Reply: Patients’ Perspective on Carpal Tunnel Release with WALANT or Intravenous Regional Anesthesia
Egemen Ayhan
Abstract
Sir: I thank the authors for their detailed queries and interest in our article.1 I hope that our point-by-point reply will mitigate their concerns and enhance the overall content of the article. The first concern was the risk of nerve injury because of possible movement of a patient’s limbs during carpal tunnel release using the “wide-awake, local anesthesia, no tourniquet” (WALANT) method. To the best of my knowledge, there has not been any reported nerve injury with open carpal tunnel release caused by limb movement.2–4 However, I certainly cannot state that there is no risk of injury. I think that this risk also exists to some extent during carpal tunnel release with intravenous regional anesthesia because of possible movement of unparalyzed shoulder girdle muscles. Moreover, any type of procedure using local anesthesia (e.g., finger operations, dental procedures, many plastic and aesthetic surgery procedures) carries a risk of injuring neighborhood structures in uncooperative patients when sedation is not used. However, sedation brings the risk of postoperative nausea and vomiting, with an incidence up to 24 percent.5 In our study, patients signed informed consent forms for the anesthesia types and surgery. This contract relies on mutual trust and confidence between patient and surgeon, not only for the surgical procedure itself but also for possible complications and postoperative care. I think that the safety of a procedure with local anesthesia depends on the preoperative patient-surgeon agreement and the patient’s cooperation throughout. Aytac et al. cited a study by Jones et al.6 that supports performing internal neurolysis and asked whether I had performed this procedure. I agree with Jones et al.6 that dissecting the epineurium might be necessary in revision operations. However, in our study, all patients underwent primary carpal tunnel release, and I did not need to perform internal neurolysis. In a prospective randomized study, Mackinnon et al. showed that the addition of internal neurolysis did not significantly improve the outcomes of patients with primary carpal tunnel syndrome.7 To avoid pain caused by nerve stimulation during surgery, I injected local anesthetic under the forearm fascia for median nerve block. It was beyond the scope of our “comparison of patients’ intraoperative experience” study to specify the modalities used for carpal tunnel syndrome diagnosis and to document the quantitative outcomes of patients, and so these were not stated in our article. I agree that carpal tunnel syndrome remains a clinical diagnosis, and that electrodiagnostic studies add minimal to no sensitivity or specificity to the clinical diagnosis.3,8,9 In clinically questionable cases, however, I used nerve conduction studies to confirm the diagnosis. When I was in doubt about space-occupying lesions after clinical examination, I used ultrasound imaging. I did not encounter any space-occupying lesions during carpal tunnel release of our patients. Nevertheless, the WALANT method provides adequate anesthesia for bones and joints when tumescent local anesthetic was injected in appropriate volumes. Several articles have been published on fractures fixed with WALANT.10–13 The last query of Aytac et al. was about the possibility of troublesome bleeding without a tourniquet. For WALANT sides, the bleeding was minimal and coagulated rapidly because of already vasoconstricted vessels. The injection of the WALANT solution 30 minutes before the surgery is important to allow the epinephrine sufficient time to produce efficient vasoconstriction. Supporting this, Lalonde has reported that he has not needed cautery for carpal tunnel releases using WALANT for 25 years.14 Sasor et al. compared blood loss of open carpal tunnel releases with and without the use of a tourniquet and reported no clinically significant difference.15 Finally, hematoma was not a problem for WALANT sides, because I could take care of any intraoperative bleeding. Indeed, I was more afraid of postoperative hematoma in intravenous regional anesthesia sides, because of uncontrolled let-down bleeding after tourniquet deflation. I appreciate Aytac et al.’s standardized choice of intravenous regional anesthesia for carpal tunnel syndrome, which was also my primary choice for many procedures before 2016.16 However, I found a number of drawbacks with intravenous regional anesthesia, including tourniquet pain occasionally necessitating sedation, preoperative preparation basics, and extended anesthesia duration to deflate the tourniquet. Moreover, there is high-level evidence on the safety, efficacy, and cost-effectiveness of WALANT.4,15,17–19 Therefore, I recommend that Aytac et al. try carpal tunnel release using WALANT. I think that they will continue to use it. I would like to thank Aytac et al. for their valuable analysis, which gave us the chance to illuminate these important points. DISCLOSURE The author has no financial interest to disclose. No funding was received for this communication. The author has no potential conflicts of interest with respect to the research, authorship, and/or publication of this communication. Egemen Ayhan, M.D.Department of Orthopaedics and TraumatologyUniversity of Health SciencesDiskapi Yildirim Beyazit Training and Research HospitalMutlukent MhAngora Evleri, No. 2/606800 Cankaya, Ankara, Turkey[email protected]Twitter: @EgemenAyhanInstagram: @egemenayhan