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Chirurgie de la main 33 (2014) 75–94

Recent advance

Carpal tunnel syndrome
Le syndrome du canal carpien
M. Chammas
Service de chirurgie de la main et du membre supérieur, chirurgie des nerfs périphériques, hôpital Lapeyronie,
CHU de Montpellier, avenue Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
Received 27 August 2013; received in revised form 31 October 2013; accepted 11 November 2013
Available online 15 February 2014

Abstract
Carpal tunnel syndrome is the commonest entrapment neuropathy and is due to combined compression and traction on the median nerve at the
wrist. It is often idiopathic. Although spontaneous resolution is possible, the usual natural evolution is slow progression. Diagnosis is mainly
clinical depending on symptoms and provocative tests. An electromyogram is recommended preoperatively and in cases of work-related disease.
Medical treatment is indicated early on or in cases with no deficit and consists of steroid injection in the canal or a night splint in neutral wrist
position. Surgical treatment is by section of the flexor retinaculum and is indicated in resistance to medical treatment, in deficit or acute cases. Miniinvasive techniques such as endoscopic and mini-open approaches to carpal tunnel release with higher learning curves are justified by the shorter
functional recovery time compared to classical surgery, but with identical long-term results. The choice depends on the surgeon’s preference,
patient information, stage of severity, etiology and availability of material. Results are satisfactory in 90% of cases. Nerve recovery depends on the
stage of severity as well as general patient factors. Recovery of force takes about 2–3 months after the disappearance of ‘pillar pain’. This operation
has a benign reputation with a 0.2–0.5% reported neurovascular complication rate.
# 2014 Elsevier Masson SAS. All rights reserved.
Keywords: Carpal tunnel syndrome; Median nerve compression; Surgery; Endoscopy

Résumé
Le syndrome du canal carpien, le plus fréquent des syndromes canalaires, est dû à des mécanismes combinés de compression et traction du nerf
médian au poignet. Il est le plus souvent idiopathique. Bien que des régressions spontanées soient possibles, une aggravation lente est observée le
plus souvent. Le diagnostic est avant tout clinique, reposant sur les symptômes et les tests de provocation. Un examen électroneuromyographique
est recommandé en période préopératoire ou en cas de maladie professionnelle. Le traitement médical est indiqué de première intention dans les
formes non déficitaires et repose sur l’infiltration intracanalaire de corticoïdes et/ou une orthèse d’immobilisation nocturne en rectitude du poignet.
Le traitement chirurgical qui comprend la section du rétinaculum des fléchisseurs, est licite en cas de résistance au traitement médical, dans les
formes déficitaires ou dans les formes aiguës. Les techniques mini-invasives (endoscopie, mini-open) aux courbes d’apprentissage plus longues
semblent créditées d’une récupération fonctionnelle plus précoce par rapport à la chirurgie classique, mais avec des résultats identiques à long
terme. Le choix dépend du chirurgien, de l’information du patient, du stade de gravité, de son étiologie et de la disponibilité du matériel. Les
résultats sont satisfaisants dans près de 90 % des cas. Rapidité et importance de la récupération neurologique dépendent du stade de gravité et du
terrain. La récupération de force demande deux ou trois mois après régression des douleurs de type pillar pain. Cette chirurgie à la réputation de
bénignité a 0,2 à 0,5 % de complications majeures neurovasculaires.
# 2014 Elsevier Masson SAS. Tous droits réservés.
Mots clés : Syndrome du canal carpien ; Compression du nerf médian ; Chirurgie ; Endoscopie

1. Introduction

E-mail address: m-chammas@chu-montpellier.fr.

Carpal tunnel syndrome (CTS) is the commonest entrapment neuropathy and is due to combined compression and

1297-3203/$ – see front matter # 2014 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.main.2013.11.010

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M. Chammas / Chirurgie de la main 33 (2014) 75–94

traction on the median nerve at the wrist. It was first described
by James Paget in 1853. In 1913, Marie and Foix published the
first description of a neuroma proximal to the flexor
retinaculum (FR). The first surgical release of the FR is
attributed to Galloway in 1924 [1].
The prevalence of CTS is estimated between 4 and 5% of the
population especially between ages 40 and 60 [2]. In 2008,
127,269 people over 20 years were operated for CTS in France,
i.e. an incidence of 2.7/1000 (women 3.6/1000, men 1.7/1000)
[3]. There were two peaks of frequency, the first and highest
between ages 45 and 59 including 75% women, and the second
between ages 75 and 84 including 64% women. Since 1999,
when 101,900 were operated, an annual rise of 2.8% has been
reported. The cost of surgery supported by the social security in
2008 was 108 million Euros. For people aged 18 to 85 with
primary operation the global cost of time off work was 81
million Euros, 42 of which were for work-related disease. The
duration of leave exceeded 56 days for 38.9% of cases after
open surgery, and 71.2% exceeded 28 days after endoscopic
release (32.8% of which exceeded 56 days).
2. Anatomy
2.1. Flexor retinaculum
The carpal tunnel is an osteofibrous outlet [4], which is not
extensible and defined as the space between the FR, which forms
its ceiling, and the carpus its floor. It is medially limited by the
hook of hamate, triquetrum, pisiform and laterally by the
scaphoid, trapezium and the septum of the flexor carpi radialis
(FCR) tunnel. The floor is formed by the capsule and the anterior
radiocarpal ligaments covering the adjacent parts of the scaphoid,
lunate, capitate, hamate and trapezium. The FR is composed
mainly of transverse fibers and has three parts [5] (Fig. 1):

Fig. 1. The three portions of the FR as described by Cobb [5]. 1. Proximal part
thickening of the deep layer of the antebrachial fascia at the distal
radius. 2. Intermediate part, characterized by its bony insertions: the pisiform
and the hook of hamate on the ulnar side, the scaphoid tubercle and the tubercle
of the trapezium on the radial side. 3. Distal fascial part extending between
thenar and hypothenar muscles.
Les trois portions du RF d’après Cobb [5]. 1. Partie proximale, épaississement
du feuillet profond du fascia antébrachial en regard de la partie distale du
radius. 2. Partie intermédiaire ou LTC, caractérisée par ses insertions
osseuses : du côté ulnaire le pisiforme et l’hamulus de l’hamatum ; du côté
radial, le tubercule du scaphoïde et le tubercule du trapèze. 3. Partie distale
aponévrotique tendue entre muscles thénariens et hypothénariens. 

the proximal part is a thickening of the deep layer of the
antebrachial fascia at the distal radius. This leaflet is
prolonged deep to the FCR, flexor carpi ulnaris (FCU) and
the ulnar bundle to surround only the 9 flexor tendons and the
median nerve; 
the intermediate part or transverse carpal ligament (TCL) is
characterized by its bony insertions: medially to pisiform and
hook of hamate and laterally to the tubercles of the scaphoid
and the trapezium; 
the distal aponeurotic part extends between the thenar and
hypothenar muscles. These two last portions represent the
‘classic’ part of the carpal tunnel.
The surface landmark of the proximal border of the TCL
corresponds to the wrist crease. According to Cobb [5], the TCL
starts about 11 mm proximal to the capitolunate interval and the
carpal tunnel ends about 10 mm proximal to the 3rd
carpometacarpal interval (Fig. 2). The mean width of the
carpal tunnel from the TCL is 25  1.5 mm distally. This gives
an hourglass shape. The mean thickness of the flexor
retinaculum is 0.6 to 2 mm proximally and 1.6 to 3.6 mm at
the level of the hamate.

Fig. 2. Radiographic projection of the three areas of FR described by Cobb [5];
its hourglass shape.
Projection radiographique des trois zones du RF d’après Cobb [5] ; sa forme en
sablier.

M. Chammas / Chirurgie de la main 33 (2014) 75–94

The flexor retinaculum has four functions: 
it represents the first pulley of reflection for the flexor
tendons. Its section causes palmar displacement of the flexor
tendons at 20–308 wrist flexion and an increase in their
excursion of 15 to 25% [6]; 
mechanical protection of the contents; 
base for proximal insertion of thenar and hypothenar
muscles; 
minor role in transverse stabilization of the carpal arch.
Superficial to the FR, there are the longitudinal connective
fibers of the palmar aponeurosis – a prolongation of the
palmaris longus (PL) tendon if present, radial fibers of the FCU
and the superficial part of the antebrachial fascia surrounding
FCR, FCU and the ulnar neurovascular bundle [5].
Guyon’s canal is superficial on the ulnar side and partially
covers the ulnar border of the TCL (Fig. 3). More distally, the
ulnar neurovascular bundle is found medial to the hook of
hamate. In some cases, it can be more lateral, which can be

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accentuated by wrist extension risking error of approach in
endoscopic surgery or direct injury in open surgery.
2.2. The contents of the carpal tunnel
The median nerve is accompanied by the four tendons of the
flexor digitorum superficialis muscle (FDS), the four tendons of
the flexor digitorum profundus (FDP) and the flexor pollicis
longus (FPL) tendon. The FPL tendon is the most radial
element, the median nerve most palmar.
Proximal to the canal, the median nerve is located either just
dorsal to PL or between FCR and PL. In neutral position of the
wrist, the median nerve is either superficial to the FDS tendon
of the index, or between FPL and FDS of the index or palmar to
the FDS tendon of the middle finger. At the distal part of the
canal, the median nerve divides into six branches: the thenar
(recurrent) motor branch, the three proper palmar digital nerves
(radial and ulnar to the thumb and radial to the index) and the
common palmar digital nerves to the 2nd and 3rd spaces.
The flexor tendons are surrounded by synovial sheaths: 
a common synovial sheath of the long finger flexor tendons
which extends beyond the upper border of the FR and often
communicates with the synovial sheath of the little finger
flexor; 
a radial digito-carpal synovial sheath surrounds the FPL.
2.3. Anatomical variations
These may explain variations in symptoms and present a risk
of iatrogenic injury during surgery.
2.3.1. Anatomical variations in nerve
2.3.1.1. Bifid median nerve with high division. Bifid median
nerve with high division (1 to 3.3% of cases) may be present
alone or associated with a persistent median artery [7].
2.3.1.2. Thenar (recurrent) motor branch. Lanz has described
five types [8] (Fig. 4): the commonest is the extra-ligamentous
form (46%), under the ligament (31%), the transligamentous
form (23%) and two rare forms: one where the thenar branch
arises from the ulnar side of the median nerve and crosses it at
the thenar muscles, and the other (9%) where the thenar branch
is superficial to the FR. Kozin found in 4% of cases there were
multiple motor branches with one of them crossing the FR
every time [9]. The fascicles making up the thenar branch are
located in the radial portion of the median nerve in 60% of
cases, palmar in 20% and central in 18% of cases [10]. The
thenar branch passes through a separate tunnel before entering
the thenar muscles in 56% of cases. These variations may
explain the variable motor deficit in severe compression of the
median nerve [10].

Fig. 3. Position of Guyon’s canal in relation to the FR. At the pisiform, the
Guyon’s canal partly covers the FR (A). More distally, it lies medial to the hook
of hamate (B).
Position de la loge de Guyon par rapport au RF. Au niveau du pisiforme, la loge
de Guyon recouvre en partie le RF (A). Plus distalement, elle se situe
médialement à l’hamulus de l’hamatum (B).

2.3.1.3. Palmar branch of median nerve. Usually the palmar
branch arises 4–7 cm proximal to the flexion crease of the wrist
and travels for 16 to 25 mm beside the median nerve, then
enters a tunnel formed by the fascia on the medial edge of the

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Fig. 4. Variations of thenar (recurrent) motor branch of the median nerve according to Lanz [8]. Extra-ligamentous form (A). Subligamentous form
(B). Transligamentous form (C). Origin at the ulnar side of the median nerve and crossing the nerve at the thenar muscles (D). Course superficial to FR (E).
Variations du rameau moteur thénarien du nerf médian d’après Lanz [8]. Forme extra-ligamentaire (A). Forme sous-ligamentaire (B). Forme transligamentaire (C).
Naissance du côté ulnaire du nerf médian et croisement de celui-ci en regard des muscles thénariens (D). Trajet superficiel par rapport au RF (E).

FCR to emerge 8 mm proximal to the flexion crease of the wrist
and innervate the skin over the thenar eminence. The palmar
branch can cross the TCL or travel ulnar to the median nerve.
2.3.1.4. Median nerve territory in the hand. The median
nerve provides sensory innervation to the palmar aspects of the
three radial fingers and the radial half of the ring finger.
Dorsally, it supplies the last two phalanges of the index and
middle fingers and the radial half of the ring finger. The origin
of the palmar branch proximal to the FR explains why the
thenar area is spared in CTS.
The median nerve innervates the muscles of opposition: the
abductor pollicis brevis (APB), opponens pollicis, the superficial head of flexor pollicis brevis (FPB) and the first two
lumbricals.
2.3.1.5. Communicating branches
Sensory and motor communicating branches (CB) with the
ulnar nerve exist.
2.3.1.5.1. Palmar communicating branch of Berretini. This sensory CB is found in 67–92% of cases deep to
the superficial palmar arch and is responsible for changes in the
sensory territory at the ulnar side of the middle and ring fingers
and the radial side of the little finger between the median and
ulnar nerves [11–13] (Fig. 5). In some cases, this branch is just
distal to the FR, where it may be injured in carpal tunnel
release.
2.3.1.5.2. Communicating branch of Riché and Cannieu. This CB is very common (77% to 100%) [12] and is
responsible for the distribution of thenar muscles between
median and ulnar nerves and can take any of various forms: 
the commonest form is a communicating branch between
thenar branch of the median nerve and deep branch of the
ulnar nerve to the FPB; 
CB in the adductor pollicis; 
CB between thenar branch and deep branch of the ulnar nerve
at the first lumbrical; 
CB between a palmar digital nerve of the thumb and the deep
branch of the ulnar nerve.
Note that the innervation of lumbricals is similar to that of the
FDP.

2.3.2. Vascular anatomical variations: Persistent median
artery
This embryonic remnant is observed in 1–16% of dissections
or operations [14]. A persistent median artery of at least 3 mm
in diameter was noted by Doppler in 26% of asymptomatic
patients (6% cases were bilateral) [15]. A bifid median nerve
may be associated.
2.3.3. Muscle and tendon variations [16]
2.3.3.1. Palmaris longus muscle variation. The PL may run
inside the carpal tunnel to insert on its deep surface, is called
palmaris longus profundus, and can cause a constriction of the
median nerve. A reversed PL with an intracanalicular muscle
body may be present, called palmaris longus inversus.
2.3.3.2. Flexor digitorum superficialis. The extension of the
muscle belly within the carpal tunnel is the most common
variation, estimated by Holtzhausen to be 46% in women and
7.8% in men [17].
2.3.3.3. Lumbricals. The insertion can extend inside the
carpal tunnel, with no proven incrimination for median nerve
compression [7].
2.4. Cutaneous innervation of the palm of the hand
Four nerve branches involved in the innervation of the palm
at the thenar and hypothenar eminences are considered at risk in
carpal tunnel surgery [12] (Fig. 6). Some of their branches may
cross the radial border of the ring finger: 
the palmar branch of the median nerve; 
the palmar branch of the ulnar nerve which is inconstant,
arising 4.6 cm proximal to the pisiform bone; 
the nerve of Henle, nervus vasorum of the ulnar artery, which
contributes to the innervation of the hypothenar eminence in
40% of cases; 
the transverse palmar branches of the ulnar nerve arising
in Guyon’s canal and innervating the skin of the hypothenar
eminence and the palm of the hand, distal to the territory
of the palmar branch of the ulnar nerve and the nerve of
Henle.

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79

Fig. 5. Variations of communicating branch between the ulnar and median nerves in the palm of the hand and implications on territories of sensory innervation
described by Don Griot [13]. Type 1: ulnar nerve connections to the median nerve (most frequent): radial digital nerve to the ring finger (42–62%) (A), to the radial
digital nerve of the ring finger and ulnar digital nerve of the middle (4–10%) (B), to the third common digital nerve (0–5%) (C), to the radial digital nerve to the ring
finger and radial digital nerve to middle (0–7%) (F). Type 2: connections of the median nerve to the ulnar nerve: towards the ulnar digital nerve of the ring finger (0–
4%) (D), to the ulnar digital nerve of the ring and the radial digital nerve of the little finger (0–4%) (G). Type 3: perpendicular connections with unknown destination
(0–8%) (E). Crossing of fibers (0–4%) (H).
Variations du rameau communicant entre nerf médian et nerf ulnaire à la paume de la main et conséquences sur les territoires d’innervation sensitive d’après Don
Griot [13]. Type 1 : connexions nerf ulnaire vers nerf médian (les plus fréquentes) : vers le nerf digital radial du 4e doigt (42–62 %) (A) ; vers le nerf digital radial du
4e doigt et le nerf digital ulnaire du 3e (4–10 %) (B) ; vers le nerf 3e nerf digital commun (0–5 %) (C) ; vers le nerf digital radial du 4e doigt et le nerf digital radial du
3e (0–7 %) (F). Type 2 : connexions du nerf médian vers le nerf ulnaire : vers le nerf digital ulnaire du 4e doigt (0–4 %) (D) ; vers le nerf digital ulnaire du 4e doigt et le
nerf digital radial du 5e (0–4 %) (G). Type 3 : connexions perpendiculaire, destination non connue (0–8 %) (E). Croisements de fibres (0–4 %) (H).

2.5. Surface anatomy

3. Pathophysiology and etiology

The proximal border of the FR corresponds to the wrist
flexion crease and the median nerve is at the middle of the wrist.
Distally, there are two methods to mark the surface anatomy of
the superficial palmar arch and the thenar branch:

3.1. Structural nerve abnormalities and clinical
correlations 

the cardinal line of Kaplan (Fig. 7) from the deepest point of
the first web and towards the ulnar border of the hand parallel
to the proximal palmar crease. The superficial palmar arch is
at least 7 mm distal to the line of Kaplan along the axis of the
radial border of the ring finger [18]. The point where the
thenar branch penetrates the muscle is between 1 and 15 mm
proximally, along the radial border of the middle finger; 
Cobb’s landmarks [19] (Fig. 7): they better locate the hook of
hamate [20] because they are not affected by any trapeziometacarpal thumb stiffness. The hook lies at the intersection of
two lines: one from the pisiform to the proximal palmar crease
along the axis of the index, the other joining the middle of the
base of the ring finger and the junction middle to medial thirds
of the wrist flexion crease. The superficial palmar arch is on
average 2.7 cm (1.8 to 4.5 cm) distal to the hook of hamate.

The entrapment neuropathy combines phenomena of
compression and traction. Anatomically, there are two sites
of median nerve compression: 
at the proximal edge of the carpal tunnel, caused by wrist
flexion and due to the change in thickness and rigidity
between the antebrachial fascia and the proximal portion of
the FR; 
at the narrowest portion at the hook of hamate [12] (Figs. 1
and 2).
The longitudinal movement of the median nerve in the
carpal tunnel was found to be 9.6 mm during flexion [21], 0.7 to
1.4 cm in wrist extension [22]. It can vary from 2.5 to 19.6 mm
depending on the position of the shoulder, elbow, wrist and
fingers [23]. The median nerve tension varies from 8%
depending on the position of the shoulder and 19% depending

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the axon, as well as alterations in the supporting connective
tissue. Lundborg proposed an anatomo-clinical classification
useful in clinic [25] (Table 1). In so-called idiopathic CTS,
several factors are behind the nocturnal increase in intracanalicular pressure: 
redistribution of the upper limb fluids in supine position; 
lack of muscle pump mechanism that contributes to the
drainage of interstitial fluid in the carpal tunnel; 
tendency to place the wrist in flexion thereby increasing
intracanalicular pressure; 
increased blood pressure in the second half of the night; 
fall of cortisol levels.
This classification, is simple, but lacks sensitivity. After
compression, not all nerve fibers within the same nerve are at
the same level of damage, the peripheral fibers are affected
before the more central ones, large myelinated ones before
smaller ones, and sensory fibers before motor fibers.
In chronic CTS, degradation occurs over months or years.
3.2. Associated pathology
Fig. 6. Distribution of cutaneous nerve branches to the palm of the hand.
Distribution des branches cutanées innervant la paume de la main.

on the position of the fingers. In addition to the longitudinal
movement, a transverse movement of the median nerve occurs
with wrist position or during finger flexion against resistance
[24]. In compression and epineural adhesions, mobility is
hindered, creating lesions due to repeated traction on the nerve
during wrist movements [21].
Nerve compression and traction may cause disorders of the
intraneural microcirculation, lesions in the myelin sheath and

3.2.1. Polyneuropathy
Any polyneuropathy, especially diabetes mellitus, can
promote CTS by structural and functional alterations of the
median nerve, making it more sensitive to any compression [26].
3.2.2. Staged nerve compression syndrome ‘‘Double crush
syndrome’’
The concept of staged nerve compression described by
Upton and Mac Comas [27] is based on the fact that proximal
compression of a nerve makes it more sensitive to another more

Fig. 7. Cardinal line of Kaplan and Cobb’s surface landmarks from Cobb [19]. H: hamate; FCR: flexor carpi radialis; FCU: flexor carpi ulnaris; P: pisiform; TB:
thenar (recurrent) branch of the median nerve.
Ligne cardinale de Kaplan et repères de Cobb d’après Cobb [19]. H : hamatum ; FCR : flexor carpi radialis ; FCU : flexor carpi ulnaris ; P : pisiforme ; RT : rameau
thénarien du nerf médian.

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81

Table 1
Anatomo-clinical classification of Lundborg [25] for staging the severity of CTS.
Classification anatomo-clinique de Lundborg [25] pour l’appréciation du stade de gravité du SCC.
Symptoms

Histopathology

Recovery after decompression

Early stage

Nocturnal

Venous stasis, epineural endoneural edema
Slowing of axonal transports

Immediate

Intermediate stage

Nocturnal + diurnal

Permanent anomalies of microcirculation
Permanent interstitial edema
Connective tissue thickening
Destruction of myelin sheath and
nodes of Ranvier

Rapid symptom relief (microcirculation is re-established)
Repair of myelin sheath (weeks or months) ! persistence
of intermittent symptoms some weeks  persistent
ENMG abnormalities

Advanced stage

Permanent sensory
trouble  deficit of
thumb opposition

Wallerian degeneration
Reactionary fibrous thickening of
surrounding connective tissue

Recovery depends on potential of nerve regeneration
Several months delay
May be incomplete, persistent ENMG abnormalities

distal compression by cumulative effects on anterograde axonal
transport. Likewise, a distal compression, by alterations in
retrograde axonal transport, can promote the emergence of a
more proximal entrapment syndrome (‘‘Reversed double crush
syndrome’’). This can occur in practice in radicular compression or thoracic outlet syndrome (TOS) associated with a CTS
distally.
3.3. Etiology
In most cases, CTS is said to be idiopathic. Secondary CTS
may be related to abnormalities of the container or the contents.
Dynamic CTS is frequently encountered in occupational
pathology.
3.3.1. Idiopathic carpal tunnel syndrome
It occurs most often in women (65 to 80% of cases) between
40 and 60 years, bilateral in 50% to 60% of cases [28].
Bilaterality increases with the duration of symptoms. It is
related to a fibrous hypertrophy of synovial flexor sheath related
to connective tissue degeneration with vascular sclerosis,
synovial edema and collagen fragmentation [29]. Metaanalyses [30] showed that sex, age, genetic and anthropometric
factors (size of the carpal tunnel) are the most important
predisposing factors. Repetitive manual work, exposure to
vibration, and cold exposure are minor predisposing factors.
Other minor predisposing factors have been identified such as
obesity and tobacco.
3.3.2. Secondary CTS
3.3.2.1. Abnormalities of the container. Any condition affecting the walls of the carpal tunnel can cause compression of the
median nerve: 
abnormal shape or position of the carpal bones due to
malunion, carpus or radiocarpal subluxation; 
abnormal shape of the distal radius due to fracture with
translation of more than 35%, or malunion of the distal
radius, metalwork on the anterior surface of the radius; 
pathology of the wrist joint such as osteoarthritis, inflammatory arthritis (due to synovial hypertrophy, bone deformity

and/or carpal shortening), infection, basal thumb arthritis,
villonodular synovitis; 
acromegaly.
3.3.2.2. Abnormalities of content. The abnormalities are: 
synovial hypertrophy; 
abnormal or supernumerary muscle: palmaris profundus
muscle, intracanalicular position of the belly of FDS muscle
or a lumbrical; 
intracanalicular tumor: lipoma, synovial tumor (cyst,
synovial sarcoma), nerve tumor (schwannoma, neurofibroma,
lipofibroma); 
obesity; 
enlargement of a persistent median artery can cause CTS on
effort, 
inflammatory tenosynovitis: inflammatory (rheumatoid
arthritis, lupus) or infectious arthritis, 
metabolic tenosynovitis: diabetes mellitus (abnormal
collagen turnover), primary or secondary amyloidosis
(chronic hemodialysis with Beta 2 microglobulin deposits),
gout, chondrocalcinosis; 
abnormal fluid distribution;
– during pregnancy [31,32] CTS occurs in 0.34 to 25% of
cases, especially in the 3rd trimester, with deficit in 37–
52% of cases, with spontaneous resolution before the 3rd
postpartum month in 85% of cases,
– hypothyroidism is a common etiology,
– an arteriovenous fistula in the context of chronic renal
failure.
3.3.3. CTS and occupational pathology
The French Table 57c of the general social security scheme
and Table 39c of the agricultural security scheme for the
recognition of CTS and compression of the ulnar nerve at
Guyon’s canal state that: ‘‘Work in the usual way, repeated
movements or prolonged wrist extension or hand grip, a carpal
stress or prolonged or repeated pressure on the pillar of the hand’’.
In 2007, with 40,537 cases, Table 57 of the general scheme
of occupational diseases accounted for 75% of reported
occupational diseases [33]. CTS is responsible for 37% of

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recognized cases under Table 57 and 27% of all recognized
occupational diseases. In addition to the criteria in Table 57c,
exposure to cold must be considered as another predisposing
factor.
3.3.3.1. Dynamic CTS. The pressure within the carpal tunnel
increases in extension and flexion of the wrist. Repetitive
movements of the wrist in flexion and extension, finger flexion
and forearm supination have been implicated [34]. An
entrapment of FDS and FDP muscle mass during extension
of the wrist and fingers was found in 50% of cases [35].
3.3.3.2. CTS and computer work. No increased prevalence of
CTS was found in case of computer work more than 15 hours
per week, an increased tendency has been shown beyond
20 hours per week [36].
3.3.3.3. Vibration [34]. Exposure to vibration is a minor
contributing factor [30] with histological effects similar to
those related to compression.
3.3.4. Acute CTS
3.3.4.1. Posttraumatic. This is most common with distal radius
fractures, especially with anterior displacement or wrist dislocation. Increased intracanalicular pressure causing acute CTS may
also be due to immobilization of the wrist in flexion, excessive
distraction by external fixator, or due to crush syndrome [37].
3.3.4.2. Non-traumatic [37]. These are rarer: 
infection and tenosynovitis, flexor sheath infection, abscess
or septic arthritis; 
hemorrhage with hematoma under pressure by anticoagulant
overdose, hemophilia, or von Willebrand disease; 
arthropathy, microcrystalline synovitis, tophi; 
high pressure injection; 
acute thrombosis of a persistent median artery; 
burn causing increased compartmental and carpal tunnel
pressure.

4.1. Diagnosis, associated pathology and differential
diagnosis
4.1.1. Symptoms [38]
The condition may be unilateral or bilateral. Paresthesias in
median nerve territory are described as needles, burning
sensation, tingling, heaviness, or electric impulses usually
accompanied by pain radiating to the forearm, elbow or
shoulder. Of insidious onset, these symptoms are predominantly nocturnal or appear on waking up in the morning, they
can also be triggered by unusual daytime activity, or by
maintaining a prolonged position of the hand or wrist such as
holding a newspaper or telephone or driving. Shaking the hand
( flick sign of Pryse-Phillips) [39] or changing the position
relieves the symptoms. At the limits of median nerve territory,
the little finger is sometimes involved due to median-ulnar CB,
after eliminating ulnar nerve compression at the elbow or
proximal cause of compression such as TOS, cervical or spinal
cord causes. A decrease of force, morning edema and cold
intolerance may be noted. As the compression progresses,
paresthesias become permanent leading to clumsiness and
dropping objects. In severe forms, sensory deficit perturbs fine
movements and thenar atrophy can be observed at this stage,
sometimes accompanied by weak opposition of the thumb if
substitution by the ulnar does not exist.
4.1.2. Provocation tests
The median nerve is felt just distal to the flexion crease deep
to the PL tendon or midpoint of the wrist: 
Tinel’s test is positive if the patient experiences paresthesias
with manual percussion of the palmar aspect of the wrist over
the median nerve. The sensitivity is 26% to 79% and
specificity is 40 to 100% [40]; 
Phalen’s test (Fig. 8) is positive if paresthesias appear in
median nerve territory on maximum flexion of the wrist with
elbow extended for a whole minute. The time taken for the
symptoms to appear is noted in seconds. Sensitivity is 67% to
83% and specificity is 47 to 100% [40,41];

4. Diagnosis
Clinical approach of a patient complaining of acroparesthesia of the hand consists of five steps: 
diagnosis by examination, provocative tests, associated
pathology and differential diagnosis; 
determine the etiology; 
assess the severity of the compression by assessing sensory
discrimination using the Weber test and the strength of thenar
muscles innervated by the median nerve; 
additional tests especially electroneuromyographic examination (ENMG); 
propose the appropriate treatment according to severity,
etiology, general condition and activity.
There is no ‘‘gold standard’’ for diagnosis of CTS.

Fig. 8. Phalen’s test.
Test de Phalen.

M. Chammas / Chirurgie de la main 33 (2014) 75–94

83

At the end of this diagnosis, differential diagnosis and
associated pathology are considered, the possibilities being: 
high clinical suspicion of CTS; 
CTS is suspected but accompanied by another pathology:
associated compression syndrome such as ulnar nerve at the
elbow (rarely at the wrist) may be suspected, or multiple
nerve compression syndromes with cervical arthritis; 
symptoms evoke another cause such as TOS, cervico-brachial
neuralgia or neurological disease.
4.2. Determining severity: anatomo-clinical classification
of Lundborg
This is determined by the timing of symptoms and
neurological deficit using the Weber test of static 2-point
discrimination for the pulp, and detection of thenar atrophy
(Table 1).
4.3. Determining etiology
Despite frequent ‘idiopathic’ forms of CTS, systematic
search for etiology is mandatory (Section 3).
Fig. 9. McMurthry’s and Paley’s tests.
Test de McMurthry et Paley. 

test of McMurthry and Paley [42] (Fig. 9) is positive if
manual pressure on the median nerve 1 to 2 cm proximal to
the flexor crease causes pain or paresthesia. Sensitivity is
89% and specificity is 45% [40]. Durkan described a variation
with compression over the FR [43], which is more difficult to
illicit; 
test of compression in wrist flexion [44] where pressure is
exerted on the median nerve over the carpal tunnel using two
fingers with wrist flexed at 608, elbow flexed and forearm
supination. The test is positive if paresthesias appear in the
median nerve territory. Sensitivity is 82% and specificity is
99% [44].
According to Szabo, nocturnal acroparesthesia is the most
sensitive symptom (96%), the most sensitive test is the direct
compression test (McMurtry et Paley) (89%) followed by
Phalen’s test and the monofilaments of Semmes Weinstein
(83%) then the score of Katz and Stirrat (76%) in the typical
form with tingling, burning, heaviness or hypoesthesia with or
without pain involving at least two of the three radial fingers
excluding the palm and back of the hand. Spontaneous wrist
pain or radiating in the direction of the wrist can exist. The
combination of four abnormal tests: compression, monofilaments, Katz and Stirrat scores and nocturnal symptoms is
correlated with the diagnosis of CTS by a probability of 0.86. If
the four tests are normal the probability of CTS is 0.0068. The
author thus concludes that ENMG is not often useful is
diagnosing moderate or severe CTS.

4.4. When to request investigations?
4.4.1. Electroneuromyography (ENMG)
The ENMG consists of a stimulation phase and a detection
phase. The stimulodetection shows sensory and motor
conduction of the median nerve and highlights any slowing
down during the passage through the carpal tunnel. It measures
amplitude and duration of motor and sensory evoked potentials.
Nerve conduction of the ipsilateral ulnar nerve and contralateral
median nerve is also measured.
The earliest and most sensitive electrical abnormality is a
slower sensory conduction (possibly shown by measuring the
distance between the palm and/or fingers and wrist). We can
consider that a median nerve conduction velocity of less than
45 m/s in the carpal tunnel is pathological, normal velocity
being at least 50 m/s [45,46].
At an advanced stage, there is prolonged distal motor latency
between wrist and APB; thus the time between nerve
stimulation at the wrist and the onset of a motor potential
recorded over APB is greater than 4 to 10 ms for a normal of 
3.6 ms, and the muscle shows signs of denervation [46].
Motor latency can be altered without abnormal sensory
conduction (3.9% of cases [47]). This isolated motor
impairment may be due to a motor branch passing through a
separate tunnel in the FR.
This examination is operator dependent. Skin temperature
and age influence the results. The ENMG may be positive in 0–
46% of asymptomatic subjects and negative in 16–24% of
patients with a clinical diagnosis of CTS [48]. In an isolated
motor distal latency study, Seror [49] found a sensitivity of 54%
and a specificity of 97.5%. In an isolated study of sensory
conduction velocity, he found a significantly greater sensitivity
of 75–92% and a specificity of 97.5%.

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M. Chammas / Chirurgie de la main 33 (2014) 75–94

Thus, the false negative rate is not negligible especially in
early disease, where only nerve fibers of small caliber are
affected. The addition of ENMG study to clinical provocation
tests does not provide significant and reliable contribution to the
diagnosis to be recommended in practice [50]. In case of
dynamic CTS, ENMG is positive only when the compression
reaches a certain degree of severity. Again, the ENMG will not
detect early forms. However, normal ENMG almost certainly
excludes a severe or moderate form. The ENMG does not return
to normal in intermediate and severe forms, despite symptom
relief.
ENMG does not provide any additional evidence to the
diagnosis of SCC compared to clinical assessment when the
clinical diagnosis is obvious [51].
Anatomical variations like Martin-Gruber and RichéCannieu can interfere with the interpretation of electromyographic studies.
However, the ENMG examination remains a reference in the
exploration of CTS. In addition to its medicolegal value,
ENMG can confirm the diagnosis, eliminate another disease
(cervico-brachial neuropathy or TOS), detect associated
polyneuropathy, specify single or multiple compression sites
and assess the severity of nerve damage thus guiding the
treatment plan.
The Working Group ANAES [52] concluded that: 
ENMG should follow clinical examination; 
ENMG is not essential for the diagnosis of a typical form of
CTS; 
ENMG is not necessary before steroid injection; 
it is recommended in cases of doubt, it is an aid in the
differential diagnosis; 
it is recommended prior to surgery; 
it is required to establish occupational disease recognition.
4.4.2. Imaging
4.4.2.1. Wrist X-rays and carpal tunnel view. Radiology is no
longer routinely indicated to diagnose etiology of CTS. PA,
lateral or carpal tunnel views of the wrist are useful: 
when there is wrist pain, limited mobility, deformity or flexor
tendon rupture; 
when the medical or history of trauma suggests abnormal
tunnel or contents.
4.4.2.2. Ultrasonography. This is an operator- and materialdependent study. In early disease, the median nerve maintains
normal morphology: a normal aspect of the nerve does not
eliminate CTS. A meta-analysis of 28 series published in 2012
[53] showed an increase in cross-sectional area of the median
nerve  10 mm2, reflecting that increased volume proximal to
stenosis was the best diagnostic test with sensitivity 87.3% and
specificity 83.3%. The ratio (index) of flattening of the median
nerve facing the hamate is a reliable criterion. Other signs are
notching, nerve edema proximal to the stenosis, decreased
mobility during flexion-extension, and the FR bulge. Ultrasound can help diagnose etiology by morphological analysis of

the content, e.g. diagnosis of a persistent median artery
thrombosis using Doppler US.
4.4.2.3. Magnetic resonance imaging. MRI is rarely indicated
but may be useful: 
in secondary tenosynovitis; 
in CTS of the child or young adult to detect intracanalicular
muscle abnormality, particularly in cases of CTS upon effort,
or an intracanalicular tumor.
5. Clinical forms
5.1. Evolving forms
5.1.1. Regression of CTS
The natural evolution of CTS has not been studied in detail
and is not an always progression. Changes may be intermittent
with periods of calm. In one third of patients symptoms regress
spontaneously [54]. According to Padua [55], at 1 year, 34% of
patients improved, and 45% were unchanged. Recent onset and
young age are favorable prognostic factors. Persistent forms
evolve to affect quality of life and can cause irreversible nerve
damage [56].
5.1.2. Acute CTS
Acute CTS often presents with a sensory deficit, possibly
hyperesthesia.
Posttraumatic forms are the most common. A patient with
chronic intermittent CTS may develop acute CTS following
trauma with further increase in intracanalicular pressure. CTS
can also develop de novo. We must distinguish acute
compression where treatment is often surgical, from contusion
where medical treatment is preferred [37]. In acute compression, the aggravation and deficit are gradual; in case of a
fracture or joint displacement, the soft tissue structures increase
in volume. In contusion, the neurological deficit is present
immediately, there is no or little displacement and no volume
increase of soft tissue structures. A pressure recording
apparatus may be used [37].
Diagnosis of the rarer non-traumatic acute CTS may be
obscured by etiology. Acute thrombosis of a persistent median
artery causing CTS is evoked by the absence of etiological
context; spontaneous acute CTS in a young or middle-aged
adult suggests this diagnosis. Sometimes a bruise, manual
exertion or exposure to vibration is present. Spontaneous acute
pain on the palmar aspect of the wrist radiating to the radial
fingers and sensory deficit in median nerve territory are
reported. A Doppler US – if tolerated – shows a persistent
median artery thrombosis often associated with a bifid median
nerve. The diagnosis is usually made during urgent surgical
exploration.
5.2. Associated forms
Another entrapment syndrome of the upper limb may be
associated with CTS. Acroparesthesia of the fifth finger may

M. Chammas / Chirurgie de la main 33 (2014) 75–94

create confusion. We must distinguish anatomical variation of
compression of the ulnar nerve at the elbow, or more rarely in
Guyon’s canal, from TOS or cervical neuropathy.
It is important to check the cervical spine and TOS for a
multiple nerve compression syndrome which may explain
persistent postoperative acroparesthesia.
Trigger fingers resulting from increased synovial volume
must be sought; they can decompensate postoperatively.
Basal thumb arthritis – with inconstant symptoms – is fairly
common after 60 years.
The coexistence of CTS and Raynaud’s phenomenon is not
rare. The differential diagnosis may be tricky since sympathetic
signs are sometimes associated with CTS.
5.3. Age-related forms
In elderly patients, a sensory deficit is often associated with a
thenar atrophy, which usually affects patient autonomy.
In the young patient, we must look for microtrauma or
intracanalicular muscle abnormality, which gives symptoms
only when using the hand.
In children, the causes are usually genetic [57] in
mucopolysaccharidosis and mucolipidosis. Other non-genetic
causes include macrodactyly and tumors.
CTS is rare in adolescents and sports are a contributing
factor [58].
6. Treatment
6.1. Prophylaxis
It is essential in occupational pathology and includes the
modification of the workplace (height) and tools (gloves,
weight, friction, temperature, shape), automation of certain
tasks, slowing down the pace, the introduction of rest periods,
and diversification of manual activities (job rotation).

Fig. 10. Carpal tunnel injection.
Infiltration du canal carpien.

85

Prevention in recreational activities such as sports and crafts
should also be considered.
6.2. Conservative treatment
There is currently a sufficient level of evidence regarding the
effectiveness of steroid injections, splinting and oral corticosteroids. Other treatment modalities such as ultrasound, laser,
diuretics, vitamin B6, weight loss are controversial.
6.2.1. Corticosteroid infiltration
It acts by reduction of synovial volume and by direct effect
on the median nerve. The main risk is injury to the median
nerve, with acutely painful sensation of electric shock, risk of
neurological deficit and persistent pain. The other complication
is tendon rupture.
Our injection point is 4 cm proximal to the wrist flexion
crease halfway between the PL tendon and the FCU, which
corresponds to the axis of the fourth finger (Fig. 10). Prior local
anesthesia is not necessary. After topical antisepsis, the needle
is slowly pushed obliquely at 458 to the carpal tunnel. There
should be no abnormal resistance. The other hand passively
mobilizes the fingers to ensure that the needle is not stuck in a
tendon then injection is performed slowly after aspiration. A
transient painful reaction can occur for some hours after
injection.
Injection between FCR and PL may cause median nerve
injury given the position of the median nerve. Dreano [59]
injects ulnar to PL. Dubert [60] reports the measured location of
the median nerve in relation to PL, FCR and FCU, 1 cm
proximal to the wrist flexion crease and identified a risk zone
located 1 cm on either side of the PL tendon. He recommends
injecting through the FCR 458 medially and 458 distally. There
is no difference at 1 year between injections at the wrist flexion
crease and one 4 cm proximal to it [61].

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M. Chammas / Chirurgie de la main 33 (2014) 75–94

Relief occurs within a few days to 2–3 weeks. Local steroid
injection is more effective than placebo injection at 1 month
and more prolonged than oral corticosteroids at 2 and 3 months
[62]. Temporary relief after local corticosteroid injection is a
good prognosis for surgery [63]. Two injections are not more
efficient than one. More than three injections are not
recommended. The minimum recommended time between
two injections is one month. Diabetes mellitus is a
contraindication especially if uncontrolled.
In intermittent CTS with no deficit, Agarwal et al. [64] found
93.7% improvement clinically and on ENMG at 3 months, 79%
at 16 months with 50% ENMG normalization. In a series of
patients with or without deficit treated by infiltration and splint
for three weeks, Gelbermann et al. [65] reported only 22% were
asymptomatic at maximum follow-up of 26 months. The
criteria for good prognosis are: symptoms for less than one year,
no motor or sensory deficit. Otherwise, failure and recurrence
were observed.
6.2.2. Night splint in neutral wrist position
The tendency to place the wrist in flexion during sleep
increasing the intracanalicular pressure has been implicated in
the occurrence of nocturnal symptoms. The position of the wrist
splint must be in strict neutral position to decrease this pressure.
A splint can be tailored to coexisting pathologies (basal thumb
osteoarthritis). Results are similar to those of corticosteroid
injection [66]. Stutzmann and Foucher [67] found improvement
in moderate CTS in 81% of cases at three years. The duration of
treatment is three weeks to three months and can be done while
awaiting surgery. The splint may be associated with an
injection.
6.2.3. Modification of mechanical and ergonomic measures
Even temporary reduction of activity often provides relief,
especially in CTS after manual overuse.
Very few studies have analyzed the ergonomic measures.
No significant improvement in symptoms and ENMG findings
was found with the use of ergonomic computer keyboards
compared with conventional keyboards in patients with proved
CTS [68].

6.3. Surgical treatment
The principle of surgical treatment is to obtain a reduction in
intracanalicular pressure by increasing the volume of the carpal
tunnel due to the section of the FR. This is usually performed as
day case surgery using a tourniquet. The operation is usually
unilateral. Three techniques are currently used: open;
techniques known as ‘‘mini-open’’; and endoscopic techniques.
Surgery with ultrasound guidance is under development and
evaluation [69]. Whatever the technique, the procedure must be
atraumatic and care must be taken not to place the median nerve
in the extension of the scar incision to minimize postoperative
epineural adhesions.
6.3.1. Anesthesia and carpal tunnel surgery
Carpal tunnel surgery can be done under local, locoregional or
general anesthesia. In distal anesthesia, tourniquet tolerance is
the main limiting factor. Regional median, ulnar and musculocutaneous block is poorly tolerated compared to wrist block.
Local anesthesia infiltration into the carpal tunnel associated
with subcutaneous injection at the incision (Altissimi and
Mancini technique [70]) gives more postoperative relief than
the subcutaneous infiltration alone [71]. The tourniquet is
inflated after injection. Local anesthesia does not cover flexor
tendon synovectomy. Local vasoconstriction by epinephrine in
the local anesthetic avoids use of a tourniquet.
For endoscopic surgery, distal median, ulnar and musculocutaneous nerve blocks when done 6 cm proximal to the wrist
flexion crease, avoid soft tissue infiltration, which is a nuisance
for endoscopy. According to Delaunay [72], after 10 min, 9%
and 32% of patients required additional anesthesia to the
median and ulnar nerves respectively. No postoperative
neurological deficit was found. If used, local anesthesia should
be injected 20 minutes prior to endoscopic surgery to avoid soft
tissue infiltration.
6.3.2. The open technique
6.3.2.1. Basic procedure. This is the oldest technique. An
incision 3 to 4 cm long from the wrist crease is made in the axis
of the radial border of the ring finger (Fig. 11) down to the

Fig. 11. Surgical approaches for conventional open surgery (A) and distal mini-open (B).
Voies d’abord chirurgie à ciel ouvert classique (A) et mini-open distal (B).

M. Chammas / Chirurgie de la main 33 (2014) 75–94

cardinal line of Kaplan. The medial fat pad is retracted and later
repositioned [73] to separate the skin from the FR after surgery.
The palmar fascia is then either incised or retracted laterally.
Subcutaneous dissection to preserve the sensory branches may
create postoperative pain and has not been proven superior to a
direct incision of the FR [74]. Hemostasis using bipolar
coagulation is performed if needed.
FR is exposed using retractors. The hook of the hamate is
identified. FR is incised in its ulnar middle portion in the axis of
the fourth finger thus providing an ulnar border to limit
subluxation of the flexor tendons. The section of FR is
cautiously continued distally, guided by the separation of the
edges up to the fat that protects the superficial palmar arch and
the communicating branch of Berretini. Proximally, the FR is
dissected from flexor synovium using scissors, and a grooved
probe is introduced along the axis of the fourth finger and that of
the forearm to protect carpal tunnel contents. Superficially, the
FR and the distal forearm fascia are separated from the
subcutaneous tissue along the groove. The skin is retracted.
Dissecting scissors are pushed slightly open, under vision,
guided by the groove to incise the remaining proximal portion
of the FR and the adjacent part of the antebrachial fascia.
Complete section is checked by pushing the probe up against
the skin while withdrawing it. The radial flap of the FR must be
carefully lifted with a hook to see the median nerve, which is
the most superficial and radial structure. The content of the
carpal tunnel is checked for muscle abnormality and aspect of
the synovium. The flexor tendons are retracted laterally to
check the floor of the tunnel. Skin is closed without drainage,
unless necessary. Comfortable dressing is placed.
6.3.2.2. Associated procedures
Flexor synovectomy is no longer systematic. A biopsy is
justified if secondary synovitis is suspected. If extensive
synovectomy is needed, the incision is extended proximally to
the distal forearm with a hook in the wrist flexion crease.
Epineurotomy of the median nerve is no longer recommended even in cases with deficit. It can be a source of
postoperative adhesions. A primary endoneurolysis is not
recommended because of the risk of adhesions and devascularization.
6.3.2.2.1. Exploration of the thenar branch. In primary
surgery this is justified only in extensive synovectomy, looking
for anatomical variations, or isolated or predominant motor
deficit where rare specific compression of this branch is
suspected.
Guyon’s canal release in acroparesthesia of the 5th finger is
not recommended in the absence of clinical and ENMG proven
ulnar nerve compression at the wrist. Sensory median-ulnar
branches may be implicated if there is no compression of the
ulnar nerve at the elbow or proximal disease (cervical spine,
TOS, spinal cord). Carpal tunnel surgery gives relief of
symptoms [75]; after open or endoscopic surgery, the pressure
in the Guyon’s canal decreases by two-thirds [76].
6.3.2.2.2. Reconstruction of the FR. The objective is to
reduce the duration of postoperative loss of strength, the risk of
subluxation of the finger flexor tendons and ‘‘pillar pain’’.

87

Various techniques have been proposed [77]: Z-plasty, VY,
zigzag incision with suture of the angles, radial border flap with
proximal pedicle or the Jakab plasty, preferred by Foucher [78]
where the apices of a distal radially based flap and a proximal
flap with ulnar pedicle are sutured, double breasting of the FR.
Most of these interventions are not used and their superiority
has not been proven (series with methodological bias). One
methodologically satisfactory publication of patients with
bilateral CTS, where one side was operated conventionally and
the other with FR prolongation, showed no difference [79].
More recently, a silicone implant and polyethylene terephthalate sutured to the edges of the FR has been proposed; the
authors compared two groups of 400 patients, and found faster
recovery of force in the implant group [80], with five implants
having had to be removed.
6.3.2.2.3. Transfer of thumb opposition. In atrophic forms
with deficit of opposition, the release of the median nerve is
associated with opposition transfer. It is rarely indicated
because the FPB receives ulnar innervation, which provides
sufficient opposition despite an obvious thenar atrophy. If the
opposition is weak, the palmaris longus, prolonged by a part of
the palmar fascia, can be used as transfer onto the APB using
the Camitz technique [81].
6.3.3. The ‘‘mini-open’’ technique
These techniques employ incision in the safety zone
regarding sensory branches of the median nerve and the ulnar
nerve. Various techniques have been proposed: 
mini-open incision over the FR [82,83]: A 1 to 1.5 cm skin
incision is made at the distal part of the FR from the cardinal
line of Kaplan in the axis of the radial border of the ring finger
(Fig. 11). The FR is then incised from distal to proximal using
scissors under retraction. A series published in 2003 reported
results that were no better than those with other techniques,
with no reported complications [82]; 
mini-open with a single incision in the wrist flexion crease:
FR is not seen and the absence of interposition bears the risk
of iatrogenic damage and/or the incomplete section of the FR.
Paine [84] uses a ‘‘retinaculotome’’ to protect the contents of
the carpal tunnel. Durandeau uses a grooved probe, making
this his preferred technique [85]; 
mini-open with a double approach, with a distal incision to
protect the neurovascular elements: again, the FR is not seen
during its section. These include the techniques of Chaise
[86] and Bowers cited by Beckenbaugh [87], with an
additional proximal incision, a distal incision 1 cm downstream of the hook of hamate using a retractor for protection.
Lee and Strickland [88] use a special knife with transillumination.
6.3.4. Endoscopic carpal tunnel surgery
This surgery was introduced in Japan by Okutsu [89] and in
the United States by Chow [90]. The Chow technique includes
two surgical incisions. Complications inherent to the distal
approach have limited its use in favor of the single approach
Agee technique [91] (MicroAire), Centerline1 (Arthrex).

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M. Chammas / Chirurgie de la main 33 (2014) 75–94

6.3.5. Postoperative
Whatever the technique, digital mobilization is possible
immediately postoperatively. The stitches are removed from the
15th day. Strength activities are reintroduced after three weeks
and fully resumed at 6 to 8 weeks. Some authors recommend a
postoperative splint for two or three weeks to decrease ‘‘pillar
pain’’ [92] and improve FR healing. On the other hand,
immobilization may promote postoperative epineural adhesions and limit mobility of the median nerve at the wrist.
Contrary to Chaise [93], no superiority to splinting has been
demonstrated by Finsen [94] and Bury [95].

Fig. 12. Endoscopic surgery through a single incision (Agee technique).
Chirurgie endoscopique à une voie d’abord (technique d’Agee).

Furthermore, placing the wrist in hyperextension in the Chow
technique increases intraductal pressure, which can cause acute
intraoperative compression of the median nerve. Endoscopic
techniques require a longer learning curve and meticulous
technique compared to open surgery.
Technique of Agee: most often under regional anesthesia, a
1 cm incision is made 0.5 to 1 cm proximal to the wrist flexion
crease on the ulnar side of the PL or the middle of the wrist
(Fig. 12). The subcutaneous dissection toggles between veins to
expose the forearm fascia using two skin hooks. Care is taken
not to breach the fascia so as not to injure the median nerve.
Dissecting scissors are placed under the fascia and the proximal
portion of the FR area. The scissors are spread and a distaly
pedicled flap from the FR of rectangular shape is elevated. A
skin hook applied on this flap is used to facilitate exposure and
show that the approach is not in the Guyon’s canal. The deep
surface of FR is rasped to its ulnar half. Care must be taken to be
extrabursal. The protuberance of the hook of hamate is felt in
the tunnel and the transverse striations of FR are identified. The
distal edge of the FR is rasped. Increasing dilators are
introduced into the carpal tunnel. The disposable knife is
mounted. Sterile anti-fog product can be placed on the
endoscope. The knife is lubricated on its deep surface to
facilitate its entry. During the slow progress under endoscopic
control, the knife is pressed against the deep surface of FR
characterized by its striations – used to confirm good position.
Rasping should be repeated until there is no interposition. If
viewing is not good or the introduction of instrument is
difficult, the procedure must be converted to open, and the
patient must be informed of this possibility before the surgery.
Forward progression stops when the distal adipose tissue is
visible. The FR section starts distally close to the adipose tissue.
When both edges of FR recede, the proximal FR flap is cut. The
knife is withdrawn and a retractor may be used to lift the fat that
invaginates between the edges of the FR, which must be
parallel. The FR flap is resected. Wash out, and skin is closed
using suture or Steristrip1 without drainage. Comfortable
dressing is placed.

6.3.6. Results of carpal tunnel surgery
6.3.6.1. Good outcome. In most cases, the outcome is good
with disappearance of pain crises and nocturnal paresthesias
immediately postoperative (early stage of Lundborg). In case of
myelin sheath alterations (intermediate stage), intermittent
paresthesia may persist a few days during the period of repair of
the sheath. If there was a preoperative deficit (advanced stage),
the discriminative sensitivity takes a few weeks to a few months
to recover depending on the severity, whereas pulp dysesthesia
with contact persists throughout this recovery period. Motor
and atrophy recovery is random and usually absent in elderly
patients.
During FR healing, pain and edema in the area facing the FR
section regresses over 4 to 8 weeks and force is recovered in two
or three months. The discomfort is even more marked when the
patient performs manual forceful labor.
The time off work varies according to the type of activity and
the surgical technique. In 2001, Chaise [86] evaluated the time
off work after carpal tunnel surgery using two incisions without
endoscopy and postoperative immobilization of 21 days. For
non-employed, the average was 17 days, for those in the private
sector 35 days, for public sector 56 days. For patients with sick
leave, time off work was 32 days and for those diagnosed as
occupational diseases 49 days. Manual workers had 29 days off
if non-employed, 42 days for the private sector and 63 days for
the public sector.
6.3.6.2. Prognostic factors. From an analysis of the literature,
Turner et al. [96] concluded that the worst results were observed
in case of: 
diabetes mellitus including polyneuropathy and impaired
general condition; 
alcohol and tobacco; 
normal preoperative ENMG; 
occupational disease; 
thenar atrophy; 
multiple nerve compression; 
length of symptoms.
Age is not considered a poor prognostic factor but rather
associated with slow evolution.
6.3.6.3. Comparing open, mini-open and endoscopic surgery. Open or endoscopic surgery is widely used. The volume

M. Chammas / Chirurgie de la main 33 (2014) 75–94

89

favor of mini-open [106]. The risk of incomplete section of FR
is higher in the mini-open [109].
The choice of open, mini-open or endoscopic surgery
therefore depends on the choices and preferences of the surgeon
[110], the information of the patient, the type of CTS, its
etiology and availability of equipment.

Fig. 13. CT view of retraction of the edges of the FR after endoscopic carpal
tunnel release.
Vue tomodensitométrique de l’augmentation de distance des berges du canal
carpien après chirurgie endoscopique.

increase in the carpal tunnel is noted regardless of the technique
used to cut the FR. After open surgery, an increase in volume of
24.2  11.6% was noted with palmar displacement of contents
3.5  1.9 mm [97]. After endoscopic surgery, increased crosssectional area was measured at 33  15% [98] (Fig. 13).
Safety, efficacy, morbidity, cost, and time to return to
preoperative activities were compared. The learning curve is
longer for endoscopic surgery. No difference was found
between the two techniques at one year postoperatively [99].
However, a number of studies have shown that endoscopic
surgery allowed earlier functional recovery especially in the
first three months [78,100–103]. Local pain was less noted after
endoscopy [104,105]. Eight of 14 studies showed a faster return
to work after endoscopy with a difference between 6 and 25
days [106]. However, this remains controversial, other studies
having shown no superiority for either technique [107].
Few studies compared endoscopy to mini-open surgery;
results were either identical or favored endoscopic surgery
regarding postoperative pain [106]. To Wong [108], the
technique of Lee and Strickland [88] seems to be associated
with less postoperative pain than the endoscopic technique of
Chow.
Conventional and mini-open surgery also show very little
difference in results with occasional short-term differences in

6.3.7. Complications of surgical treatment of CTS
6.3.7.1. Minor complications
6.3.7.1.1. Neuropathic scar pain. The four nerve branches
involved in the innervation of the palm (palmar branch of the
median nerve, palmar branch of the ulnar nerve, nerve of Henle,
palmar transverse branches of the ulnar nerve) (Fig. 6) may be
adversely affected by the incision, resulting in scar pain or a
neuroma formation. This is not observed after endoscopic
surgery. For open surgery, even for the classic recommended
extension of the incision along the radial side of the 4th finger,
there is no zone of absolute safety, given the overlap of nerve
territories [12,111]. Ozcanli justifies the mini-open with a distal
incision between the superficial palmar arch and the distal
territory of the palmar branch of the median nerve, which
presents less risk of damage to the superficial nerve branches
[112]. However, it has not been demonstrated that the incision
for mini-open is free of such complications [82].
6.3.7.1.2. Pillar pain [92]. Postoperative pain in the
hypothenar eminence and thenar is the rule in the initial
phase. There is concomitant edema around the FR. Persistent
loss of strength is fortunately less common (1% to 36%)
[92,113] and may occur regardless of the type of surgery
[82,113]. It is related to pain on forced manual activities at the
insertions of hypothenar and thenar muscles, the edges of FR
and/or at the piso-triquetral joint. Resolution of edema at the cut
FR coincides with relief of pillar pain. It has not been
demonstrated that postoperative immobilization prevents this
complication [94,95]. Treatment includes immobilization,
reduced activities and symptomatic treatment or corticosteroid
injection.
6.3.7.1.3. Complex regional pain syndrome type 1. It is
less common because of progress in anesthetic and analgesic
techniques. The severest forms can be seen after contusion or
acute intraoperative compression of the median nerve.
6.3.7.1.4. Instability of ulnar flexor tendons through the cut
FR. This is manifested by a sharp pain in the ulnar tunnel
radiating to the forearm along the ulnar flexor tendons. A tab of
the RF may be left on the hook of the hamate to reduce the
frequency. Persistence is rare. It is exceptionally observed after
endoscopic surgery because of the size of the endoscope which
leaves an ulnar edge of the FR. FR reconstruction theoretically
avoids this and may be the treatment if confirmed on imaging.
6.3.7.2. Major complications
These are rare but serious, and even more so since this
surgery is common and credited with very satisfactory results in
the minds of the general public. In a review of the literature
from 1966 to 2001 for open surgery and 1989–2001 for
endoscopic surgery Benson et al. [114] reported 0.49% serious
complications for open surgery and 0.19% for endoscopic

90

M. Chammas / Chirurgie de la main 33 (2014) 75–94

surgery. Prevention should be emphasized, particularly in
endoscopic or mini-open surgery.
6.3.7.2.1. Nerve complications. Transient neurapraxia
may occur (1.45% after endoscopy and 0.5% after open), after
partial or total median or ulnar nerve section (0.14% for
endoscopy and 0.11 for open) or their branches (0.03% for
endoscopy and 0.39% for open) [114]. The common palmar
digital nerve of the 3rd space and the cutaneous branches of the
common palmar digital nerves of the 3rd and 4th spaces may be
affected especially in the double approach endoscopic surgery or
the mini-open. This cutaneous branch is between 2.3 and 10 mm
from the distal edge of the FR [115]. In case of total or partial
nerve section, the results of surgical repair – which must be
early – are incomplete, sometimes with residual permanent
severe pain.
6.3.7.2.2. Injury to the superficial palmar arch. It is
reported in 0.02% of cases [114]. The superficial palmar arch
is close to the distal edge of the FR. This may be associated with
injury of communicating branch of Berretini or common
palmar digital nerve of the 3rd space. The Cobb or the Kaplan
method may be used for its identification (Fig. 7).
6.3.7.2.3. Section of the flexor tendons of the fingers. These
have been reported only after endoscopic surgery (0.008%)
[114].
6.3.8. Information for patients
Preoperative information is a legal necessity, even if it is not
well registered by the patient. This may be oral, but difficult to
verify, so the best is oral and a written form supplying
information and informed consent and including even exceptional complications. A summary of the key elements to include was
proposed by Goubier in 2006 [116].
Julliard [117], in his expert experience, noted that nearly
three quarters of trials were due to unmeditated, passionate or
inappropriate comments amongst colleagues or mismanagement of a crisis situation with the patient. A quarter of
procedures were barely justified by technical faults: section of
the nerve, infection, unnecessary procedure. . .
6.4. Therapeutic indications in CTS
6.4.1. Acute CTS
6.4.1.1. Posttraumatic CTS. A progressive compression following contusion with symptoms at onset and little edema, is
not in principle surgical and must be distinguished. In case of
compression without deficit the urgent, simple reduction is
often enough to relieve symptoms, to be verified by a careful
clinical monitoring with limb elevation. In case of compression
with deficit or significant edema without deficit, emergency
open surgery is necessary. Shorter operating time is associated
with faster recovery [37].
6.4.1.2. Non-traumatic CTS. Urgent open surgical decompression is required, with an incision that may be extended to
the forearm, and treatment of etiology. In case of acute

thrombosis of a persistent median artery, the artery is excised
after release of an often bifid median nerve.
6.4.2. Subacute or chronic CTS
Medical treatment is the first line in early forms.
It is less effective in intermediate forms with nocturnal and
diurnal acroparesthesia with risk of development of a deficit. It
can be tried first or immediate surgical treatment can be offered
depending on the context.
Surgery is indicated for resistant forms and advanced forms
with deficit.
The contra-indications for endoscopic surgery include
[118]: 
isolated motor form; 
acute CTS; 
hypertrophic synovial pathology requiring extensive synovectomy; 
intracanalicular tumor; 
poor visibility; 
secondary surgery; 
small wrist with deficit (risk of intraoperative compression).
6.5. Persistence of symptoms, recurrence or new symptoms
In a recent analysis of the causes of secondary surgery for
200 cases operated over a period of 26 months, Stütz et al. [119]
found incomplete section of FR in 54% of cases and perineural
fibrosis in 32% of cases (anterior scar adhesion in 23% and
circumferential fibrosis in 9%) and iatrogenic nerve injury in
6% of cases.
In the absence of a proximal cause, reoperation is indicated
in three clinical pictures with a frequency varying from 0.3 to
12% [120] (Fig. 14): 
persistence of symptoms. This is the commonest complication after CTS surgery, mainly due to an incomplete section
of FR, most often in the distal portion. The absence of a
symptom-free interval, the persistence of symptoms and
positive provocation tests are suggestive. ENMG abnormalities may persist despite effective release. However, a normal
ENMG eliminates persistent compression. Open revision
surgery is justified without the need for modification of
median nerve surroundings; 
recurrence of symptoms. After a free interval of three months,
symptoms may recur due to a progressive entrapment after
FR scarring with fibrous perineural adhesions, causing a
‘‘traction neuropathy’’ (Hunter’s syndrome) [121]. Recurrence of symptoms and a positive clinical examination
suggest a syndrome of epineural adhesions. Again ENMG
may be faulty. Procedures to restore gliding between the
median nerve and its surroundings are often required;
examples are synovial flap [122], hypothenar fat flap [123],
pedicle flaps [124], biomaterials [80] or anti-adhesions gel
[120]; 
appearance of new symptoms. These are mostly secondary to
intraoperative iatrogenic lesions of the median nerve trunk,

M. Chammas / Chirurgie de la main 33 (2014) 75–94

91

Abnormal symptoms aer carpal tunnel release

Symptom-free interval

No symptom-free interval

Proximal signs (++) or
signs in other
nervousterritory
-Negave provocaon
tests
-Negave ENMG

Local signs (++)

Persistence of
symptoms
-Posive
provocaon
tests
-Posive
ENMG

-Mulple crush syndrome
-Diagnosc mistake: other
neuropathy involving
spinal, radicular or
truncular structure

Incomplete
secon of
flexor
renaculum

Postoperave adhesion with
epineural +/- interfascicular fibrosis
aer abusive neurolysis
-Short free interval
-Provocaon tests +/-Pain and acroparesthesias while wrist
flexion-extension
-ENMG +/-

True recurrence
-Inial recovery
-Posive provocaon tests
-Abnormal ENMG

New symptoms
-New or impaired
neurologic deficit
-Symptoms of neuroma
-Provocaon tests +/-ENMG +/-

Operave lesion of median
nerve or its branch(es)
(contusion, secon)

Fig. 14. Treatment algorithm in cases of recurrence, persistence, or appearance of new symptoms after carpal tunnel surgery.
Algorithme décisionnel dans les cas de récidive, persistance ou nouveaux symptômes après chirurgie du canal carpien.

the thenar (recurrent) branch, palmar digital nerves, the
superficial palmar branch or tendons. These complications
can occur alone or combined with one of the above clinical
presentations. Nerve repair of the terminal branches aims to
recover sensitivity and reduce neuropathic pain. In case of
neuroma of the palmar branch, a desensitization is indicated
and, if unsuccessful, burial. Repair of thenar branch is
indicated depending on the presence of functional impairment, age and the potential for regeneration and the site of
the lesion. Otherwise palliative tendon transfer surgery is
proposed.
Disclosure of interest
The author declares that he has no conflicts of interest
concerning this article.
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