. **Do not spread.** With small snips, open the flexor retinaculum towards the wrist. Pass a 4 Penfield into the carpal tunnel and attempt to pass it under the skin into the forearm. The proximal ligament is completely release when the tip of the 4 Penfield passes easily into the subcutaneous tissue of the forearm.
60
61 Reorient your body such that you are seated alongside the patient, in the axilla. Again use the blunt end of the Sen retractor to retract the skin and soft tissue directly upwards, towards the ceiling. Using the same technique, dissect the space between the flexor retinaculum and median nerve with the closed tips of the Metzenbaum scissors then carefully cut through the ligament. the distal decompression is complete when you see fat.
62
63 = Closure =
64
65 Do not close the flexor retinaculum. Use a single layer of 3-0 Nylon interrupted suture to close the skin and soft tissue.
66
67 Dressing:
68
69 1. Bacitracin ointment
70 1. Xeroform over the incision
71 1. "Fluffed" 4x4 gauze
72 1. Webril wrap
73 1. Ace bandage
74 1. "Swiss cheese" yellow foam arm support
75
76 [[image:https://www.deroyal.com/images/default-source/patient-care/foam-positioners/foam-positioners.png?sfvrsn=a0922b93_3||alt="Surgical Item" height="282" width="207"]]
77
78 = Postop =
79
80 Patients go home the same day. The bandage stays on for 3 days then can be removed and the patient can shower. Send home with two 5 mg tablets of oxycodone. Most pain can be controlled with Tylenol. Return to clinic in 2 weeks for a wound check.
81
82 = Dictation =
83
84 (% class="box infomessage" %)
85 (((
86 DATE OF SURGERY: ~*~**
87
88 SURGEON: Dr. ~*~**
89
90 ASSISTANT: Dr. ~*~**
91
92 PREOPERATIVE DIAGNOSIS: ~*~** symptomatic carpal tunnel syndrome
93
94 POSTOPERATIVE DIAGNOSIS: ~*~** symptomatic carpal tunnel syndrome
95
96 PROCEDURE PERFORMED:
97 ~1. Release, decompression and neuroplasty of ~*~** median nerve
98
99 CPT Coding:
100 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel
101
102 ANESTHESIA: Local with IV sedation
103 ESTIMATED BLOOD LOSS: 5 ccs
104 FINDINGS: Significant ~*~** median nerve compression under flexor retinaculum 
105 DRAINS: None
106 COMPLICATIONS: None.
107 DISPOSITION: stable to PACU
108
109 INDICATIONS FOR PROCEDURE
110 HISTORY: Patient is a ~*~** who presented with ~*~** 
111 DIAGNOSTIC STUDY: EMG demonstrated ~*~** 
112 SURGICAL RISKS: The patient was well apprised of all objectives, benefits,
113 risks, and potential complications of the procedure, including but not limited
114 to:
115
116 worsening of motor nerve paralysis as well as loss of sensory function in the 
117 noted distribution, the possible need for further procedures, the risk of 
118 infection, hemorrhage, sepsis, coma, and even death.
119
120 No assurance was given whether symptoms would improve following the procedure. 
121 Informed consent was obtained and secured in the chart after the patient voiced 
122 understanding of these risks and decided to proceed with the operation.
123
124 DESCRIPTION OF THE PROCEDURE
125 The patient was transferred to the operating room and was given preoperative
126 prophylactic IV antibiotics.
127
128 ANESTHESIA: The patient was given IV conscious sedation by the anesthesia 
129 service. A Bair Hugger was placed to maintain control of core body temperature. 
130
131 POSITIONING: The patient was positioned in the supine position with the right 
132 arm extended, resting on an arm board. All pressure points were carefully 
133 padded. The planned carpal tunnel incision was demarcated based on the wrist 
134 and volar crease in the right hand and the interspace between the third and 
135 fourth digits.
136
137 OPERATIVE TECHNIQUE:
138 The patient was prepped and draped in the standard sterile fashion.
139
140 A 4 cm straight incision was performed in the proximal palm after infiltration 
141 with local anesthetic. The incision was deepened down through the palmar fascia 
142 to the level of the flexor retinaculum. Subsequently, the distal flexor 
143 retinaculum was incised and the perineural fat exposed. Neuroplasty was carried 
144 out both proximally and distally, incising the entire flexor retinaculum to 
145 release the entire median nerve. The median nerve was preserved intact 
146 throughout the entire procedure. A blunt dissector was passed proximally and 
147 distally to ensure that the entire length of flexor retinaculum had been incised 
148 and the nerve decompressed. There were no other noted points of nerve 
149 compression.
150
151 The wound was irrigated with antibiotic saline solution until clear and 
152 hemostasis meticulously achieved. The flexor retinaculum was not reapproximated. 
153 The skin was closed with vertical mattress interrupted 3-0 nylon suture. The 
154 incision was dressed in a clean dry dressing.
155
156 All sponge counts, needle counts and instrument counts were correct at the end
157 of the case. The patient tolerated the procedure well, without any complications
158 and was transferred in stable condition to the recovery room. Dr. ~*~** was present
159 during the critical portions of the case.
160 )))