Optimizing the Evaluation and Management of Carpal Tunnel Syndrome and Trigger Finger Previously Recorded: Wednesday, January 22 | 6:00 PM ET
Dr. Michael Cohn, orthopedic hand and upper extremity surgeon with Baptist Health, shares expert insights on optimizing the evaluation and management of common but often challenging conditions: carpal tunnel syndrome.
In this session, Dr. Cohn will walk attendees through the latest advancements in diagnosing and treating these conditions, offering practical strategies for improving patient outcomes. Through case examples, Dr. Cohn will explore current surgical and non-surgical approaches, the latest research on treatment efficacy, and his approach to personalized care.
Whether you're a primary care physician, orthopedic specialist, or healthcare provider working with patients experiencing hand and upper extremity issues, this webinar will provide valuable takeaways to enhance your clinical practice and patient care.
This session is a must-attend for healthcare professionals seeking to stay at the forefront of hand and upper extremity medicine.
All right. Let's say it's about 6 o'clock, so we're ready to get started. Um, I wanna welcome everybody to the Baptist, uh, webinar series. My name is Alex Coughlin. I'm an orthopedic surgeon at, um, Boca Raton Hospital. Uh, I am, uh, here to moderate the session for Doctor Coe. Uh, Doctor Cohen is, um, our hand and upper extremity surgeon. He did most of his training up in New York and it's been Uh, down in South Florida for the last, um, 15 years or so since 2012, and, uh, I'm pleased to call on my partner. Um, so in the interest of time today, we're gonna have a slight change in our session. So we're gonna be talking mostly about the optimization, evaluation and management of carpal tunnel syndrome. Um, there is a question and answer, uh, uh, a portion of it that we'll engage in a little bit later, but please feel free, uh, to write your questions down and, and send them to a chat box and then we can discuss them, um, right towards the end. This is probably gonna be about 25, 30 minutes, um. And without further ado, introduce uh Doctor Cohen. Doctor Cohen, do you wanna take it away? Thank you very much, Doctor Gockman, and thank you to all the attendees. Um, as Doctor Gockman stated, tonight, we're going to discuss optimizing the evaluation and management of carpal tunnel syndrome. Uh, in the interest of time, I trim my talk to uh remove trigger finger for this evening. Um, my name is Michael Cohen, um, orthopedic hand surgeon in South Florida with Baptist Health. So carpal tunnel syndrome is one of the most common orthopedic conditions. Uh, it's been shown to affect more than 13 million people in our country at any given time. Women have a 3 times more likely chance of getting carpal tunnel compared to men, and it's been shown that about 1 in 10 people will be affected by carpal tunnel syndrome in their lifetime. That's quite a lot of people, very common condition, as we all know. Um. I'm sure we all know the symptoms of carpal tunnel syndrome, but I'll briefly review. Um, this typically involves, uh, paresthesia, numbness and tingling, typically in the thumb, index, middle, and radial ring finger. Um, oftentimes, uh, there's not involvement of all of the fingers. It just depends on which fibers are affected. Sometimes patients will come in complaining of a loss of grip strength. They might be dropping things in the kitchen. Um, they oftentimes will report numbness and tingling in their fingers. Uh, oftentimes it'll start as a nighttime phenomenon. Um, as the disease progresses, the symptoms can become more frequent, happening day and night and moving towards constant nature. Occasionally, patients will report forearm tenderness and even pain that radiates upwards in the, in the upper arm. Um. Moving along Uh, the symptoms of carpal tunnel syndrome, uh, while uncomfortable, can also make normal everyday tasks such as ADL's very, very difficult for our patients. That's what usually brings them in. Uh, what are the causes? So, there can be a number of causes. Um, repetitive maneuvers, overactivity can play a role. Obesity has been shown to be a risk factor for the condition. Uh, pregnancy often can come in the 3rd trimester with fluid accumulation. Oftentimes it'll resolve post-pregnancy. Um, arthritis can sometimes play a role if it, if the arthritis encroaches on the volume of the carpal tunnel space. Uh, endocrine disorders can play a role such as diabetes and hypothyroidism. Um, sometimes carpal tunnel syndrome follows trauma oftentimes to the distal radius from nerve stretch, and also from hematoma. However, most cases are idiopathic. We're just not exactly sure um where it came from. So carpal tunnel syndromes caused by the median nerve being compressed, traveling through the carpal tunnel, um, it's compressed by the overlying transverse carpal ligaments, you know, uh, best on the slide on the right. And how do we diagnose carpal tunnel syndrome? Well, as with anything, it starts with the patient's history. They'll often report numbness, tingling, and a typical median nerve distribution to the radial 3.5 digits. Um. Symptoms can be, like I mentioned, oftentimes nocturnal from the position of sleep. Um, as the disease progresses, the symptoms can oftentimes occur during the day with normal activities such as driving or working at a keyboard. Um, a physical exam is then performed involving sensory and motor evaluation. Um, the photo on the upper, uh, the upper photo rather is, uh, Sensory evaluation with SEMs. Weinstein monofilaments, which has been shown to be an extremely accurate way to assess sensation. Um, motor testing is done primarily of the thenar motors, which are served by the thenar motor branch of the median nerve, and then provocative tests are performed typically I'll perform 3 tests called the Dirkin's carpal compression tests, where we hold pressure over the median nerve at the carpal tunnel entrance, um. And see if it provokes their symptoms. Um, next, a Tel sign can be tested for tapping over the median nerve, um, typically at the same level at the carpal tunnel inlet. And then phalan's test when we have the patient, uh, allow their wrist to fall into flexion and see if this uh provokes their symptoms. This is all documented. And then additional testing is typically done in in my hands. Um, I use a validated clinical tool that I'll mention called the CTS 6. It's rapid. It's a scoring system that can give you, uh, whether the patient has a high probability or not of having the condition right in your office during the consult. Um, as we all know, electrodiagnostic studies have played a role historically and still do. I'm moving away from these in my practice, as I'll explain. And then, uh, In more modern times, some physicians and surgeons are using ultrasound to help the diagnosis. We'll discuss this tonight too. One can measure the swelling of the median nerve at the carpal tunnel entrance, and with a high probability and with validated clinical studies, this can be used as a confirmatory test to make the diagnosis. So the CTS 6 is a validated clinical tool that helps us confirm the diagnosis of carpal tunnel syndrome. And uh here it is listed here. There's, there's 6 figures. Two of them are based on a patient's reported symptoms, and the rest are on your physical exam. Um, the The scoring is, is, uh, either a 0 or the full value of the number to the right, and you total it up at the bottom. If you look at the bottom of the slide, um, what I look for is if they have a score greater than 12, I know they have about an 80% or better chance of carpal tunnel syndrome just from this clinical tool. Uh, I want to talk a little bit about ultrasound examination in the office with regards to making the diagnosis of carpal tunnel syndrome. Um, it's been shown in many studies, um, that the swelling of the median nerve, um, can be an excellent way to confirm the diagnosis. The most common value I've seen for the cross-sectional area in the literature. Uh, that's been shown to be consistent compared to electrodiagnostic studies is a size greater than 10 square millimeters measured at the carpal tunnel inlet, which under ultrasound can be defined as either the level of the scaphoid and PISA form or just proximal to this at the level of the lunate. Um, but the, the nerve should be measured wherever it appears largest. Typically, we'll, we'll freeze the image and then there's different, um, functions that you might have on an ultrasound machine that allow you to automatically calculate the cross-sectional area. I performed this um these days, probably for the last 12 to 15 months, I performed it as part of my initial consultation after the um uh the history physical exam and a brief CTS 6 score. Um. And it's been shown in some studies to have even a higher sensitivity and specificity for making the diagnosis than electrodiagnostic studies. The images on the right, you'll see the upper image is patient with carpal tunnel syndrome. You can see they have a measurement of 15.5 square millimeters for a cross-sectional area where a normal control is on the bottom at 7.5. So Fowler published a study in JBJS in 2015, evaluating uh common tools that we have for making the diagnosis, including ultrasound exam, nerve conduction studies, and the CTS 6. And the important part, I've circled at the bottom, the study found that, um, Similar to some other studies performed, if, if you do a CTS 6 in the office and an ultrasound exam, and they're consistent with carpal tunnel syndrome, this can be a highly accurate way to make the diagnosis. Um, probably 95% or better accuracy with, uh, along with history and physical exam. And that typically nerve conduction studies are not going to be necessary in most cases. This saves the patient time and money and possibly a painful test. So what are the treatment options, um, So, one can modify aggravating behaviors, activities, uh, especially if it's overuse related. Um, there can be some minor value for stretching. Um, bracing and steroid injections have been validated as useful measures for non-operative care. Um, in mild cases, you might even get a cure with bracing. Steroid injections are more, uh, uh, for temporary symptom relief and possibly to help confirm the diagnosis for some. Uh, one can also consider anti-inflammatories. And then moving on to surgery, there's, there's basically 3 types of surgery from less invasive to more invasive. Carpal tunnel release with ultrasound guidance, endoscopic carpal tunnel release, and then, of course, open carpal tunnel release. So, I use the disease severity to guide my treatment and counseling of the patients. Oftentimes I don't see the patients at the mild stage. Um, they often show up in my clinic when it's been going on for a long time and they're, they're more into a moderate, uh, unfortunately, sometimes a severe case. Um, however, in mild cases, I define that as typically for most patients, it, it might be nocturnal symptoms. They wake up in the middle of the night, they shake their hand because their hands numb and tingly. But, you know, it doesn't really happen during the day. It might have just started in the last few weeks, few, few months. These patients certainly can try splinting. They should try splinting for at least 6 to 12 weeks every single night and see if we can improve those symptoms or even cure them, if we catch it early enough. One might consider a steroid injection, um. That's, that's up to uh surgeon preference. Some surgeons offer it, some don't. Um, I'm offering less steroid injections these days, um, cause it's certainly a temporary measure, and I fear that it may delay the patient to have definitive treatment when, when needed. Um, moderate carpal tunnel syndrome, I define that as when it's not only just at nighttime, now they're getting symptoms during the day. However, they do have periods of time during every day where they, they have no symptoms. So it's not constant, it's still intermittent. Uh, you can still do a trial, non-operative, um, management, mentioned above. If they haven't done that, certainly, it's an option depending on how long this has been going on and how the patient feels. However, some patients come in at this stage, whether or not they might have had a trial of non-operative care, and sometimes they want to have surgery with me. Um, you know, their, their symptoms at this stage are not gonna go away on their own. They might not go away. Um, probably not gonna go away with non-operative care. It's gonna make them feel better, partially, temporarily, however, um, you know, there is, there is a risk that they, with further time, they can move on to a severe case. So a lot of them opt to have surgery at this stage, um, to avoid severe carpal tunnel syndrome with constant numbness. Um, at this stage, they're still likely to get a resolution of most or all of their symptoms. And moving on to severe carpal tunnel syndrome, we all know those are the patients with constant symptoms of numbness, typically, um, weakness, objective atrophy of the Tars. Um, these are the patients that it's been going on a long time, um, sometimes for many, many years and either just neglected or they might have been fearful of surgery. Um, and at this stage, at least where I live in South Florida, a lot of these patients are in their 80s and 90s at this point. Um, and, um, non-operative care, sometimes it's an option. It can be palliative, uh, depending on, um, you know, your particular patient, but occasionally I see, you know, 95 year old with severe disease that just wants to have a little less pain or sleep a little better at night and they don't want to have anything else really done. Um, you know, you might go down the non-operative route with, uh, splinting and possibly an injection, uh, once or twice a year, uh, in the elderly. However, surgery still plays a role to preserve whatever function they have. Um, that's my number one goal with operating on these patients is to preserve what they have. That's all I, I kind of promised to them. Um, you know, there's, we're not gonna cure all of their symptoms. Their numbness is probably not gonna get better. They're gonna have a longer recovery. The nerve might take 12 months or more to be at its best. They're gonna have an incomplete recovery and, you know, I have to counsel them that our goals are limited here. So, let's dive into the treatment options from a surgery perspective in a little more detail. So, of course, there's open carpal tunnel release. There's two real versions extended across the wrist crease, um, verse mini open where the incisions in the thenar crease, distal to the wrist crease. Um, endoscopic carpal tunnel release is done similar to arthroscopic surgery with video camera and specialized instruments. It was initially introduced by Outso in 1987, Japanese orthopedic surgeon. Early concerns that made surgeons weary of trying this were reports of median nerve injury and uh incomplete release, um, which weren't as much of a problem with open carpal tunnel release. However, um, newer papers have shown that, um, the chances of median nerve injury is quite low, chance of incomplete release also quite low. These patients can oftentimes have a faster return to work, which has been shown in a number of studies over the years. And then lastly, carpal tunnel release with ultrasound guidance. This was introduced actually in 1997 by Nakamichi, um, There's been several devices that have been developed for this. There's a more modern, elegant one that I use these days that has a number of safety features. Um, however, some of the early designs were a simple hook blade. I'll show a couple pictures later on. Um, this has become more of a possibility with the improvement in ultrasound machine quality as far as the picture and the view. We can now see the small important structures clearly and protect them throughout the procedure with a high-quality ultrasound machine. We can see the thenar motor branch, we can see the third common digital branch of the median nerve and accurately protect them and allow for a complete release while doing so. So everything has its pros and cons, um, open carpal tunnel release. Has been shown to have the longest recovery, um, sometimes many weeks or months even. Obviously has the biggest scar, which for a lot of patients actually is important. Endoscopic carpal tunnel release has improved on that, um, in my opinion, because it's been shown in a number of studies to have a faster recovery, an open carpal tunnel release, faster return to work, even 6 to 8 days earlier in a couple of studies I, I mentioned here at the bottom. Incision small can be as small as 1 centimeter, sometimes up to 1 inch or so. It does require, um, similar to arthroscopic surgery, video screens, sterilized special equipment. Um, so that would be pretty difficult to do in, in one's office. Um, and then carpal tunnel release with ultrasound guidance. This is what I now do. Um, I find that it's the best patient experience by far, which I'll highlight, um, you know, what I've noticed, um, as I've been offering this procedure. It's been shown to have the most rapid recovery in a number of studies. Uh, has the smallest incision, um, just, you know, the, the length of a 15 blade for me, 4 to 5 millimeters. And with ultrasound guidance, ironically, you can see everything, keep it safe. I used to be an endoscopic carpal tunnel release surgeon, and, um, I never thought about the ulnar artery and where it is. I never really thought about the third common digital branch. All I thought about is I don't wanna see the median nerve. All I want to see is ligament above me and release that. But when I started doing ultrasound carpal tunnel release, I realized all these other things I'm not seeing, I'm not keeping safe. It was eye opening. So a recent Han Society survey to its members, um, I was surprised by this, but, um, it, it showed that 80% of those that responded still do either mini open or open carpal tunnel release these days, while about 20% or the rest did endoscopic, obviously only a small amount these days, um. are, are doing ultrasound guided surgery which, which I think might be the future. So, as far as carpal tunnel release surgery, in our population, there's a significant unmet need. Out of the 13 million Americans diagnosed with carpal tunnel syndrome every year, about 2.7 million are indicated for surgery annually. However, only 580,000 carpal tunnel release surgeries are performed. So why are these patients delaying or not having surgery? Um, so, on, on some market research studies, it's, it's major, majorly three factors. Um, those are intimidated by surgery, um, those that are worried about recovery time, being out of work, um, and then economic concerns, um, doing it in the operating room or the hospital, there can be significant costs, your insurance deductible, paying for an anesthesiologist provider. Um, these are the three major concerns that's been shown. So, these are the things we need to work through to treat all those patients that are delaying surgery. So just to talk a little bit more now about ultrasound, carpal tunnel release, as I mentioned, first reported in 1997. And then the following year, Nakamichi defined a term we still use called the transverse safe zone. If you look on the image on the right. And what it is, it's, it's the working space for us to perform an ultrasound-guided carpal tunnel released safely. It's the measurement between the ulnar edge of the median nerve and the ulnar artery, or the hook of the hamate, whichever is closer. So, ultrasound carpal tunnel release with the device I use, it's a single-use disposable device, um, therefore, it doesn't require any other specialized equipment aside from your ultrasound machine. Obviously, we use real-time ultrasound guidance and it can be performed under local anesthesia, which personally, I was never able to successfully um anesthetize my patients enough for local anesthesia for endoscopic carpal tunnel release. However, with ultrasound guided carpal tunnel release, um, I, I only do the surgery under local anesthesia unless they're having other procedures like a distal radius fracture repair. So, as you can see on this cartoon, we make about a 4 millimeter incision at the base of the wrist, and the goal of the surgery with any carpal tunnel surgeries is to transect that transverse carpal ligament to take the pressure off the median nerve. So, um, this is a picture of the device that I use, um, has some nice safety features that um keep us safe while we're working. Uh, this is the ultrasound machine that I like to use, um, but it's a simple, safe and effective way of offering uh carpal tunnel surgery to our patients. So, some clinical pictures of wounds following on the left, and ultrasound carpal tunnel release I did, that's 4 days post-op. Um, there's no sutures, the incision rapidly heals. Uh, the patient on the right had had a previous open carpal tunnel release surgery, extended open, as you can see with, um, quite a large kind of nasty scar there. They much preferred their left wrist with very, very uh cosmetic and small scar. So, benefits of ultrasound carpal tunnel release include a number of benefits, um, such as the ability to do the procedure in a procedure room or your office setting if you choose. Some, some do it in the um ASC or the hospital setting, uh, but you have options. Um, the surgery can be done under local anesthesia as many do. Um, many surgeons don't use sutures to close the wound. I, I simply close the wound with dermabond. Um, my patience almost. Completely don't take opioids at all. I'd say about 90% of them take no opioids. Um, I take Tylenol and typically ibuprofen and find that that covers their pain. Um, most are back to their normal activities within a few days, not months. I have a number of patients that within a week, we're back to things they like to do down here in South Florida like golf, tennis, or exercise. Uh, the patient has an opportunity for fewer follow-up appointments as the incision is very small and requires less direct monitoring. So, um, from a patient database, um, we found that Patient satisfaction was reported about 92% at two weeks post-op. They were returning to normal activities at an average of 3 days. Uh, return to work was 5 days with a range of 3 to 6 days, and there's very minimal, if any, intraoperative pain reported with local anesthesia. So patients can expect with ultrasound guided carpal tunnel release fewer office visits, which saves them time and money. Who doesn't love that? Um, this can be, like I mentioned, performed at a number of different venues, uh, but it can even be performed in one's office, uh, under local anesthesia or what's known in hand surgery as Walo, wide awake, local anesthesia, no tourniquet. Um, many hand surgeries these days are performed with local anesthesia using this method. Um, no sutures are involved. Patients love that, and they rapidly get back to their activities, as I mentioned. So what's the clinical data? Well, there's been 21 publications thus far, um, over 1500 patients, over 2000 risks. No neurovascular injuries were reported. There were no conversions to open. Uh, follow-up was 3 months to over 2 years. Clinical success was over 97%. There was one incomplete release. Patient had some persistent symptoms requiring revision. One late recurrence over a year post-op. And these studies have shown that ultrasound carpal tunnel release is superior to many open carpal tunnel release in many ways. Um, of note, these publications were primarily with the device seen on the bottom picture, which is a hook blade, rather than the device I was talking about that I currently use. Um, there was a perspective randomized, uh, study performed by Rojo and Man, um, or I think I'm sorry, it's Rojo Manau, it's 11 surgeon, but it was a single surgeon that performed 41 ultrasound guided carpal tunnel releases versus 41 mini open carpal tunnel releases. You followed them for up to 12 months. You found no complications in the ultrasound guided group. Um, and interestingly and importantly, the ultrasound guided group had 5 times fast, faster return to activities. They stopped their meds a lot quicker and they had immediate relief of paresthesias typically. So, why haven't more surgeons adopted the ultrasound guided technique? There's a few reasons. Um, you know, knowledge and skills, it does take additional training and expertise. Um, many surgeons are happy with their open and endoscopic releases. They think their patients do great. They don't really have a large impetus to, to seek change and go through further training to buy an ultrasound possibly. Um. But, um, you know, I think we just didn't have the right tool. Um, you know, previously we had tools like, like you can see on the two right photos and patients found, um, found it intimidating to not only learn ultrasound but to um perform the release with kind of these primitive tools, I think. Moving on to the surgical technique, uh, for ultrasound guided carpal tunnel release, um, with the method I use. In the holding area, when I greet the patient, typically we'll do the local anesthesia block. I use lidocaine with epinephrine. I usually use about 10 ccs. You can see the video on the left, uh, ultrasound view of the block. Um, the, uh, anechoic fluid is filling the space adjacent to the median nerve. Um, looking at the video on the left, that's not paused. Let's see if I can get control of this. Um, I'm not sure if you can see my cursor, but on the left here, the honeycomb structure here is the median nerve. Um, these, um, round structures that have a broomstick appearance at the end or what tendons look like in cross section. Those are the flexor tendons of the carpal tunnel. Um, and then we have the, um, bright signal here is the lunate. Uh, it's like a snow-capped mountain when you're looking at a bone, it's very reflective with ultrasound. So as you can see, once you get used to looking at it, you, you can really see everything really great. On the right is a video. Showing further hydrodissection during the block in the long axis view, just deep to the transverse carpal ligament. You can see a pathways created uh for later placement of our device. And here's a device insertion through the small incision at the base of the wrist. The device goes just ulnar to the median nerve, um, much like the endoscopic carpal tunnel release devices. It sits between the hook of the hamate and uh ulnar to the median nerve. But, uh, like I mentioned, you can see the ulnar artery here. You can keep it safe. You can rotate the device, um, away from the ulnar artery and the median nerve to box it out. Next, uh, long axis view, the device is being advanced more distally in the tunnel, um, getting it in position at the distal transverse carpal ligament. With this device I use, the release is done retrograde. The blade only cuts in a retrograde fashion. It recesses proximately and distally along a track. Um, the handle stays stationary while you do the release, so none of the anatomy is going to move. That's a great safety feature. Um, and as you'll see, I think on the next slide, we deploy these, um, fluid-filled balloons, which gives 8 millimeters of space to the sides pushing the nerve away, um. And the blade sits right in between those two blades. It's currently recessed. You can't see it just yet. Once the surgeon's in optimal position. Uh, with the thumb will activate the blade. You could see the shark fin-like structure engaging with the distal transverse ligament. And then you switch to the transverse view, you want to see where the ulnar artery is. Um, you want to make sure that median nerve is boxed out. You can see the bright signal of that shark fin-like blade dividing the ligament under live ultrasound guidance. I typically save live videos of the whole procedure just for documentation and to show the patient later if they have interest. After this, you want to, I'm sorry. And go forward, one moment. After this, you want to probe your release so you confirm that you got a full release. The video on the left you'll see is what the probing looks like with the Penfield elevator for me typically before the cut. And then on the right, you'll see the Penfield elevator popping through the ulnar flap of the released transverse carpal ligament. And I'll do a live video scan from distal to proximal showing the entire TCL has been released. Once that's completed, I'll do an anatomical live video scan from proximal to distal showing the median nerve and its branches are all safe, intact, and, and have been protected at the end of the procedure. So, the next 3 videos are uh a live case I did a couple of weeks ago, um. It's, it was done under Wa lot, a patient obviously wide awake, and uh I, I wanted to show these videos to show what the patient experience is like. Hopefully you can hear my voice on these. I'm not gonna speak here, you'll just hear my voice hopefully from the recorded videos. evaluate the um the end of the TCL as well as the SPA. It's right here. Very good. Let's see the 15. It's good. A little older The inner. The 4 millimeter incision. The OK. Comfortable? Yeah. Insert the device and the carpal tunnel and take the balloons. That's to be a voice. Center line off. And walks out the median nerve, which is below us and radial through our balloons. Ulnar arteries protected. Let me check our position on the long axis view here. A position there for release safely proximal to the SPA as well. Activate voice, click save. And we're doing the release now. You'll see the blade come through superficially. A great signal. Dividing the PCO. We're done. But Look at that. Oh that's what you do. I'm moving on to the next video, it's a series of 3. We're confirming a full release with the Penfield. We save. I feel it's popping through. The TCO, which has been divided. We do an anatomical scan at the end. The commons and impact as well. And one final video showing the. Showing the dressing and a little patient counseling here. And here's our incision. We're about to close with Dermabond. Takes 5 to 7 days to heal typically. The patient will keep it clean, dry, and covered fully the 1st 2 days. On the 3rd day, they can shower uncovered, and then they'll just apply a band-aid. That's. Yeah, a small plastic bag can be placed over the hand these 1st 2 days when you shower, and then you'll take the bandage off and shower uncovered on the 3rd day. Thank you. Let's just make sure we're real dry on the periphery. Very good. Any questions? Oh good. And here's ours. So with regards to Um, my chosen device, the experience has been greater than 36,000 procedures done by, um, hand surgeons across the nation. Um, usually a 3 to 6 day recovery. No device-related adverse events have been found, and it's done very, very well on multiple peer-reviewed publications. Um, this is a kind of a busy chart, but I'll highlight the important part. Um, the device that I prefer to use is shown here, um, comparing to that perspective randomized study of ultrasound guided carpal tunnel release. And as you can see, all along from, you know, pre-op to early post-op weeks, it performs very nicely and similarly as level one data has shown. You can see these these other two lines up top are the dash score of those uh that underwent open mini open or endoscopic releases, and it looks like it took about 3 months to get the similar dash scores compared to ultrasound-guided carpal tunnel release. So, it's a, it's a nice procedure that addresses many of those patient concerns that require them or uh make them delay their operation while they slowly drift into uh moderate to severe category disease. I think the most powerful thing in my practice is, it's kind of highlighted on this slide, um, with my endoscopic carpal tunnel releases. When I thought about it, the patients really had oftentimes up to 9 visits from their perspective. Uh, to get their, their problem treated, whereas now they're down to 2.5 visits. Just briefly, with endoscopic carpal tunnel release, of course, they'd have an initial consult and before I became handy with ultrasound measurement, a lot of times I'd have to order an electrodiagnostic study to confirm the diagnosis. It can sometimes take 6 weeks or more in my experience locally. Then they would have to come back and see me for another consult to review the study and make sure they're indicated and, and book their surgery. And a lot of times, of course, they would need a medical clearance because we're doing it under sedation. And along with that, they're gonna need pre-op testing appointments. Um, and then of course the surgery day, which was under sedation. And then I would oftentimes see them 3 times in the office post-op, post-op week 1 to change the dressing, check the wound and counsel them, post-op week 2 to remove the sutures that I placed, and then oftentimes post-op week 2 to see how they're recovering. Um, my experience with ultrasound carpal tunnel release has brought it down to 2.5 visits typically. Um, and we're talking about the majority of patients I see, like I mentioned, have had the disease for months or years. Um, if they have a mild new case, we're treating it non-operatively. As far as the operative cases, um, you know, they're gonna have a consult with me. Um, nowadays I do the CTS 6 which Takes, takes me 20 seconds to do on my template as I do my note, calculate the score, and then I'll do an ultrasound confirmation of the size of their median nerve. If all of that is conclusive that they have carpal tunnel syndrome and they want to proceed with surgery, next time I see them, a surgery day under local anesthesia. And then now we move to phone call follow-ups. We usually do about 5 days later and check in with the patient, um, counsel them further, answer any concerns and questions, and the doors always open if they want to come in. I'd say maybe 1 out of 25 end up coming in. Um, they, they seem to appreciate the phone call follow-up. It saves them time. They don't have to have another half day off of work to come see me just to check a minor wound. Um, so they're, they're loving that aspect as well. This has been, this slide really highlights how this has been a game changer for my patient's experience and why I'm a huge advocate of uh this procedure as opposed to endoscopic carpal tunnel release, which I usually uh or previously performed. And that's the end of the talk, so. Thank you, everyone, and uh I'd be happy to answer any questions you might have over the next few minutes. Alex, you want to, I was very, very informative. Your incision is about as small as my hip incision. Um, but we do have some questions. Uh, first one that came into the chat box was when can CTS be attributed to workers' comp injuries and how do you deal with this in your patients? Yeah, that's a, that's a good question. Um, I don't think there's an objective way to um answer that question, um, for the work comp carriers. Um, I think it's up to your judgment, um. You know, there haven't been a lot of um jobs out there that Our literature is documented that they're high risk for developing carpal tunnel syndrome in and of themselves. Um, you know, I think a lot of the patients that we see under workers' comp for carpal tunnel syndrome, um, they believe that their repetitive activities at the keyboard, for example, are playing a role, but I wish I had a good objective answer for you on that one. However, it's really just based on, on your own opinion and judgment, uh, case by case basis. Um, next question is, I use EMG to see if patients get better over time. Do you find that the cross-sectional area of the median nerve on ultrasound decreases back to normal after surgery. So much like electrodiagnostic studies, um, ultrasound, evaluation, you know, I, I think it's, it's shown that the median nerve doesn't go back to its normal size. Um, if it does, maybe it takes a long time, maybe we're not watching those patients or having another look five years later. However, you know, obviously we're looking at their symptom resolution, which is often Even the night of surgery, um, they often report that their symptoms went away or, or started to get significantly better. So that's the most important thing. Follow them clinically. Um, that's interesting to hear that. Um, uh, how do you handle cases where CTS is part of a broader systemic, uh, issue and such as rheumatoid arthritis or diabetes and how does this affect your treatment strategy? Well, you have to counsel the patient as always about expectations. Um, you know, those diabetic patients might have an incomplete recovery in some cases, um, due to their neuropathy. Um, some patients obviously come in with, um, double crutch syndrome like a herniated disc at C5 or 6. so you counsel them that, you know, we're gonna take care of, of your carpal tunnel. However, you may have some persistent symptoms that still need to be evaluated and treated. Um, possibly with another specialist. Uh, doctor Cohen, do you think general orthopedic surgeons can do the ultrasound assisted release? and how do you recommend getting trained for it? So I think it's possible. Um, it does take significant training. Um, some of the companies that make the devices do offer, um, direct, uh, in-person labs, uh, weekend courses to learn the basics, followed by follow-up, um, uh, practice, if you will, on cadaveric specimens, um. You have to also, you have to get access to a machine whether you own it or you're borrowing it from, from your uh your hospital, etc. You need to get a, a high-quality machine that you can feel confident in in seeing all the small structures we need to see. Um. And then, you know, you need, I would highly recommend anybody that's interested in doing this also, um, to ultrasound, literally every day. Make it a part of your practice. I do many of my injections in the office for the last 12 or 13 years under ultrasound guidance. Um, I use ultrasound for diagnostic purposes many times. Um. Even with trigger finger, which I really didn't get to have the time to go over tonight, um, I'll, I'll show the patient how the tendons are moving and how they're impinging at a one pulley level under ultrasound to educate them. Um, we'll, we'll use ultrasound to diagnose masses. Is it, is it a solid tumor? Is it a cyst? So a lot of times we can save the patient in MRI, so they're, they're thankful for that. But basically, long-winded answer, but sure, you know, orthopedic general surgeons can learn how to do this. You just have to put in the time and just, you know, make sure you go about it in a methodical way. Um, starting with, you know, uh, seeking training possibly from, from these companies that make the devices or the Han Society meetings. Every time I go, there's more and more ultrasound guided education and courses. You just got to get involved, get educated, but yes, this, this is something learnable. um, you just have to dedicate the time and energy. Uh, question about the cost of the device. Um, So, I, I, I don't feel comfortable talking about that. I think, you know, it's not my place to talk about the, the cost, but I will tell you um along those lines that, um, you know, some, as I mentioned, some surgeons do the procedure um in a hospital setting or ASC versus their office. Um, I find that if you're gonna offer it in the office setting, you may need to ask the patient to purchase the device, the disposable device, because that's not gonna be covered by insurance. If one does the procedure at at a hospital or ASC setting, um, that can be potentially bundled into their facility fee payment. Um, but these are some of the logistics that one needs to work through, uh, with your facilities when you're, when you're gonna start offering these procedures. Um, how about in your experience what patient characteristics most strongly influence the success of conservative treatments versus surgical intervention? It's really about the disease severity. Um, if you have a mild case. You know, I certainly encourage them to start with some non-operative care. If, you know, whenever that's completed, um, you know, if it's, if it's just not going away and they're just tired of wearing a brace every night, um, a lot of them would like to have surgery. Most patients obviously do great because they brought a relatively healthy nerve to the table. On the other end of the spectrum, those severe cases, like I mentioned, you really have to lay the rate. They have to understand they're not gonna, they might not even notice any symptom improvement. And really my, my only goal might be just to stop the disease progression in its tracks, so it doesn't continue to deteriorate where their numbness is more dense. Now they're burning their fingertips and they're trying to cook or their weakness becomes so terrible, they're, they just, they're dropping things left and right in the kitchen. Um, so, always the disease severity is what guides the success of both non-operative and operative management. I never want to see a patient get to that severe kind of category. I always, um, you know, educate them when I see them, when they're in that mild to moderate category that really, we got to keep a close eye on this and you never want to go to a constant nature where I know some of your nerve is damaged. All right. And then the last question from the chat box is do you incorporate a multidisciplinary team approach for complex CTS cases and how does this influence the overall treatment plan? Um, personally, no. I mean, typically, Like I mentioned in the talk, it's, it's really um consultation um with me. I'm doing the, the confirmatory um. Uh, testing in the office with the ultrasound and the CTS 6. Now, if, if the question might be referring to those that have also an endocrine issue that might be playing a role or amyloidosis playing a role, yes, you, you may need to have um a more multi multidisciplinary approach, depending on the specialist you need to call and ask on, um, such as an endocrinologist, possibly, um. And um yeah. OK, that's fascinating. Uh, thank you for presenting that. So that's the, um, all the questions from the chat box and housekeeping. Uh, there is gonna be an on-demand viewing that's gonna be available for the same URL looks like about 24 to 48 hours or so. Um, but that pretty much wraps up the webinar. Uh, it doesn't look like there's any more questions. Let me just check, but yeah, that seems like that's it. Uh, so thanks for joining everybody. I was very informative, and again, like I said, this is gonna be, uh, available in the next 24, 48 hours. Thank you everybody for attending. Thank you, Doctor Gockman. And uh everybody have a great night. Take care.
