Open Carpal Tunnel Release Technique

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain.

• Assessing the learning curve for percutaneous ultrasound-guided release in carpal tunnel syndrome
• Prospective, Randomized, Intra-subject Controlled Trial Comparing Ultrasound-guided Thread and Mini-open Carpal Tunnel Release
• Reoperation Rates and Short-Term Complications Following Endoscopic vs. Open Carpal Tunnel Release: A Longitudinal Analysis
• Differences in the Incidence of Amyloid Deposition in Biopsies Performed During Bilateral Carpal Tunnel Release
• Long-term patient-centered outcomes following carpal tunnel release surgery: a 10-year follow-up
• The Role of Palmar Cutaneous Branch Release in Enhancing Surgical Outcomes for Severe Carpal Tunnel Syndrome
• The Association Between Bariatric Surgery and Surgical Outcomes Following Open Carpal Tunnel Release
• Endoscopic Carpal Tunnel Release after Prior Distal Radius Fixation: Clinical Outcomes and Intraoperative Findings

The patient is typically placed in the supine position with the following considerations:

Arm position: The affected arm is abducted on an arm board at approximately 70–90°, with the hand supinated (palm facing up).

Tourniquet (optional): A pneumatic tourniquet is applied to the upper arm (or sometimes forearm), inflated just before the incision to provide a bloodless field.

Hand table: A hand table or arm board is used for proper support and access.

Padding: Bony prominences (elbow, shoulder) are well-padded to prevent nerve compression or pressure injuries.

Lidocaine for Carpal Tunnel Release.

Skin incision: 2–5 cm longitudinal incision over the volar wrist, aligned with the radial border of the ring finger.

Location: Along the longitudinal axis of the ring finger, starting just distal to the wrist crease and extending distally toward the proximal palmar crease.

Length: Typically 3–5 cm, adjusted based on patient anatomy and exposure needs.

Orientation: Slightly ulnar to the palmaris longus tendon, avoiding the palmar cutaneous branch of the median nerve.

Landmarks:

Proximally: Distal wrist flexion crease

Distally: Kaplan cardinal line (imaginary line from the apex of the 1st web space to the hook of the hamate), staying radial to it

Dissection: Carried carefully through the subcutaneous tissue and palmar fascia to identify and incise the transverse carpal ligament (TCL).

Avoid injury to:

Palmar cutaneous branch of the median nerve

Superficial palmar arch

Recurrent motor branch (usually thenar and extraligamentous)

• Dissection: Through subcutaneous tissue, preserving the palmar cutaneous branch of the median nerve.
• Identification of Flexor Retinaculum: Incise the transverse carpal ligament (flexor retinaculum) from distal to proximal.
• Inspection: Carefully visualize and decompress the median nerve; release fibrous bands or hypertrophic synovium if present.
• Hemostasis: Meticulous.
• Closure: Skin sutures only; subcutaneous tissue may be left open to reduce tension.

Advantages:

• Direct visualization of structures.
• Safer in complex or recurrent cases.

Disadvantages:

• Larger incision.
• Longer recovery.
• Potential for postoperative “pillar pain”.