local anaesthesia in carpal tunnel release

8/4/2019 local anaesthesia in carpal tunnel release

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Somesh Beeharry Hopital Schweitzer France

Ultrasonic 3D visualisation of ulnar

nerve

at elbow :

Plea for focal decompression


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PROVOCATIVEIn a recent survey

44% of surgeons are not satisfied with results

After treatment of ulnar neuropathy at elbow

C.B. NOVAK and S.E. MACKINNON

HAND 2009


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PROVOCATIVEIn a recent survey ( JHS )

44% of surgeons are not satisfied with results

after treatment of ulnar neuropathy at elbow

R. Hoffmann JHS 2006 SZABO 1999 success rate :80%

A.C. Watts JHS 2009 55 Patients 19 endoscopic release : success rate 79%

15 open insitu release : success rate 60%

T.k. COBB Hand 2009 134 endoscopic release success rate 78%

of which recurrence 5 %


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CAUSES of

ULNAR NEUROPATHY

G.FILLIPOU

Clin Rhumatology

TREATMENT

154 hand surgeons

C.Novak S.Mackinnon

Hand 2009

B.Palmer T.Hugues

JHS 2009

CompressionSubluxation, Luxation, Osteophytes,Accessory muscle

Articular ganglion,Post-traumatic lesion

Insitu decompression

Open decompression

Endoscopic decompression

Transposition (intramuscular or submuscular)Epicondylectomie


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CAUSES of

ULNAR compression

TREATMENT

154 hand surgeons

C.Novak S.Mackinnon

Hand 2009

B.Palmer T.Hugues

JHS 2009

Compression

ArmStruthers arcade, anomalous anconeus

Elbow

Retrocondylar grooveOsborness ligament=Cubital tunnel retinaculum

Deep layer of FCU =Osbornes fascia

ForearmDeep layer of fascia FCU

Between bellies of

FCU and flexor digitorium profundis


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Site of

ULNAR compression

Ulnar nerve anatomy

D. Polatsch

Hand clinics 2007


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Site of

ULNAR compression

Ulnar nerve anatomy

D. Polatsch

Hand clinics 2007

Die Endoskopiche

Dekompression

C.Bultmann

R.Hoffmann

Operative orthopadie

2009


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Site of

ULNAR compression

Les lesions des gros

Troncs nerveux

DejerinePresse medicale

1915

Peripheral nerve

Fascicle

John D Stewart

Muscle and nerve2003

Internal topogropraphy

Of nerves

M. Jabaley

JHS

1979

Can we localise

siteof

compression ?


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Site of

ULNAR compression

Clinical exam


Troncs nerveuxDejerine

Presse medicale

1915

Peripheral nerve

Fascicle

John D StewartMuscle and nerve

2003


Of nerves

M. Jabaley

JHS1979


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Site of

ULNAR compression

Clinical exam



Presse medicale

1915

Peripheral nerve

Fascicle


2003


Of nerves

M. Jabaley

JHS1979


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Site of

ULNAR compression

Clinical exam



Presse medicale

1915

Peripheral nerve

Fascicle


2003


Of nerves

M. Jabaley

JHS1979


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Site of

ULNAR compression

Clinical exam



Presse medicale

1915

Peripheral nerve

Fascicle


2003


Of nerves

M. Jabaley

JHS1979

NOSelective damage of pedicle

Of five pedicles at elbow very

Often only 2 are damaged


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Site of

ULNAR compression

Clinical examNerve conduction

In CTS theVelocity

Is measuredPrecisely

In the tunnel

Example of CTS


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Site of

ULNAR compression

Clinical exam

Nerve conductionFor ulnar nerve

Velocity

Is measuredOn a long distance

We cannot knowPrecisely

Site ofcompression

Ulnar nerve


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyStatic

Fusiform swellingproximalto the compression(Nerve oedema )

Sometimesthinningat compression

CTS


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyStatic

CSA 21sq mm

CTS


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyStatic

Tunnel dimension

CTS


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyStatic

Ulnar nerve normal


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyStatic

Ulnar nerve normal


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyStatic

Ulnar nerve normal


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyStatic

Ulnar nerve normal


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyDynamic

Ulnar nerve normal


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Site of

ULNAR compression

Clinical exam

Nerve conduction

SonographyDynamic

Ulnar nerve normal


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Site of

ULNAR compression

Clinical exam

Nerve conduction

Sonography3D

Ulnar nerve normal


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Our Study

Compare :

Sonographic aspects of nerve

Operative foundings

Our studycompare


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Sonography

High frequency (5-16 MHz)

Patient supineElbow flexed 90Transverse section (1/2 cm)

+longitunidal ? Not used hereComputerised 3D recontruction

Our studyCompare

Sonographic aspect


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Sonography

High

Pe

Tr

+

Our studyCompare

Sonographic aspect


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Operative findings

Open at the groove

Endoscopic at forearm (15 cm)Patient supineElbow flexed 90

Dimension of nerveAspects

Our studyCompare

Sonographic aspect

Operative findings


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Operative findingsOur studyCompareSonographic aspect

Operative findings


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Case no 1

Oedema of nerveCompression at

Osbornes ligament

ARM Elbow nerve oedema

Osbornes lig Forearm


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Case no 1


Osbornes fascia

ARM

Elbow nerve oedema

Osbornes fascia

Forearm


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Case no 1


Osbornes ligament

ARM


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Case no 2

Hourglassconstriction


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Case no 2

Hourglassconstriction


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Case no 3

Compression

In the Groove


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Case no 3

Compression

In the Groove


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Reporting

10 cases

HUS found the site of compression in all cases

Strongly correlated with operative findings


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Reporting

10 cases

Six cases compression was in the groove

Four cases compression was distal :Under Osbornes ligamentOr under aponevrosis of FCU


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Reporting

10 cases

Six cases compression was in the groove

Four cases compression was distal :

Under Osbornes fascia

Or under aponevrosis of FCU

No evidence of compression elsewherealthough bands are seen in forearm


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Reporting

10 cases

No evidence of compression elsewherealthough bands are seen in forearm


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Reporting last

Recent caseYoung man

Recurrent symptoms5 years after open decompression

NCS positive

Treatment options ?


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Reporting last case

HUS

Evidence of

Compression

At

End of Tunnel


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Reporting last case

HUS

Evidence of

Compression

At

End of Tunnel


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Reporting last case

HUS

Evidence of

Compression

At

End of Tunnel


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Conclusions

Should we rely on sonography ?

In CTS we do

Should we limit our decompresion ?

open question

Thank you

local anaesthesia in carpal tunnel release

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