Why mess with a good thing? Diagnosis and treatment of carpal tunnel syndrome

Season 4, Episode 1.  In our inaugural episode for season 1, Chuck and Chris welcome Amy Moore and Dominic Power to discuss nerve!  Specifically, in this journal club format we review 4 recent JHS European articles as a format to discuss current concepts in diagnosis and treatment of carpal tunnel syndrome.  Amy and Dom share their extensive experience and insights in this collaborative effort between The Upper Hand Podcast, Journal of Hand Surgery European, the British Society for Surgery of the Hand, and FESSH.  Enjoy!

Carita, et al High- resolution ultrasound in the diagnosis of failed carpal tunnel decompression: a study of 35 cases.  JHS Eur 47:364-68, 2022

Mackenzie, et al.  Carpal tunnel decompression in patients with normal nerve conduction studies.  JHS Eur 45: 260-4, 2020

Asserson, et al.  Return to work following ultrasound guided thread carpal tunnel release versus open carpal tunnel release: a comparative study.  JHS Eur 47: 359-63, 2022

Ratasvuori, et al.  Ultrasonography for the diagnosis of carpal tunnel syndrome: correlation of clinical symptoms, cross- sectional areas and electroneuromyography.  JHS Eur 47: 369-74, 2022


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Transcript

Charles Goldfarb: 0:03

Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.

Chris Dy: 0:07

We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.

Charles Goldfarb: 0:15

Please subscribe, wherever you get your podcasts.

Chris Dy: 0:18

And thank you in advance for leaving a review and leaving a rating wherever you get your podcast.

Charles Goldfarb: 0:24

Oh, hey, Chris.

Chris Dy: 0:25

Hey, Chuck, how are you?

Charles Goldfarb: 0:27

I'm really, really well, and I'm super excited.

Chris Dy: 0:30

I'm excited to it's a big episode for us starting a new venture with with some friends over in in Europe,

Charles Goldfarb: 0:36

we are hosting a first collaboration between the upper hand podcast, the BSSH, the Journal of Hand Surgery European, and FESSH to talk about your favorite thing.

Chris Dy: 0:50

Well, I think we're going to talk about my favorite thing, but we're not necessarily doing the partnership for our favorite thing unless you want to. We can talk all about nerve with our European colleagues for many, many episodes, if you would like

Charles Goldfarb: 1:01

No, thank you. Good. Good point. I do not only want to talk about nerve, but I have humored everyone, and we're gonna get through this nerve podcast.

Chris Dy: 1:09

Fantastic. Well, we did already did our multi part series on radial nerve palsy treatments. So we're dragging you back in. But this is a little bit more of a bread and butter topic. So to say we're going to talk about carpal tunnel syndrome. Do we need to change how we do things? Or should we stick with the tried and true but why don't we first introduce our guests?

Charles Goldfarb: 1:26

That would be great. I would love to introduce Amy, Amy Moore, who I'm sure all of our listeners have learned from previously. Amy is a long term friend who I've known for 15 years, maybe, given her first stage in her career at Washington University in the plastic surgery division. And now as chair of Plastic Surgery at The Ohio State University. Amy, welcome.

Amy Moore: 1:52

Hey, thank you so much. It's great to be here. And love being here with your friends you guys are always makes me smile and laugh. So this will be fun.

Chris Dy: 2:00

Indeed, it will be fun. And our other guests is Dominic Power from the United Kingdom. So it's morning here in the US. And it's afternoon in the UK. So thank you for joining us. Dom has a hand in peripheral nerve and brachial plexus surgeon in Birmingham in the UK. He's incredibly well known and funded throughout funded for his research and well known throughout the UK and internationally. And it's he is on the board of directors for the global nerve Foundation, which I have started to work with. And I've enjoyed learning from them and excited to see him I think I'll be over there in February as well. So, Dom, welcome to the podcast.

Dominic Power: 2:35

Great, thanks very much. It's nice to see you all. And it's great to be talking about nerve again. It's a great thing that you're doing with this podcasts. And I've watched watch with interest. So it's really nice to be able to take part finally.

Chris Dy: 2:46

So super excited, we picked out some articles, which will be listed in the show notes from the European volume of the journal hand surgery. And the topic really centers on carpal tunnel syndrome and what we could potentially do to maybe improve our diagnostics maybe improve our treatment and our outcomes, and then how to how to deal with the patient who has recurrence potentially as symptoms. So why don't we jump into the first article, the first article that I wanted to talk about really revolves around the diagnostic dilemma, you know, perhaps the patients who have electric diagnostically negative studies, but end up having a positive ultrasound, how often do you see that in your practice? Amy?

Amy Moore: 3:29

Yeah, I mean, nowadays, I'm going to just give my disclosures that I'm seeing more revision surgery then versus primary. But I have the more of the professionals who come like our neurosurgery residents or, you know, others that are younger but have the symptoms of carpal tunnel syndrome, but they do not have electrical evidence yet. And so that is where we sit and like, no, it's come in. So I think it's a small portion of my clinical practice now. It is ones with maybe a little more high intensity of just wanting to do the right thing. So this is really great for me.

Charles Goldfarb: 4:08

Yeah, and, Dom maybe a brief overview on your patient population that may be clinically positive and electro diagnostically negative.

Dominic Power: 4:17

Very similar to Amy. Most of my patients tend to be the problem diagnosis or previous failed surgery, unfortunately, that they're great. They're they're an interesting challenge, but I don't tend to see so many of those early stage carpal tunnels, just a word that probably we should throw out there is that negative neurophysiology with classic symptoms that can be other diagnoses, explaining what's going on. So it's always really important to do a thorough overview and look for some of those other causes before we make a diagnosis of neurophysiology negative carpal tunnel.

Charles Goldfarb: 4:51

And maybe for sorry, Chris, and maybe for our younger listeners, or for people like me who don't live and breathe they're what are Some of those other diagnoses that you immediately think of with a negative carpal tunnel nerve

Chris Dy: 5:06

I mean, for me, you know, what I think about first study. thing I don't want to miss is something that is not peripheral nerve related, you know, so a competing neurologic diagnosis that is central. But then I think about the cervical spine I think about cubital tunnel syndrome, I think about TOS. And I think all those things you can get a reasonable sense of based on based on clinical exam in history. You know, I've you know, we'll talk about this I have found ultrasound very helpful in this kind of gray area patient but you know, too many of us and, and we've seen clinical practice guidelines have all evolved this way. This is a clinical diagnosis more than anything else. And we know that that are in Chief of the American Journal. Brent Graham has done a lot of work in terms of developing scoring systems like the CTS six that are very helpful. And you know, in this article from from Jane McEachan group in the UK, I thought it was a little disappointing. They didn't implement the the CTS six as part of their gold standard in terms of, you know, scoring for clinically relevant carpal tunnel syndrome. But perhaps it's just not part of their practice and Edinburg.

Amy Moore: 6:12

Yeah, my only thought also was that, you know, they're, it's a great, it's a great city, because they have so many patients, and they had so much follow up. So that that always is impactful, which I think is adding to it. But it also like I think like if it's less than 50, and their their criteria was, you know, greater than 42. So to the Vaci. So I think it was sort of their diagnostic was also including more people on their NCS than maybe I would have so who knows what that means. And not all of them got injections with steroids, which I thought was also an interesting between the groups to know. Okay, well, am I going to inject with a steroid to see if that's going to help? And I think that didn't bear out from that study?

Charles Goldfarb: 6:55

Yeah, that's exactly my follow up question. So maybe Dom, I'll start with you. In this in this patient where there's no obvious other diagnosis, you do believe the patient likely has carpal tunnel, but the nerve studies are negative. What is the role of a diagnostic corticosteroid or therapeutic work with steroid injection for you?

Dominic Power: 7:13

I use I use carpal tunnel injections quite widely for diagnosis, see if we can alleviate symptoms. Also, in its very early stage, I look at exacerbating factors, I look at risk splintage, I'll look at as we said, already looking at those other potential causes. And I see this group of patients as well that develop symptoms coming on during the day rather than at night, with some sort of inflammatory component and maybe some tea and synovitis, perhaps associated with tendon adhesions or tendon anomalies around the wrist, particularly, patients using lots of keyboards or using lots of works workstation. So yes, steroid injections are helpful for me, because if you get a good response to surgery and then a relapse, then I think they're the sort of patient that I would then offer surgery to

Charles Goldfarb: 7:59

Amy, a similar approach and similar similar perspective.?

Amy Moore: 8:02

Yeah, so I don't I don't know what to take from the steroid injection. So I maybe that's, I haven't implemented it into my practice. I'm just going to be completely honest, sometimes I will, when I don't really know. And it's a patient that I'm, you know, I have worked up through like therapy like I honestly a lot of patients who have muscle imbalance up near their neck, and that sort of comes down to where they're working and how they work and how they sleep. And so when they're negative on their electrodiagnostic, then is that steroid going to tell me if I think I've narrowed out everything else. So I do use it but it's not as clear cut as it sounds like for Dom. Chris do you use it?

Chris Dy: 8:47

I found myself using injections less for diagnostics, and more for as a temporizing treatment. And I counseled patients as such that it is likely not a cure, although I think we are biased as surgeons to think that the only cure is surgery, if they fail if they fail splinting, you know, but instead, I think there's a lot of literature in the non surgical journals showing that injection can be a cure. But I think the most recent article that we read Chuck, in one of our you know, hands service journal clubs, said that 85% of people who had a carpal tunnel injection still had surgery within a year in that study. So and that was the European study. You know, so for me, I use that number now. But I, in the diagnostic dilemma case, I've leaned more into ultrasound and I found it incredibly helpful. In my practice, just kind of point of care ultrasound that I do quickly just to measure the diameter nerve. Has Dom or Amy, do you use ultrasound? No, Chuck doesn't because he he's just moving too fast can't get access to the machine.

Amy Moore: 9:49

You guys have high volume down. What do you think? Do you use it?

Dominic Power: 9:52

I haven't really started using it widely. I've got a point of care ultrasound that are using clinic for looking at other things, tumors and lumps and so on, but I'm Not the most skilled ultrasonographer. And I think the more you do more adaptive become and the more it becomes just part of your diagnostic tool in your clinical examination. And I think that's where I'm moving towards. Our access to formal radiology for ultrasound is so delayed and so difficult that I haven't found a need for it in my normal practice, but I was really interested in the papers showing, showing how it's being thought of now is a really reliable tool for adding where there's uncertainty, to try and help with that diagnosis and perhaps as a screening tool in the future. So yeah, I think my practice will continue to evolve. And it'll take more active role, but not, it's not universal in my practice at the moment.

Amy Moore: 10:45

Yeah, I love ultrasound, I have a great team, like our neurologist, as both the NCS and then also the ultrasound, I don't personally do it, although we've just priced out to get a machine in the clinic. I'm excited to use it because now I'm having to wait so long to get my patients into the physiatrist and, or the neurologist and not that they don't want to help me, but I want to start doing more injections with it. And so I think it's going to be a higher role in my practice. But I definitely this is the patients that I'll send for electrical diagnostics, study and ultrasound, and I find it to be helpful. Ideally, I would get them out of the not doing the NCS because it hurts patients, patients hate it, you know, I'm doing this clinical trial now trying to, you know, prove that nerve stimulation helps in the compression and getting them to come back patients to come back for you know, diagnostics afterwards. It's hard, it's hard to convince them to just do it, because we want to study it. And so it's got it's not our primary outcome,

Chris Dy: 11:52

Don't, tell me that, Amy, we're about to enroll in your study.

Amy Moore: 11:55

Okay, well, you convinced them that you're much more charming than I am, Chris. So

Chris Dy: 11:59

I find that incredibly...

Amy Moore: 12:02

will tell you, it's so that's the hardest part, but we'll get the pinch and grip because that's going to be it for us.

Charles Goldfarb: 12:08

Super interesting. And I as Chris said, I don't personally use ultrasound, but I do have the benefit of dietary partners who will perform a nerve studies and often get ultrasound, I do think it's helpful. And I there is no doubt that the landscape is changing in front of our eyes. Regarding the role of ultrasound, I do want to, you know, maybe as we pivot to a different article, this is an interesting study to me, because I think it's a study that is really hard, it will for me at least I could not draw my own personal conclusions, as this article demonstrates. So for those who haven't read the article that are listening, this article basically demonstrated that one can improve and may be expected to improve after carpal tunnel release with negative electrode diagnostics, but to a lesser degree, compared to those who are positive on the electro diagnostics. So I haven't experienced that, in my practice, maybe you three more experience neurosurgeons have but it's a really interesting finding. It does help potentially with patient counseling.

Chris Dy: 13:07

I'm a less experienced surgeon than you Chuck. But I have found this to be true, I think there is a sweet spot on carpal tunnel. And the patients who who come in with electro diagnostically negative but have CTS, six positive carpal tunnel syndrome, they respond, they're just not the homerun when you get into that sweet spot of the patient who has early electrodiagnostic findings, but no signs of innovation, no advanced clinical findings that is a harder patient to make better. So Don might cut you off. But I mean, this has been my experience.

Dominic Power: 13:38

No, obviously I agree with everything you said, I think I think the sweet spot is that patients with more advanced carpal tunnel. Certainly in the UK, I'm interested in Jeremy Bland's work with just seven grades of carpal tunnel, those patients with three, four and five are more likely to get a positive response from those very early stage zero and ones. Now that may be that their symptom profile is different. There's less reversible compression, but it's also creeping into that subset of the patients with negative neurophysiology that may have another diagnosis has been missed, of course. And so this is big data on seven or 8000 cases. And similarly at the other other end, those patients with the most severe neurophysiology are less likely to get a favorable outcome because they're nervous shots. So I think we have to be clear about what this paper is actually saying is still saying you can offer carpal tunnel surgery to patients with negative diagnostic test tests, and there's a reasonable chance of getting a good outcome. But I think I would go back and question the diagnosis. Always look for that other diagnosis first. And then obviously it helps with counseling the patient in terms of defining the outcome for that particular patient. It can sort of guide really, that's my take on it.

Amy Moore: 14:49

And I totally agree. I had a really strong fellow Jana Dangler, who wrote a paper on mimickers of carpal tunnel. And all I can tell you is that it There's the scary things that you don't want to miss. And it's those who come in early with the numbness and tingling. So but but for the most part, you know, they're there. It's just that they're earlier. I think patients set and setting expectations is key. And I agree with you, Chuck, that this is probably what we can use to help them that yes, you have this early, but you may not have a slam dunk, but I think patients who come in and they finally have waited a long time to get to see the surgeon, they're ready for intervention, because the most of the time they've already been splinted and or have their therapy fail.

Chris Dy: 15:35

So let's move. I mean, I love those points. And I think that leads us to our next article. So say they've come in and they've been splinted. They've failed splinting. And then they've come in and they were tortured by somebody else and got electrodiagnostic not by Dr. Moore. But those have come back those will come back as electrophysiologically Normal. What do you do at that point? Are you going to do the we talked about the potential role of injection? say they don't want to be stuck with another needle? Do you talk with them about surgery at that point, or do like the article? The next article is Ratasvouri? And you know, the ultrasonography for the diagnosis of carpal tunnel syndrome. And this is out of Helsinki. Do you use the ultrasound at that point? Do you just say, You know what, I think you've got carpal tunnel, let's move forward with talking about surgery. Do you think the ultrasound has value that point? So Dom? You say it's hard for you to send people because of the waiting lists? Are you going to send it for an ultrasound? Are you going to move forward with surgery, which also might have a long waiting list?

Dominic Power: 16:35

As I said before, I'd look for other diagnoses always continue to have a bit of unconvinced as carpal tunnel with positive provocation tests clinically, I'd go for either a diagnostic injection if the if the symptom profile is mild trial of splintage. And if there's a relapse, and as you alluded to earlier, there always is relapse with a steroid injection, then offer them surgery. And I just do a standard open. Certainly.

Chris Dy: 16:59

So no, no sending it for ultrasound. So Amy, would you send them for an ultrasound or when you get your fancy new machine?

Amy Moore: 17:05

I think I would just offer the surgery. I'm not afraid of the surgery, people do really well after carpal tunnel release. And so I think that's where I stand on it is that I don't I don't go and try to find all i Yes, I'm with Dom, I will look for everything else. But in the end, I'm not afraid to operate. And I'm not afraid for our patients. I think patients do really well with this operation. I think that we have to be mindful that all surgery has risk. But for the most part like I'm not going to keep sending for more expensive diagnostic test is to offer them surgery.

Charles Goldfarb: 17:39

It is I'm struggling with this currently in the United States, we have a perhaps a more challenging group of patients that is the injured worker. And I don't know Dom If if that is a problem group for you in the UK. And in the United States, there's such a legal involvement in everything that it really is helpful to have a firm tool for diagnosis. And so the concept of taking an injured worker with electro negative testing to the operating room is still something we can do. But then if the result isn't as expected, it's a problem. More problem in a worker than a non worker, or someone treated under our workers compensation system, I should say. So Dom, how do you think about that in the UK? And is that population, like as like I was alluding to challenging?

Dominic Power: 18:29

Yeah, we don't have a formal Worker's Compensation Scheme. But many patients obviously will have work issues or work concerns or the worry that perhaps onset of the symptoms is triggered by their work environment, I just treat the patient as is, you know, make a diagnosis and then go and pursue that. Obviously, when you're unraveling something either failed carpal tunnel or a patient who's got a medical legal case, positive tests and negative tests are useful in terms of trying to explain and and describe their condition and find causes for it. But I it doesn't really tend to reflect our practice anyway or steer us either way. I think there's enough confidence that you as a clinician will make the diagnosis and pursue it and we're not looking for a funder to necessarily agree or not agree to pay for the care based on absence of positive tests. Having said that, a few years ago, part of the squeeze in the NHS and UK carpal tunnel, the whole of carpal tunnel was described as a procedure of limited clinical value. And therefore there was a sort of moratorium on referring patients. We did a quick audit and we showed that we met all the criteria on cases we operated surgery. So you know, they had to have had sustained symptoms more than three months neurophysiological proven tests or with negative response to steroids. So it didn't actually change or change our practice apart from the headline that that the funders weren't going to pay for it because they didn't think it was beneficial to patients. But in actual fact, if you look at the quality of life years for some cancer therapy versus carpal tunnel, carpal tunnel winds. So, you know, it depends how you look at it, but it doesn't doesn't steer my practice.

Chris Dy: 20:08

I remember that sensational period of time in which the British society was responding. It was a, it was great to see everybody mobilized so quickly and demonstrate what we do has a lot of value. To

Dominic Power: 20:19

me, sometimes I'm sometimes like Brexit doesn't always

Chris Dy: 20:27

So this, this, this article was interesting in that, you know, I think that as somebody who's learning the ropes with ultrasound myself, you know, it's interesting that they found that the best sensitivity specificity for the diagnosis of ultrasound was using a cut off of 11.5 millimeter square for the cross sectional area, because most of us will use either 10 or 11. And then they just measure it based on where it's the largest at the entry to the carpal tunnel. So there's a little bit of a fudge factor and bias in there, because you can make it look bigger based on how you tilt the probe and with the move approximately, or distally. You know, so there's something there that I think that leads us to maybe perhaps measure, you know, leads us towards measuring a larger nerve than perhaps what really is. And then I think there's also some people are just bigger, some people are smaller, and using a number, without any sort of control, I think has its issues. But I find it to be helpful. I think it's starting to supplant the diagnostic injection for me, as we discussed before. So, in terms of treatment, you mentioned, Amy, that you're not afraid of offering surgery. And I think that is absolutely fair. What's your current protocol in terms of how you do the surgery? Before we jump into? Maybe we should be doing this surgery differently? So are you doing, you know, size of incision is an under what kind of anesthesia is at the office? Is it in the OR? You know, Amy what's your what's your protocol, and then we'll ask Dom and Chuck with their protocols.

Amy Moore: 21:49

I'm such an old lady in this because I think it's it's rare that I have it that I have not been forced into trying to fill in many during a day. And so it's usually if I have a carpal tunnel, like I did yesterday was like, so nice being like, Oh, this is great. So most of the time I do it under MAC, I haven't gone to wide awake, because in the office for me is I just haven't figured that out, although our hand surgeons, you know, my partners do a ton. And so I do Mac and local. And I do big incision, because I have not regretted it. And I've not had to revise any of my own. And that's hundreds of not having to revise my own. And so if it's working, why change it? And so I think that's the mentality, which makes it interesting. And I hate I don't want to be stuck in my ways. But I think I am right now. So convinced me otherwise. And I will I will start thinking about it. But how about you all? Yeah, Dom.

Dominic Power: 22:48

I'm definitely stuck in my ways. So I do traditional open carpal tunnel on the local. I used to just use lignocaine or lidocaine and a longer acting local anesthetic. And forearm tourniquet and now I'll just do a lidocaine with adrenaline. Unless there's something else going on, unless there's significant tenosynovitis or something like that, or revision case, in which case, I'll do regional anesthesia, to allow me to do more extensive surgery under a lot under tourniquet. But yeah, I just I just stick to what I do. Now, I recognize that the majority of my patients get a great outcome. And that's not me, it's the fact that we've decompressed the nerve, and it's a successful operation for many. And I recognize that getting the hand moving, and being able to get the patient confidence start using the hand early . That's key to success. But you know, I also recognize that innovation happens and innovation can be for the benefit of our patients either reduced resource use, you know, office procedures earlier return to function, and maybe you know, I'm not looking critically enough at the outcome and time for my patients in that first few weeks after surgery. But most, most of my patients who are office based self employed are back at work that same day or the next day, those are working for another employee, maybe take a few weeks, those do manual workers will take a bit longer. So whatever thinks my surgery, that's just my take on it. But the reason I feel so strongly about just sticking with open at the moment is I've, in my practice, seen so many complications from other interventions, and there's clearly a learning curve. You know, I've seen I've seen a patient with a minimally invasive procedure done overseas, and the incision was a transverse wrist incision longer than my standard carpal tunnel decision nervous come to. So, you know, I, I've seen I've seen all of those complications, so and it's shocking. So I just stick to what I know. But I think even with open surgery, it's important to make sure the incisions in the right place is not directly over the nerve. There are refinements that we have to follow and make and continue to to end force, and therefore not every carpal tunnel open is the same. And so you have to be careful what you're looking at and how you're How are you measuring outcome? That's my that's my little. That's my summary really.

Charles Goldfarb: 25:13

I love it. Yeah, I think that's really well said. It's funny, I think I'm similar in some ways to both of you. So I was taught how to do a carpal tunnel, really, by Tom Kiefhaber at the University of Cincinnati, during my fellowship 20 years ago, and I do the technical part, exactly the same two centimeter incision, directly over the carpal tunnel, I find visualization is excellent. And I'll make a larger decision if need be. I have evolved, if that's the right word, and I'm doing most of my carpal tunnels under local only, and had been really, really happy with that approach. I do it in the operating room. And that's a systems issue here in St. Louis. So I've been I've been happy with that, you know, Amy, the length of the incision, honestly, I don't think it changes a thing. Because if patients have pain that limits them postoperatively it's because of the incision directly over the carpal tunnel and extending it a little bit distally doesn't matter. So no, no judgment, I would hope by anyone on that. What's interesting is, I, you know, I tell patients that crop dental surgery is one of my favorite surgeries, because the results are so reliable and so predictable and so good. But we all know there's that subset that just struggles for whatever reason, and I don't think like you damn, I don't think it's technical. I think it's just the patient. There's patient factors, and there's work backwards, and there's life factors. But what a great surgery, and there's a lot of ways to get it done, Chris?

Chris Dy: 26:37

Well, I mean, I'm just for context. I also like you do similar surgery on my incisions, probably 2.5 centimeters if we're measuring. I know crazy. Will on style. Yes, exactly. In the not in the office, and like you said systems issue, but no tourniquet. And the vast that's pretty much my standard unless the patient asked for something else. So I think it's interesting that, you know, I just see a number of patients that have a painful scar and or this vague concept that we call pillar pain. And I see enough of them where it's a little frustrating, which is why I'm interested in maybe there's a different way to do this. And the next paper that we want to talk about is from our friends at the Mayo Clinic, talking about doing an ultrasound guided thread carpal tunnel release, which when I first heard about this, I thought was absolutely nuts. But I, you know, during my my travels for the American society's government fellowship, I went and was visiting the plexus team at Mayo, and I saw Alex Shin and incredibly talented surgeon do 13 of these in an in an afternoon with Jeff. The physiatrist which anybody who's who knows Alex and I say this in a very loving way, it's pretty classic of Alex to go really hard on something. So he did 13 of these in an afternoon. That's pretty standard big for him, apparently. And, you know, the procedure. He's very skilled at it, Jeff and Alex have a great system of doing it. And it got me thinking, is this something that, you know, is there something to doing this surgery in a different way that will get people back faster? You know, me or Dom or Chuck, have you considered doing anything, you know, either in the endoscopic realm or ultrasound guided tip perhaps get to a subset of patients that might benefit. Maybe start with me and then go to down.

Amy Moore: 28:25

Yeah, I I, you know, I trained with Alex and that team, and I actually saw them do a case and I'm not sure if it was when I was visiting or what have you. And it's it's very, I think, probably has a pretty high learning rate for it curve. And seeing somebody who's very thoughtful like Alex about nerve and nerve surgery. His adoption, I think, is helps me think like, oh, maybe this could consider it. I think I just have to rely on my bias and my biases. I see people's complications. I have not seen any complications from threaded, but I don't think it is done as much as endoscopic. And so I think it's rare that I'll see a complication from open surgeries. I see them from the endoscopic, again, bias. And I think I always say if anyone asks me on stage, I'm always like you do what you know what you know how to do. And like you stick with what you know how to do, and make sure you do it well. And so I don't I think that's a cop out. Sorry, Chris. It's a cop out. I think yes, there's everything can you do what you do? And I'm gonna stick to my open and probably be less than to the threaded because it's just intimidating to me not to be able to see as well. And I don't have the ultrasonographer right there beside me making it happen.

Chris Dy: 29:48

Do you feel the same way?

Dominic Power: 29:50

Yeah. As I said before, you got to see the need to change. Clearly, we need innovative innovators. And the problem is that the those experts in early adopters doesn't necessarily translate to the rest of the population. You know, we're not all that really good at reading ultrasound, we're not as all as good at looking in 2d and trying to assume what a 3d structure looks like. That's the challenge. And I think that improves your visualization to allow you to do smaller incisions is something elsewhere in the body that has been accelerating in the last 30 years, isn't it laparoscopic endoscopic procedures. short stay in hospital reduce recovery times. For us when it's already a simple day case procedure. Those gains may be more marginal, but they may be there, we just need to look for things like pillar pay. And it might be we need to treat huge numbers to make a significant impact on our population. And then at what cost, you know, if the academic injury rate goes up from 0.25% to 5%, that that, to me is an unacceptable cost. I think ultrasound guided minimally invasive procedures is an exciting way to go. Seeing the nerves seeing where it is and making sure it's protected all the way through. Yes. In my hands at the moment. No, I just don't have the skills or the time to invest to develop to become comfortable. But I watch this space with great interest. I think it's a really interesting concept. But like me, endoscopic for me is not sufficiently robust in terms of visualizing the nerve and knowing that the nerves absolutely saved throughout. And because of the complications, I wouldn't do that in my own practice.

Chris Dy: 31:36

So try not to old dog with the new trick, maybe? Yeah.

Charles Goldfarb: 31:39

So Chris will like this. I have two comments here. I always have two comments. My first is that I have gone the route of endoscopic previously, and I liked it. But Richard Gelberman said something that has stuck with me to this day, which is basically question that when you finish an endoscopic carpal tunnel, have you really added stress to your day, a little uncertainty about being 100% positive, that you completely released a carpal tunnel, and positive that you did everything in your power to help that patient. And he was right, because when I and others, others who are more experienced, perhaps within a scopic may see it differently. But it wasn't satisfying for me in the same way that an open carpal tunnel is satisfying. So I stopped. There's another system I'm evaluating currently. But I am really happy as both Dom and Amy said with what they do now. And the results are predictable, reliable, and I like to provide that surgery for my patients. The second thing I'll say is that I also agree, while I may not be a regional or national referral center, like Dom, Amy, and Chris, I see my fair share of either patients in the clinic or legal issues regarding nerve injuries. And while the literature would tell us that open and this endoscopic have similar complications. I don't buy that a bit. Because I just don't think there's I think I'm not questioning the authors. But I don't think there is accurate reporting of the rate of injury within the scopic. And what probably is necessary is a group like you guys, all putting together your revisions or nerve repairs. And then looking back and seeing which of those were in this topic and opens. I think it's a fascinating topic, but I don't buy the literature that says there's an equal rate of risk with open and endoscopic.

Amy Moore: 33:38

I totally agree with that. I mean, you talked to a couple of the surgeons who have one injury, and it's just devastating. Right. And so I think the reality is probably under reported. But again, that's my bias. I'll be quiet. We've disclosed it.

Chris Dy: 33:55

Don't be quiet. I think that's that's reality, we all have bias in our practices. I mean, you know, I think that, you know, and then also the, you know, you have complications with open surgery, too, that are underreported. So I think that the iatrogenic complication rate is is higher than what is in the literature. And you know, that that's I don't think that bias is going to change. You know, I one question I wanted to ask the group to pull us back towards the article. I think that the way that this group defined return to work, although they tried very hard to make it objective by keeping everybody through occupational health and then the same health system, I think return to work is just such a hard outcome because it's so individual both at a patient level and a job level. So I don't know if I, you know, there's bias I think and how, like we discussed return to work. If you're going to discuss a less invasive technique, you're probably going to put it in the context of an earlier recovery, whether that's work or recreational sport activities. So I think that's a little bit of a limitation here. Dom, you mentioned with your patients, some people won't go back to work on the same day. I think Americans are not that tough. So they want more time off of work. What do you say your average return to work are just for people who work at the desk, people who have some elements of heavier labor, and then a true manual labor? And then I'll ask the same question to me afterwards.

Dominic Power: 35:16

Yeah, it's, it's, again, as I said, it depends on someone's root motivations. Generally, if they're working doing office based work, I would be encouraged them to stay away for somewhere between two and four weeks, knowing that keyboard use from prolonged keyboard use can be uncomfortable, like manual four to six weeks and heavy manual, we can't get ourselves sometimes takes a little bit longer. But six weeks is a sort of, I would, I would be very disappointed. Every of everybody that I've operated on isn't back and almost forgotten about their surgery by six weeks. That's the problem that you know, those that have got pillar pain or persistent scar tendons? Yes, there's always a few. And that's the group that we should try and improve. They'll take a little bit longer sometimes

Chris Dy: 35:57

Amy. Same question you,

Amy Moore: 35:59

For sure. Within two weeks, I think five days. So I operate on Tuesdays, sometimes, right? But Tuesdays, and they're back to work by Monday. And I haven't felt that that's been not appropriate. I don't let people like I always say when you make a fist, you know, all of your tendons pop to the front, right. And if the nerve is sitting at the top of that, and you're gripping hard, I think I just want to avoid that I want to keep all your nerve gliding and trying to minimize the scar tissue that's been stuck around. And so I will say I don't want them lifting more than a half a gallon of milk for the first two to four weeks, and then a gallon of milk from four to six. And then after six weeks, you can live whatever you want. And so my manual Labor's you know, I put them on restrictions for wheat, you know, until six weeks, and I haven't had any, like pushback. And yes, there's definitely those who have the hypersensitivity or you know, the pillar payment, we should talk about pillar pain, maybe because I don't know what it is really, right. I think it's that we've, we've cut between the two muscle groups, and now they're flying loose, and and they're just having to resettle. But I always just I think massage is going to be the best thing for it. But by six weeks, they're back at work. And I think you five days back is fine. And I want them typing and eating with their hand on the same day. But the return to work, I completely agree. I think return to work is such a nebulous concept in such a personal one, that I would hate to say that oh, because this paper said it, my patients have to be back to work within 12 days. Right? Like that's not an expectation I want the insurance companies getting or, you know, other occupational health getting? Because I think when someone chooses to undergo surgery, it's it is it is it is shouldn't be seen as you know, getting your eyebrows waxed. Right? Like it just shouldn't, right? I just don't think it's as simple and so I don't know.

Dominic Power: 37:55

So well wax my eyebrows. I think it'd be off for at least two weeks.

Amy Moore: 37:59

Probably everything again, I probably shouldn't have used that analogy. But I think it's something like you know, going in and getting whatever it is surgical like it's not to be minimized. It's, you know, it's the number one litigation under nerve surgery in the US is for carpal tunnel syndrome and releases that have gone bad. So I think we have to just sort of use that as a, you know, the sacred space. And so telling somebody that you're going to absolutely feel that good by 12 days is I think unfair.

Chris Dy: 38:29

I learned a lot from Chuck and Chuck, who takes care of a lot of injured workers. And, you know, you chuck, maybe you could say I remember you saying that you pretty much everybody gets back to full activities by a month. And I think that's the baseline you said, but I think people people's trajectories are different.

Charles Goldfarb: 38:45

Yeah. And I everyone I like to five day, essentially all my patients go back to work and five days, but they might be light duty. And then I shoot for a month now there's some workers that require a little longer, but a month, six weeks, I think I agree is probably max, I'd be disappointed if it's not six weeks. So I like those timeframes. And I like the graduated lifting that Amy described as well. So clearly an imperfect science clearly.

Chris Dy: 39:13

Do any of you place any restrictions on your patients after surgery aside from you know, Amy, you mentioned the lifting, the amount of lifting but you know, I guarantee you any if any of the four of us have the surgery, we probably wouldn't be doing much more than what we tell our patients to do.

Amy Moore: 39:27

I've taken care of enough surgeons who go back to work really quickly and then they ate for longer. I mean that's the truth and so I was like I know you're gonna go back to work but I'm telling you your if you could take the time take the time because you're gonna hurt longer. I don't know Don, what do you think?

Dominic Power: 39:46

Yeah I encourage functional use the hand because I think wrist extension with finger flexion is a way of getting glide and keeping the nerve away from prolapsing into the scar so I think it's important to functionally use the hand. It is so simple activism to you know what someone does and their perception of what they can do. And I think particularly with the response to over prescribing of opioids, what we probably need to do is have much, much more stewardship about what's expected and how analgesic is use using this population. I think this is part of the pre education, if you explain to patients that what's expected, and you talk to them realistically about the journey, and that they will have some discomfort and that their whole post operative period is much more tolerated, if they expect it to be pain free surgery, because you say it's only a tiny operation. And, you know, there'll be disappointed. So I think, I think we have to do a lot better as well in our run up to surgery for patients and bring them on the journey with us. And I think that early investment, time speeds up recovery.

Chris Dy: 40:50

Could not agree more. You know, I guess as we bring this to a close been a fun journal club discussion. The last article is, is out of, I think it's out of Verona and the first article of the first author's Carita, looking at if patients have a failed carpal tunnel decompression, either recurrent or persistent symptoms, and the use of ultrasound now just quickly to hit this. So Amy, do you use ultrasound in the evaluation of the patient with potential persistent or recurrent symptoms? And either way, whether use ultrasound or not, what do you find in surgery, typically, in terms of is there a residual point of compression on incomplete release? Reformation of whatever you recall the transverse carpal ligament at that point? And then same question to Dom.

Amy Moore: 41:34

Yeah. So it you know, when I learned from you, and we talked about this, but it was we also refer to it like, you have to understand is it new? Is it recurrent, or is it persistent? And so that's beyond today's talk. But I think every time I see a patient who has not had the expectation of recovery that we would from a open release or endoscopic release, or you're just primarily, let's refine it that way, then I'm searching and I love ultrasound for that reason, because then you can see changes in the nerve. And it helps in myself, you know, framing, okay, well, if I'm going to find it, am I going to need to graft, any revision surgery just takes longer no matter what intraoperatively I've found distal failure to release. And it's also where I found the most injuries is at that third webspace. Unless it's just catastrophically proximately cut. So I guess I've seen both. And I think ultrasound is very helpful. For me, it doesn't determine if I'm going to go the operating room or not. And I think that's the part where I've been much more because it's hard to get people in, I'd probably steered away from it, because until I get it in my own hands, I think it's just okay, well, let's go back explore because this can't be what you have the rest of your life. Got it.

Chris Dy: 42:51

Damn similar findings and thought process.

Dominic Power: 42:55

Doubt the diagnosis, Doubt the quality of the surgery and Doubt, the condition of the nerve. So I always do neurophysiology again, I always try and get hold of the original operation out and see who did the surgery, what the greatest condition was prior to surgery, whether it was a spontaneous recovery and relapsed, or whether it never got better whether symptoms changed. But I tend to always make sure I've got neurophysiological studies and try and compare them to pre op, if they've been done. I have to say, I rarely would do ultrasound routinely, because I think we know the nerves not going to glide very well, we know it's going to look swollen proximately I'm not completely convinced that when ultrasound is done, like someone can say that's the original flex and rattle thing that hasn't been released, I need to visualize it. So they normally end up with surgery, and regional bloc, extensive surgery and a further look at it. So not a huge part in my practice. Unless there's something else odd, the swelling, you're suspicious of some of the pathology in the carpal tunnel, then an MRI or ultrasound, but it's not a big part of my practice at the moment. But again, I think it comes about like you me too, having delays to getting that sort of imaging available to you. And once it's at the bedside or in the office, and we're comfortable with it, we'll be using it as part of our clinical examination on patients. Doesn't doesn't cost anything. It's not painful.

Amy Moore: 44:17

Yeah, Chris, what about you? Can I ask you and Chuck?

Chris Dy: 44:21

So Chuck, why don't you go first and then I can give my thoughts at the end.

Charles Goldfarb: 44:25

Yeah, I think Amy said it beautifully. And I would just say that for me, I will occasionally use ultrasound as a surgical planning tool. Not to help me determine whether or not to go to the operating room, but it can be helpful and you know, is this a 30 minute revision carpal tunnel? Is it a longer is it a more of just another carpal tunnel so that's how it helps me because you may have different thoughts.

Chris Dy: 44:51

I agree surgical planning tool. Also it is helpful for me in terms of evaluating completeness of release. I do not trust prior operative notes I I doubt the prior procedure. I doubt the prior nurse studies. I doubt everything like Dom said. What's interesting is that, you know, the only point I'll make is I think that the, in my experience with revising carpal tunnels, it's not necessarily the distal point for me, which I know is different than what Amy said different than what's in this paper and different than what's the largest series from students. Many years ago, it to me, what I usually see is an incomplete release approximately, or a nerve injury approximately, but always looking for, you know, that distal third web injury or the incomplete release by the arch. But for me, it's been at the risk crease from what I've had to revise the surgery of others who have come in. So you know, I think that there's a lot to learn from this. I encourage our listeners to review these great articles from the European volume. We'll have them in our show notes. This has been a really fun collaborative and we really wanted to shout out the people at the BSSH. Obviously Dr. Wee Lam has been incredibly helpful in facilitating all of this. And Emily Lakin at the home office for the BSHH Dr. Gemma Batton who's going to be working on the social media front for this. So thank you to the to the BSSH, JHS Europe and FESSH teams for that. Dom and Amy, thank you for joining us. It's been a lot of fun catching up with you guys. You're always fantastic guests and a lot I've learned a lot from both of you. Thank you.

Charles Goldfarb: 46:21

Yeah, thank you so much. I would have thunk that I would enjoy talking about nerve with but even even with you guys

Amy Moore: 46:30

Continue to convert you Chuck. It's

Chris Dy: 46:32

Closeted nerve nerd over there. Chuck Goldfarb. But have a wonderful day and afternoon, everybody and we'll talk to you next time.

Amy Moore: 46:40

Cheers.

Dominic Power: 46:41

Thanks for this. Hey, Chris.

Charles Goldfarb: 46:43

That was fun. Let's do it again real soon.

Chris Dy: 46:45

Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb: 46:50

Mine is@congenitalhand. What about you?

Chris Dy: 46:53

Mine is @ChridDy spelled d-y. And if you'd like to email us, you can reach us at handjefpodcast@gmail.com.

Charles Goldfarb: 47:01

And remember, please subscribe wherever you get your podcast and be

Chris Dy: 47:05

sure to leave a review that helps us get the word out.

Charles Goldfarb: 47:07

Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time