Transverse mini-incision for carpal tunnel release

Background: Carpal tunnel syndrome is a commonly prevalent entrapment neuropathy characterized by median nerve compression within the carpal tunnel. The aim of this study was to compare the outcomes of transverse mini-incision and tradi�onal mini-palm incision for carpal tunnel release. Methods: A non-randomized interven�onal study was done at Kurmitola General Hospital, Dhaka and US Bangla Medical College Hospital, Narayangonj between January 2019 and December 2021. Forty-two pa�ents diagnosed with idiopathic carpal tunnel syndrome were allocated to the transverse mini-incision group (n=20) and tradi�onal mini-palm incision group (n=22). Results: Pa�ents operated with transverse mini-incision returned to their work signiﬁcantly earlier (mean 10.3 days) than pa-ents operated with tradi�onal mini-palm incision (mean 18.7 days). No signiﬁcant diﬀerence was found between transverse mini-incision group and tradi�onal mini-palm incision group as determined by the McGill pain score improvement ( P =0.16), the Bangla version of the Boston carpal tunnel ques�onnaire symptom severity score ( P =0.61) and func�onal severity score ( P =0.43). Conclusion: Transverse mini-incision is comparable to the tradi�onal mini-palm incision in terms of pain, other symptoms


ABSTRACT
Background: Carpal tunnel syndrome is a commonly prevalent entrapment neuropathy characterized by median nerve compression within the carpal tunnel.The aim of this study was to compare the outcomes of transverse mini-incision and tradi onal mini-palm incision for carpal tunnel release.
Methods: A non-randomized interven onal study was done at Kurmitola General Hospital, Dhaka and US Bangla Medical College Hospital, Narayangonj between January 2019 and December 2021.Forty-two pa ents diagnosed with idiopathic carpal tunnel syndrome were allocated to the transverse mini-incision group (n=20) and tradi onal mini-palm incision group (n=22).
Results: Pa ents operated with transverse mini-incision returned to their work significantly earlier (mean 10.3 days) than paents operated with tradi onal mini-palm incision (mean 18.7 days).No significant difference was found between transverse mini-incision group and tradi onal mini-palm incision group as determined by the McGill pain score improvement (P=0.16), the Bangla version of the Boston carpal tunnel ques onnaire symptom severity score (P=0.61) and func onal severity score (P=0.43).

Conclusion:
Transverse mini-incision is comparable to the tradi onal mini-palm incision in terms of pain, other symptoms, and func onal outcome.However, pa ents in transverse mini-incision group could return earlier to work.

ORIGINAL ARTICLE
Several studies have investigated the clinical outcomes and efficacy of these two CTR techniques, but a consensus regarding the superior approach remains elusive. 12While some studies report comparable outcomes between the two techniques in terms of symptom relief and functional improvement, 12,23,24 others suggest potential benefits of the transverse miniincision technique, including decreased scar tenderness and earlier return to daily activities. 23,24 owever, variations in study designs, sample sizes, patient characteristics, and follow-up periods contribute to conflicting findings, emphasizing the need for a comprehensive investigation to draw definitive conclusions. 25,26 hus, the primary objective of this study was to compare the transverse mini-incision and traditional mini-palm incision techniques for CTR.

Patients and study design
Initially 50 patients diagnosed with idiopathic CTS were recruited from Kurmitola General Hospital, Dhaka, Bangladesh and US Bangla Medical College Hospital, Narayangonj, Bangladesh from January 2019 to December 2021.Initially, CTS was diagnosed by at least three of the following symptoms: night pain or paresthesia, numbness along the median nerve, and struggling in grasping and using small substances, positive Tinel or Phalen's test, and positive electrophysiologic changes in electromyography. 10ter that, those who had idiopathic CTS, ineffective conservative treatment for six months, unilateral CTS, and moderate to severe CTS on electrophysiological study were included in the study.Conversely, those who had previous operation, bilateral CTS, secondary CTS, anomaly of hand, and psychiatric or neurological problems, were excluded from the study.A pre-anesthetic check-up was done for those who satisfied the inclusion criteria and had an ASA I or II physical status. 27The patients were allocated into two groups, 25 patients in each group and named as (a) transverse mini -incision group (intervention group) and (b) traditional mini-palm incision group (control group).Five patients in the transverse mini-incision group and three patients in the traditional mini-palm incision group could not complete the follow-up.

Outcome measurements
Outcome measures were assessed and documented by two investigators.The Short-Form McGill Pain Questionnaire (SF-MPQ) 28 and the Bangla version of the Boston Carpal Tunnel Questionnaire (BCTQ) 29 were used to evaluate patients' conditions before surgery, one month after surgery, three months after surgery, and six months after surgery.Additionally, postoperative complications such as infection, postoperative pain, and ugly scars were also recorded.

Transverse mini-incision group
Patients in this group underwent surgery using a minimally invasive technique involving a 2 cm long transverse incision located 1 cm proximal to the wrist flexion fold.The palmaris longus tendon was identified laterally to the median nerve on the palmar side and the upper border of the transverse ligament.The transverse ligament was then cut to expose the median nerve. 24

Traditional mini-palm incision group
Patients in this group underwent surgery using the traditional mini-palm incision method.The incision started just below the distal wrist flexion crease and marginally ulnar to the midline of the wrist, extending distally about 2.0 to 3.0 cm along the third web space.
The transverse carpal ligament was exposed and carefully divided to open the carpal tunnel. 1

Statistical analysis
Continuous data were presented as mean (standard deviation), while other data were expressed as number (percent).Within-group improvements were compared using paired sample t test, and between-group differences were examined using an independent

RESULTS
Forty-two patients were included in this study as all of them completed a 6 months follow-up.Twenty patients were operated with transverse mini-incision and traditional mini-palm incision were done on 22 patients.The mean (standard deviation) age of the patients was 41 (9.3) years where around 93% (n=39) were women.Three-fifth (60%) had right hand CTS and more than half (52%) had severe CTS according to electrophysiological criteria (TABLE 1).
The transverse mini-incision group (mean and standard deviation: 10.3 and 2.1) needed significantly lower days to return to work than the traditional minipalm group (mean and standard deviation: 18.7 and 2.3) (TABLE 2).Using paired sample t test within both the groups, both McGill short form of pain questionnaire and BCTQ were significantly improved (P<0.05) after operation.
For comparison of effectiveness of operation between the two groups, independent sample t test was done.No   31 The grip force, movement, and cosmetic outcomes were the metrics that revealed disparities. 31Al-Mofty et al. showed that transverse mini-incision reduced scarring. 32In another trial, there was no statistically significant difference between the conventional method and the transverse mini-incision technique.However, four out of fifty patients in the conventional group complained about their scars. 12Our study also had no significant difference regarding pain and outcomes.Faraj et al. showed that patients in both approaches were symptomatically improved.The scar length in mini-transverse wrist incision technique was shorter than the traditional one.Patients with minitransverse wrist incisions returned early to work. 33 a realistic amount of time for symptom alleviation and functional recovery, we chose six months as the follow-up objectives.Longes follow-up could provide further understanding superiority of the approaches.
Three doctors with various surgical skill levels carried out the procedures but the influence of surgeons experience cannot be determined because of the small number of subjects for each surgeon.We did not collect information on the patients' forms of job, and it is plausible that this might have an impact on how soon they may start working again.There might be between hospital difference which we are not sure.

Conclusion
We conclude that both transverse mini-incision and traditional mini-palm incision are safe and effective surgical options for CTS.No significant difference was found regarding pain, symptom and functional outcome.However, in case of return to work after operation, transverse mini-incision.However, the patients in mini-incision group can return to world earlier than the traditional mini-palm incision group.

TABLE 1
significant difference was found between two groups in McGill pain score improvement (P=0.16),symptom severity score (P=0.61) and functional severity score of BCTQ (P=0.43).There were minor complications in both groups.There were two cases of CTR in the traditional mini-palm incision group that did not improve.DISCUSSION In this interventional study, we compared transverse mini-incision versus traditional mini-palm incision.Patients with transverse mini-incision had returned significantly early to work.In a recent article, Khoshnevis et al. demonstrated the advantages of minimal incision surgery over conventional open surgery, which is consistent with our observations Morshed T et al.Bangabandhu Sheikh Mujib Medical University Journal 2023; https://doi.org/10.3329/bsmmuj.v16i3.68183Transverse mini-incision for carpal tunnel release 169 Background characteristics of patients with carpal tunnel syndrome Morshed T et al.Bangabandhu Sheikh Mujib Medical University Journal 2023; https://doi.org/10.3329/bsmmuj.v16i3.68183Transversemini-incision for carpal tunnel release 168 HIGHLIGHTS 1.The efficacy of transverse mini-incision is similar to the efficacy of traditional mini-palm incision in terms of postoperative symptoms, pain, and functional outcomes.