| Research objective Objective: To study the feasibility of the transverse carpal ligament operation under the guidance of ultrasound, and to insure the safe area by observing the anatomical structure of the hand under ultrasound and MR. To explore the clinical effect of loop cutting technique in the treatment of patients with carpal tunnel syndrome, and to observe the significance and effect of the nerve entrapment treatment by animal trails.Research method 1. Collect wrist MRI datas of 20 patients with carpal tube syndrome and 20 normal cases, 15 were wrist specimens. Observe the median nerve cross-sectional area at the level of distal radius and pea bone, the horizontal distance from the ulnar artery in the MRI images. The ultrasound- guided link cutting operation were went on the wrist specimens. Then we analyzed the local anatomy of wrist joint after the operation and observed the distance between distal transverse ligament, superficial palmar arch and deep palmar arch, the thickness of transverse carpal ligament, the features as median nerve return out of shape and the safety area of link puncture and cutting operation. 2. 91 cases(135 sides) with carpal tube syndrome were treated from January 2012 to September 2015. 37 cases were male(51 sides) and 54 cases were female(84 sides).Open surgical decompression was performed in 27 cases(45 sides), ultrasound guided ring cutting operation was performed in 64 patients(90 sides). The incision was in the ulnar palm thenar crease. The transverse carpal ligament was exposed and cut off to achieve the purpose of carpal tunnel decompression. Loop cutting procedure is carried out under the guidance of ultrasound. Thread needles respectively from the deep and shallow transverse carpal ligament, form a ring sleeve, cut off the transverse carpal ligament and decompress the carpal tunnel. Observe the length and width ratio(the length and width ratio of median nerve cross section in hamate level) and swelling ratio(the ratio of median nerve transection area in pisiform level and distal radius level) of median nerve by ultrasound before operation, after operation and after 3 months. After 3 to 6 months, evaluate the symptoms of carpal tube syndrome and function of wrist joint by Boston carpal tunnel questionnaire(BCTQ) through telephone. 3. Experimental animals concluded 30 adult male SD rats. They were divided into A, B, C three groups. Rats in group A were served as control group, only exposed the sciatic nerve, did not entrap, and detected the nerve electrophysiological and monitored neural microcirculation blood flow. Rats in group B were used as group. The sciatic nerve was exposed and the pressure model of the sciatic nerve was established. It relieved after 4 weeks. Then we measured the changes of the nerve electrophysiological and the neural microcirculation blood flow. 6 week after the lifting of the pressure, we also measured the changes of the nerve electrophysiology and the neural microcirculation blood flow. Rats in group C were used as the group of nerve outer membrane after sciatic nerve entrapment. Rats were established the sciatic nerve chronic compression model by Mac Kinnon method [14], lifted the entrapment after 4 weeks and measured the changes of neural electrical physiological and nerve microcirculation blood flow. Then dissect the nerve tissue envelope under the microscope by using syringe needle. In the 6 week after the lifting of the pressure, measured the changes of the nerve electrophysiology and the nerve microcirculation blood flow again.Result 1. T test was adopted in the carpal tunnel syndrome group and the normal group. The cross section of the median nerve in the two groups was statistically significant at the level of the carpal canal, P < 0.05. The median nerve was not statistically significant between the two groups at the distal part of the radius. The thickness of transverse carpal ligament was slightly thickened in carpal tunnel syndrome group, but there was no significant difference between the two groups, P > 0.05. There was no statistical difference in the distance between the median nerve and ulnar artery of the two groups. 2. 11 cases were absent, 80 cases were followed up for 3-27 months, average 11.6 months. The BCTQ scores of incision decompression operation group and loop incision group were(28.5±4.6) and(29.4±5.3). There was no significant difference between the two groups(t=1.34, P=0.528). The BCTQ scores at 3 months after operation were(16.3±5.7) and(15.7±4.9). There was no significant difference between the two groups(t=1.12, P=0.674). The median nerve length width ratios were 3.8±0.7 and 2.6±0.4 before and after 3 months in the open decompression group. The swelling ratio was 2.3±0.4 and 1.2±0.3. The differences had statistical significance before and after the operation(P < 0.05), respectively. The median nerve length width ratios were 3.9±0.6 and 2.7±0.5 before and after 3 months in the loop cutting group. The swelling ratio was 2.1±0.3 and 1.4±0.4. The differences had statistical significance before and after the operation(P < 0.05). There were no infection, poor healing, and vascular nerve injury both in the two groups. At the same time, the two groups were compared in the length of stay, the number of days before operation and the cost of hospitalization. 3. In the A group, the nerve conduction velocity, CMAP amplitude and the latency of the nerve were not significantly different between before the operation, 4 week and 10 week after the operation. But the B group and C group were different in the preoperative, postoperative 4 weeks and 10 weeks. The comparison had statistically significant differences(P<0.05). There were no statistically differences in the blood flow of nerve micro circulation between the 4 week and the 10 week after the operation in the A group. But the neural microcirculation blood flow of group B and group C in the preoperative and postoperative 4 weeks, 10 weeks were significant different. The comparison had significant statistically difference(P < 0.05).But it had no significant statistically differences between the two groups(P > 0.05). After 10 weeks, the nerve blood flow recovery was significantly lower in group C than that in group B. It had statistical difference between the two groups(P < 0.05).Conclusion(1) The proximal 1 cm of far side of the wrist between long palm tendon and ruler is proximal artery puncture point. The ring finger and big, small hypothenar muscles intersection point is the distal puncture point. It can be used as the safety of the operation area and avoid the injury in the middle of back and palm branch, ulnar artery and ulnar nerve and superficial palmar arch, deep palm bow.(2) Loop cutting technology can be used as a safe and effective surgical treatment of carpal tunnel syndrome. The ultrasound is useful for the diagnosis of carpal tunnel syndrome, intraoperative monitoring and prognosis.(3) It can achieve the same operation effect between releasing and not releasing in the operation. So the loose solution of epineurium is not necessary to neurolysis. |
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