ONE mm incision | Carpal Tunnel Syndrome | Dubai | UAE
“Ultra-MIS refers to those procedures performed thru a ONE millimeter skin incision”
Rojo-Manaute JM, J Ultrasound Med. 2013
Dr. Jose M. Rojo-Manaute MD, PhD, is a European Board Certified Orthopedic Surgeon (FEBOT) and a European Board Certified Hand Surgeon (EDHS/FESSH). He has proudly served patients since 1996
Note about Dr. JM Rojo and about his personal relation with Carpal Tunnel Release procedures
Dr. JM Rojo required surgical carpal tunnel releases in both hands. On his left wrist was due to a traumatic accident (1999). On his right due to the most common cause of Carpal Tunnel Syndrome (unknown origin). After all nonoperative measures failed, he decided to undergo an operation of his right (2016). The left was operated with a large classic incision. For the right, he SELF-operated his wrist on March 2016 with the aid of Dr. Tyson Cobb (Iowa, USA) using his own technique, pioneered and published in 2013 (Rojo-Manaute JM, J Ultrasound Med, 2016).
These are Dr. JM Rojo’s views about the two procedures: “After having undergone both procedures, I will always suggest my patients with Carpal Tunnel Syndrome to undergo an Ultra MIS release when all conservative measures failed”. Dr JM Rojo’s postoperative experience as a patient has been summarized in some videos in this web page (see below)
What is carpal tunnel syndrome (CTS)?
The carpal tunnel is a narrow passageway located on the palm side of the wrist and bound by bones and fibrous tissue (ligaments and fascia). This tunnel protects a main nerve to the hand (median nerve) and nine tendons that flex the fingers. The median nerve controls palm side sensitivity from the thumb to the ring finger, as well as hand muscles that allow thumb opposition and provide an aid to finger flexion for the thumb, index and long fingers. Carpal tunnel syndrome (CTS) occurs when the median nerve becomes entrapped and pressed at the carpal tunnel. CTS is the most diagnosed entrapment neuropathy, in which the body’s peripheral nerves are affected1,2.
What conditions and diseases cause carpal tunnel syndrome?
For most patients, the cause of their Carpal tunnel syndrome is unknown. Other conditions that can lead to CTS include diabetes, pregnancy, thyroid disease, inflammatory arthritis, obesity, and trauma (acute or repetitive). More rarely, some conditions and diseases can also lead to compression of the median nerve (e.g.: amyloidosis, sarcoidosis, local tumors, alcoholism, etc..)1.
What are carpal tunnel syndrome symptoms and what is the natural history of this syndrome?
People with CTS initially feel numbness and tingling of the hand in the distribution of the median nerve. These sensations are often more pronounced at night and and may also be associated with different manual activities. Carpal tunnel syndrome may be a temporary condition that completely resolves or it can persist and progress. If the disease becomes chronic, patients can develop a burning sensation, cramping or weakness of the hand. Chronic CTS can also lead to wasting (atrophy) of the hand muscles, particularly those near the base of the thumb in the palm of the hand. Severe chronic Carpal tunnel syndrome symptoms can become partially or totally permanent even after surgical treatment, if not corrected early enough. This can lead to lack of dexterity of the affected fingers2.
How is carpal tunnel syndrome diagnosed?
At present, the best available evidence2 shows that the combination of clinical (symptoms referred by the Patient and physical examination performed by the Doctor) and electrophysiological findings is the best way to confirm the existence of Carpal tunnel syndrome for guiding its treatment.
What is the treatment for carpal tunnel syndrome?
The choice of treatment for CTS depends on the severity of the symptoms and any underlying disease that might be causing it. According to the latest recommendations of the American Academy of Orthopaedic Surgeons (AAOS)3:
- A course of nonoperative treatment (local steroid injection or splinting) is an option in CTS patients without evidence of advanced disease (median nerve denervation). When the current nonoperative treatment fails to resolve the symptoms within 2 to 7 weeks, another nonoperative treatment or surgery are both considered valid options. Oral steroids or ultrasounds are other alternative secondary treatment options. At present, the following nonoperative treatments carry no recommendation for or against their use: activity modifications, acupuncture, cognitive behavioral therapy, cold laser, diuretics, exercise, electric stimulation, fitness, Graston instrument, iontophoresis, laser, stretching, massage therapy, magnet therapy, manipulation, medications (including anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs), nutritional supplements, phonophoresis, smoking cessation, systemic steroid injection, therapeutic touch, vitamin B6 (pyridoxine), weight reduction and yoga.
- Early surgery should be considered as an initial option when there is clinical evidence of advanced disease or if the patient elects to proceed directly to surgical treatment.
- Surgical treatment of Carpal tunnel syndrome is recommend by complete division of the fibrous tissue at the carpal tunnel that originates a nerve compression, regardless of the specific surgical technique. Postoperative wrist immobilization is unnecessary.
What is the risk/benefit for carpal tunnel syndrome Surgery?
Surgery may be performed with three different techniques: Open, Endoscopic and Ultra-Minimally Invasive Surgery. Even though the final results of these techniques are similar (they all release the ligaments that compress the nerve), each technique has its own risks and benefits, which should be discussed with your surgeon before surgery.
During the healing process after the surgery, the fibrous tissues gradually grow back together while allowing more room for the nerve than existed before and, thus, ending the compression. Surgery risks may include incomplete release of the ligament, wound infections, scar formation, and nerve or vascular injuries. Soreness or weakness may take from several weeks to a few months to resolve after surgery. Most of the times, normal hand sensitivity returns to normal before the second postoperative day, however, some cases may take several weeks. If your symptoms were very severe before surgery, symptoms may not go away completely after surgery. Though it is uncommon, symptoms can recur.
What is there new for carpal tunnel syndrome surgery?: Ultra Minimally Invasive Surgery (Ultra-MIS).
The incision’s size for carpal tunnel release (CTR) has been described as classic (> 4 cm), limited (2 – 4 cm), mini (1.0 – 2 cm), percutaneous (0.4 – 0.6 cm) and ultra-minimally invasive, or “Ultra-MIS” (≤1 mm).
When comparing CTR techniques with different incision lengths, the smaller incisions show a faster return to work and better cosmetic results and lower pain rates (Figure 1). In this sense, endoscopic CTR has shown clinical superiority to classic open CTR, however, concerns persist over incomplete releases and complications to neurovascular structures and tendons. Mini-Open CTR has matched endoscopic CTR in clinical results and morbidity, nevertheless there is concern that part of the procedure is performed blindly4,5.
Figure 1. Relative incisión’s size for the different CTR techniques. Pct: percutaneous.
Recent anatomic findings suggest that a complete nerve release is possible by sectioning the deepest fibrous layer at the carpal tunnel without intruding into the more superficial palmar anatomy (skin and underlying tissues), which is rich in nerve fibers that may elicit local pain when surgically injured. Dr. Jose M. Rojo-Manaute (et al) 4-7 recently showed internationally that an ultrasound guided Ultra-MIS CTR can be safe and effectively restricted to the deepest fibrous layer of the carpal tunnel, preserving the superficial anatomy and showing significantly better results (when compared to Mini-Open CTR) in the average postoperative days of pain (2.24 versus 12.5) and time to functional recovery of the daily activities of our patients (5.5 times faster)6,7, without complications or recurrences during a one year follow-up (See videos below and Figure 2).
Carpal Tunnel Surgery Videos
DR JM ROJO’S SELF OPERATION
DR JM ROJO POSTOPERATIVE PHASES AND ADVISES FOR HIS PATIENTS
14 HOURS AFTER SURGERY
72 HOURS AFTER SURGERY
2 WEEKS AFTER SURGERY (LIST OF ADVISES)
Figure 2. Clinical post-operative aspect of the incision one week after the procedure for Ultra-MIS (≤1 mm) and Classic Open CTR (>4 cm).
Summary for our patients concerned about a possible Carpal Tunnel Syndrome
CTS is a frequent condition that occurs at the wrist due to nerve entrapment. It is felt as hand numbness and tingling. It may be temporary, persist or progress. Weakness and muscle wasting can occur in advanced cases. Severe untreated chronicity can lead to partial or total permanent symptoms, even after treatment. Patients with a diagnosed Carpal tunnel syndrome can be successfully treated nonsurgically (e.g.: night splinting) if there are no signs of an advanced disease. Surgery is an indicated treatment after 7 weeks of unsuccessful nonsurgical treatment or an advanced disease. The Ultra-MIS skin incision (≤1 mm) for CTR is up to 6 times smaller than the smallest known incisions. Experimental and clinical results have shown a functional and pain recovery 5 times faster than with mini open techniques.
1. Brunton MB, Chhabra AB. Hand, Upper Extremity and Microvascular Surgery. In: Miller MD, Thompson SP, Hart JA, eds. Review of Orthopaedics, 6th edition: Saunders, Elsevier; 2012:549-56.
2. Keith MW, Masear V, Chung K, et al. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg 2009;17:389-96.
3. AAOS. American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome. Summary of Recommendations. http://www.aaos.org/news/aaosnow/oct08/clinical3.asp. 2014.
4. Rojo-Manaute JM, Capa-Grasa A, Rodriguez-Maruri GE, Moran LM, Martinez MV, Martin JV. Ultra-minimally invasive sonographically guided carpal tunnel release: anatomic study of a new technique. J Ultrasound Med 2013;32:131-42.
5. Capa-Grasa A, Rojo-Manaute JM, Chana-Rodriguez F, Vaquero-Martín J. Ultra minimally invasive sonographically guided carpal tunnel release: An external pilot study. Orthop Traumatol Surg Res 2014 (in press). http://dx.doi.org/10.1016/j.otsr.2013.11.015.
6. Capa-Grasa A. Doctoral Thesis: Ultra-minimally invasive ultrasound guided carpal tunnel release: research, development and application of a new technique (Thesis Director: Rojo-Manaute, JM). Madrid: Universidad Complutense; 2013.
7. Rojo Manaute JM, Capa Grasa A, Chana-Rodriguez F, Perez-Mañanes R, Rodríguez Maruri G, Sanz-Ruiz P, Muñoz-Ledesma J, Aburto-Bernardo M, Esparragoza-Cabrera L, Del Cerro-Gutierrez M, Vaquero Martín J. Ultra Minimally Invasive ultrasound guided carpal tunnel reléase: a randomized clinical trial. J Ultrasound Med. 2016 Apr 22. pii: 15.07001.
FULL DETAILED DESCRIPTION OF THE TECHNIQUE CAN BE FOUND AT:
Rojo Manaute JM, Capa Grasa A, Chana Rodriguez F et al. Ultra-Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial. J Ultrasound Med. 2016 Apr 22.
Rojo Manaute JM, Capa Grasa A, Chana Rodriguez F, Perez Mananes R, Rodriguez Maruri G, Vaquero Martin J. Ultrasound Guided Carpal Tunnel Release. Award for the work: “Ultrasound Guided Carpal Tunnel Release: A new Ultra Minimally Invasive Technique”. American Association of Orthopaedic Surgeons, Annual Meeting, Orlando, USA. http://www.aaos.org/CustomTemplates/VideoGallery.aspx?id=4294967467&page=3
Rojo Manaute JM, Capa Grasa A, Chana Rodriguez F, Vaquero Martin J. Ultrasound Guided Carpal Tunnel Release. In: Atlas of Ultrasound-guided Musculoskeletal Injections. Ed: Malanga G, Mautner K. McGraw- Hill. New York. March, 2014; 186-198. ISBN: 0071769676, 9780071769679, 9780071772044
Capa-Grasa A, Rojo-Manaute JM, Chana-Rodriguez F, Vaquero-Martín J. Ultra minimally invasive sonographically guided carpal tunnel release: An external pilot study. Orthop Traumatol Surg Res. 2014 May;100(3):287-92.http://dx.doi.org/10.1016/j.otsr.2013.11.015.
Rojo Manaute JM, Capa Grasa A, Rodríguez Maruri G, Moran LM, Villanueva Martinez M, Vaquero Martín J. Ultra Minimally Invasive ultrasound guided carpal tunnel release. Anatomic MRI study of a new technique. J Ultrasound Med. 2013 Jan;32(1):131-42.
Capa-Grasa A. Doctoral Thesis: Ultra-minimally invasive ultrasound guided carpal tunnel release: research, development and application of a new technique (Thesis Director: Rojo-Manaute, JM). Madrid: Universidad Complutense; 2013