Carpal tunnel syndrome (CTS) represents the most common form of peripheral nerve entrapment. Although idiopathic and systemic etiologies are not uncommon, repetitive and stressful wrist motion activities represent a large majority of the cases. Its clinical presentation is classic, and diagnosis can easily be corroborated with electrodiagnostic studies. As a single clinical entity, CTS was not recognized until 1854, when it was first described by Paget (1). His description included a patient who sustained traumatic compressive injury of the median nerve at the distal radius. Subsequently, in 1880, Putnam (2) reported on a series of patients who presented with symptoms consistent with CTS. The first report of surgical release of a compressed median nerve following a traumatic injury was by Learmonth in 1933 (3). In 1946, Cannon and Love (4) first reported the first surgical release of a nontraumatic entrapped median nerve at the wrist. However, beginning in 1950, and during the subsequent two decades, Phalen (5-10) reported on a large number of patients with idiopathic spontaneous CTS, treated by surgical transection of the transverse carpal ligament. He is acknowledged as single-handedly popularizing the surgical treatment of CTS.

In all surgical procedures, the basic principle in the treatment of CTS is the sectioning of the transverse carpal ligament, thereby increasing the carpal tunnel's capacity. The main variation between the open surgical releases centers around the location and length of the incisions. Some advocate small (<2 cm) palmar incisions, whereas others are proponents of long incisions extending from midpalm across the distal wrist crease and into the forearm. In all these procedures, normal structures (dermis, subcutaneous fat, palmar fat pad, palmar aponeurosis, and palmar brevis muscle) are sectioned and dissected to gain access to the transverse carpal ligament. In the process, dissection of these richly innervated structures can lead to longer and more painful recovery periods. As with many other minimally invasive techniques introduced into neurosurgery, the goals of endoscopic carpal tunnel release include less postoperative pain, less tissue disruption, earlier return to work, increased patient satisfaction, and

From: Minimally Invasive Neurosurgery, edited by: M.R. Proctor and P.M. Black © Humana Press Inc., Totowa, NJ

comparable or better outcomes to proven open surgical techniques. This chapter describes the different types of endoscopic carpal tunnel releases and the author's preferred method for sectioning the transverse carpal ligament.

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