Most Successful Surgery for Carpal Tunnel Syndrome
Classic open surgery for carpal tunnel syndrome (CTS) comes with a list of possible complications. The incision can become scarred down and very sensitive. A cut is made across the wrist crease and through the interthenar fascia. This fascia is a band of connective tissue between the muscle of the thumb and the muscle on the other (little finger) side of the palm. Cutting through this tissue contributes to hand weakness.

Surgeons have worked hard to develop less invasive surgical techniques. Now, a tiny incision can be made and an endoscope can be slipped under the skin into the carpal tunnel. The transverse or carpal tunnel ligament can be released without damaging the other nearby soft tissues.

Problems can still occur even with the endoscopic approach. The median nerve (or one of its tiny branches) just under the ligament can be nicked by mistake. In some people, the ulnar nerve (which also goes through the carpal tunnel) is closer to the median nerve than expected. It can be unkowingly damaged during the procedure.

Studies on cadavers (bodies preserved after death for study) show a 50 per cent rate of incomplete ligament transection with endoscopy. Without an open incision and clear visualization of the ligament, it isn't always easy to tell if the ligament has been completely cut through. Using the endoscope takes time and practice. Some surgeons consider this a major drawback of the technique.

In the last 10 years, a new method has been developed for the surgical treatment of carpal tunnel syndrome. The Indiana Tome Technique combines the benefits of open incision and endoscopic (minimally invasive) approaches. It allows a partial direct view with decreased tissue trauma.

First, a tiny incision along the palm is made to gain access to the transverse carpal ligament. Then, a special tool called a cutting tome is inserted. It looks like the flat prongs of a front-end loader. It can be pushed deep enough into the carpal tunnel to allow the surgeon to completely cut the transverse carpal ligament without damaging the median nerve and nearby tendons.

Results of previous studies using this system report a 92 per cent success rate. Success was measured by complete pain relief or only minimal residual symptoms after surgery. Other measures used to measure success included grip, key, and three-point pinch strength. The results for these variables with the Indiana Tome technique was similar to open incision surgery.

In this study, the charts of 1,332 carpal tunnel patients were reviewed after surgery was done. Carpal tunnel releases using the Indiana Tome system were done by two fellowship-trained hand surgeons. The researchers were particularly interested in complications and complication rate using this method. They also kept track of the time it took for patients to get back to work or to a preoperative level of function and activities.

There were very few complications (less than one per cent) with this technique. Everyone went back to their preoperative work status quickly. The few patients with numbness or hypersensitivity recovered over time. In two cases, the patients' ability to feel two points of pressure (called two-point discrimination) was decreased permanently.

The authors conclude that the Indiana Tome technique is safe, reliable, and effective. It must used by an experienced hand surgeon specifically trained to use this tool. In-depth knowledge of the anatomy is a must. In the hands of such an expert, there is less soft tissue damage when compared with the open method.

There is no need for extra equipment and set-up of the endoscopic equipment. If the need arises to switch to an open approach, it can be done easily. This doesn't happen very often, which is another advantage of the system.
W. P. Andrew Lee, MD, et al. 13-Year Experience of Carpal Tunnel Release Using the Indiana Tome Technique. In The Journal of Hand Surgery. September 2008. Vol. 33A. No. 7. Pp. 1052-1056.