| Background:Carpal tunnel syndrome has always been one of the dominant diseases in needle-knife treatment.The clinical practice is generally treated by the four-point needle method invented by Professor Zhu Hanzhang.Since the acupotomy is a closed surgery,it still has a certain operation under non-direct vision.Risk and difficulty,but lack of specific safety assessments.In recent years,ultrasound visualization technology has developed rapidly.Clinically,doctors have combined ultrasound and acupotomy to treat carpal tunnel syndrome.However,there is still a lack of a fixed surgical procedure for the convenience of ultrasound-guided acupotomy for carpal tunnel syndrome.Purpose:To explore the safety of the classic acupotomy in the treatment of carpal tunnel syndrome and the safety and accuracy of the ultrasound-guided acupotomy dissection of the carpal tunnel ligament in the treatment of carpal tunnel syndrome,and provide anatomic basis for clinical treatment.Methods:Twenty-six adult specimens of 10%formalin-preserved fixed specimens(15 males and 11 females)were selected,aged 60-95 years,mean(82.54±6.94)years old,with 52 sides(two of them could not be tested).The specimens were collected from the Donation Center of the Peking University School of Basic Medicine.The research period was from November 2017 to May 2018.Experiment 1:Simulating the traditional four-point needle insertion method on the human body specimen,the two needle insertion points at the proximal and distal ends of the temporal side are the needle insertion point 1 and the needle insertion point 3,and the ulnar side proximal end and the distal end point respectively.The two needle insertion points are the needle insertion point 2 and the needle insertion point 4,respectively.Measure the shortest lateral distance(C-L1,C-L2,C-L3,C-L4)of the four needle points 1,2,3,4 from the median nerve,and the shortest lateral distance of the needle points 1,3 from the shallow branch of the radial artery(C-L13 and C-L14)),the shortest lateral distance(C-L5 and C-L6)of the ulnar artery at the needle point 2,4,the shortest lateral distance(C-L7 and C-L8)of the ulnar nerve,and the shortest longitudinal distance(C-L9 and C-L10)of the shallow branch of the ulnar artery.The shortest longitudinal distance from the superficial branch of the ulnar nerve(C-Lll and C-L12);the data obtained were processed and analyzed,and the rate of neurovascular injury was calculated.Experiment 2:Simulate ultrasound-guided needle-knife release of the transverse ligament of the wrist on a human specimen.The distal needle insertion point is the needle insertion point 1,and the proximal needle insertion point is the needle insertion point 2.Safety measurement:measure the shortest lateral distance(U-L1 and U-L2,U-11 and U-12)of the needle insertion point 1,2 and its needle cutting marks from the median nerve,and the shortest lateral distance of the isolated artery(U-L3 and U-L4,U-13 and U-14),the shortest longitudinal distance(U-L5)from the needle point 1 to the shallow bow of the palm,and the shortest longitudinal distance(U-15)of the needle tip of the needle point 2 from the shallow bow of the palm.Accuracy measurement:measure the length(L)of the total cut marks of the needle point 1 and the needle point 2,and divide the L into four intervals to calculate the number and percentage.The first interval La is the total release.The length L is less than half the width W of the transverse ligament of the wrist(La<W/2);the second interval Lb is the total release length L is greater than or equal to half the width W of the transverse ligament of the wrist and less than the width W of the transverse ligament of the wrist minus 4 mm The value(W/2?Lb<(W-4));the third interval Lc is the total release length L is greater than or equal to the width of the transverse ligament of the wrist minus 4 mm and less than the width W of the transverse ligament of the wrist((W-4)?Lc<W);the fourth interval Ld is the total release length L equal to the wrist transverse ligament width W(L = W).Anatomical measurements:measuring the width of the transverse ligament of the wrist(W);the thickness of the distal boundary of the transverse carpal ligament(U-T1)and the thickness of the proximal boundary(U-T2);the lateral edge of the median nerve to the lateral edge of the ulnar artery The shortest lateral distance between the two(U-L6).And measuring the angle between the acupotomy and the horizontal line at the needle insertion point 1 and the needle insertion point 2(U-D1,U-D2),and the needle insertion point 1 and the needle insertion point 2 from the proximal end wrist transverse pattern The distance between them(U-L7,U-L8).And measure the vertical depth(U-H1,U-H2)of the needle point 1 and the needle point 2 to reach the transverse ligament of the wrist,and the length of the needle body(U-L9,U-L10).The resulting data was processed and analyzed to calculate the damage rate of nerves,blood vessels and tendons,and the damage rate of nerves and blood vessels was compared between the two procedures.Results:Experiment 1:The shortest lateral distance of the needle insertion points 1,2,3,4 from the median nerve was C-L1 4.48±1.92mm(1.98?11.06 mm)and C-L2 was 12.47±2.81 mm(8.01?20.55 mm).C-L3 was 4.41±1.88mm(2.08?11.12mm),and C-L4 was 12.08±2.73mm(7,58?19.65mm).No obvious median nerve injury was observed.The shortest lateral distances C-L13?and C-L14?of the needle points 1 and?3?from the superficial branch of the radial artery were 5.42±2.08mm(1.91?11.60mm)and 2.43±1.38mm(0?6.46mm),respectively.For example,the superficial branch of the radial artery is damaged.The shortest lateral distances C-L5 and C-L6 of the insertion point 2 and 4 of the ulnar artery were 2.37±1.15 mm(0.76?6.12 mm)and 4.07±2.32 mm(0.46?9.17 mm),respectively,and no obvious ulnar artery injury was found.The shortest longitudinal distances C-L9?and C-L10?of the needle branch?2,4?and the distal branch of the ulnar artery are?9.08±3.67mm(0?17.50mm)and 4.01±3.00mm(0?11.46mm),respectively.In the case of a shallow branch of the ulnar artery,3?cases of ulnar artery shallow branch inj ury were found at 4 points of the needle point,and 2 needle needles were close to the shallow branch of the ulnar artery.The shortest lateral distances C-L7 and C-L8 of the ulnar nerve at the needle point 2 and 4 were 0.98±0.79 mm(0-3.74 mm)and 1.70±1.45 mm(0-6.39 mm),respectively,and 3 cases of ulnar nerve were found at the needle point 2 Injury,4 needles were placed close to the ulnar nerve,2 cases of ulnar nerve injury were found at 4 points,and 4 needles were close to the ulnar nerve.The shortest longitudinal distances C-L11 and C-L12 of the needle branch 2,4 and the shallow branch of the ulnar nerve are 8.80±3.67mm(0?17.50mm)and 1.89±1.94mm(0?8.11mm),respectively.In the shallow branch of the ulnar nerve.3 cases of ulnar nerve injury were found at 4 points of the needle insertion,and 3 cases of needle needles were close to the shallow branch of the ulnar nerve.There were 7 cases of direct nerve injury by needle-knife four-point approach and 6 cases of direct damage to blood vessels,accounting for 14%and 12%respectively.In the operation,the shortest distance between the acupotomy and the nerve vessel was less than 2 mm,and the number of cases was 48 and 41,respectively,accounting for 96%and 82%.Experiment 2:Safety:The shortest lateral distance U-L1 of the needle point 1 from the median nerve is 2.40±1.44 mm(0.77-7.13 mm),and the shortest lateral distance U-11 of the cutting mark from the median nerve is 2.51±1,35 mm(0.58?6.54).Mm),no obvious median nerve injury.The shortest lateral distance U-L3 of the needle-pointing artery is 3.50±1.65mm(0.91?7.01mm),and the shortest lateral distance U-13 of the cutting path from the ulnar artery is 3.51±1.94mm(0.57?8.73mm),no obvious Ulnar artery injury.The shortest longitudinal distance U-L5 of the needle point 1 from the palmar arch is 3,01±2.01 mm(0.79?7.98 mm),and no obvious palmar arch injury is observed.The shortest lateral distance U-L2 of the insertion point 2 from the median nerve is 2.27±1.30mm(0.67-6.98mm),and the shortest lateral distance U-12 of the cutting trace from the median nerve is 2.38±1.23mm(0.64-6.18mm),no obvious Median nerve injury.The shortest lateral distance U-L4 of the needle point 2 from the ulnar artery is 4.38±1.95mm(1.51?9.70mm),and the shortest lateral distance U-14 of the cutting trace from the ulnar artery is 4.02±2.01mm(0.71?9.65mm),no obvious Ulnar artery injury.The shortest longitudinal distance U-15 of the needle point of the needle point 2 from the palmar arch is 10.68±3.95mm(3.99?18.67 mm),and no obvious shallow arch injury is observed.In this experiment,there were 4 cases of the median nerve sheath or flexor tendon sheath severely damaged by ultrasound-guided needle-knife rupture of the transverse carpal ligament,accounting for 8%of the cases,and 5 cases of minor injury,accounting for 10%.Accuracy:The total cutting mark length L of the needle insertion point 1 and the insertion needle point 2 is 17.52±4.69mm(7.36 to 24.39 mm).The first interval La is 7 cases,accounting for 14%;the second interval Lb is 11 cases,accounting for 22%;the third interval Lc is 17 cases,accounting for 34%;the fourth interval Ld is 15 cases,accounting for 30%.There were 43 cases in which the cutting marks were greater than or equal to half the width of the transverse ligament of the wrist,accounting for 86%.Anatomical measurement:the needle point 1 is 37.59±3.56mm(28.87?43.60mm)from the proximal wrist transverse line,and the needle point 2 is 3.45±2.64mm(0?8.80mm)from the proximal wrist.When the needle is inserted,the angle U-D1 between the acupotomy and the horizontal plane is 23.36±6.50°(12.41?39.56°),and the angle U-D2 between the acupotomy and the horizontal plane of the needle point 2 is 23.66±4.94°(11.28?36.91).°).When the acupotomy reaches the transverse ligament of the wrist and can be released,the length U-L9 of the needle insertion point is 21.81±3.39mm(11.70?30.40mm),and the length U-L10 of the needle insertion point is 19.34±2,96mm(11.40?25.30mm).At this time,the vertical depth U-Hl of the needle point to the skin is 10.60±1.31 mm(5.50?13.10 mm),and the vertical depth U-H2 of the needle point 2 to the skin is 8.98±1.40 mm(3.70?12.10 mm).The chi-square test(Fisher exact test)was performed on the nerve injury rate and vascular injury rate of the two procedures,PN<0.05,PA<0.05.The difference was statistically significant,indicating that the ultrasound-guided acupotomy procedure was superior to the traditional four-point procedure in the safety.Conclusion:The classic acupotomy for the treatment of carpal tunnel syndrome has a low surgical safety and is not recommended for clinical use.In contrast,ultrasound-guided acupotomy release of the transverse carpal ligament for the treatment of carpal tunnel syndrome is safer and more accurate,and is recommended for clinical use. |
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