Okay, good morning everyone. Thanks for coming to our session on local anesthesia for endoscopic carpal tunnel. I'm Dr. Michael Wheatley from Colorado Springs, Colorado. We're fortunate to have Randy Lovell from Grand Rapids and Bill Pianka from Fort Worth, Texas, who are with us this morning as well. And we're going to review techniques for local anesthesia and WAL-ANT for endoscopic carpal tunnel release. And this is our group here. So what are the benefits of local anesthesia for endoscopic carpal tunnel release? And the first benefit, which is a little bit hard to imagine, but actually is true, and I think Randy and Bill will talk about this, is that it just really is more effective anesthesia. We've all had the experience of using a MAC anesthesia for these patients, and many times they can get disinhibited. And sort of the classic sequence with MAC anesthesia is that the anesthesiologist will sedate the patient and then he'll give the local, and that doesn't give the local enough time to work. And so a lot of times the patients will feel pressure from the scope going in, then they'll get disinhibited, or then they'll start to move and then the anesthesiologist will sedate them further, and then they'll start to get wild and disinhibited. And so one of the real benefits that I've found in my practice is that just straight local anesthesia works better. You get better anesthesia, the patients are cooperative, they can respond when you give them commands or instructions. So I personally think it's just much better anesthesia, and probably I will get Randy and Bill's opinion, I think that they would concur. As I said, the patients are more cooperative because you don't have the problem with disinhibition with MAC anesthesia. Without having a dedicated anesthesia team there, you just simply get faster O.R. turnovers because you don't have to do the pre-anesthesia workup, and then the IV and the sedation, and then the waking up from sedation. As an accompanying that, patients are actually able to leave the recovery room more quickly and go home, so that's a benefit as well for your PACU nurses. One of the things that Microware is really working to, in terms of instrumentation, is to facilitate movement of endoscopic carpal tunnel release to the office. And of course, in an office setting, local anesthesia would be the only way that you'd be able to do this. But it has worked very, very nicely in the practices that have adopted this to be able to do endoscopic carpal tunnel release in the office. As I said, there's no need for IV placement without sedation, which I think is always a positive for patients. And then the thing that I found in my practice is that patients really like it. It takes a procedure that is a big deal where you come in, you talk to the PACU nurse, you get your IV, you get sedated, you wake up from sedation, you go home, and you're kind of drowsy for the rest of the day to just a simple procedure where you come in, you get some numbing, you get it done, you're awake and you're alert, you leave in 20 minutes after you're done. And so it really makes it very efficient for patients. They don't have to come in as early and they don't have to stay as long once they get done. So I think there are really multiple benefits. And I think that Don Lalonde taught us the value of WALINT anesthesia. And always the question is, is it applicable to endoscopic carpal tunnel? And I think if you can do distal radius fractures and flexor tendons, then the answer is certainly yes, that it's very applicable to endoscopic carpal tunnel. And then where is this being used? And it's really being used in all settings. So you can use it in a hospital setting, you can use it in a surgery center setting, or you can use it in an office setting. And it gives you really great versatility in where these procedures are performed. And then just in terms of technique, I think that the nice thing about our panel here is that each of us does a different technique for local anesthesia. All three are effective. And so it kind of gives you different perspectives on sort of different paths to get to the same goal, which is to having patients that are well anesthetized for the procedure. So my particular technique, I think just to highlight a few of the things, because we'll do a little cadaver where we each show our technique, is that I use really small needles. So I think one thing that Don Lalonde has advocated when he talks about WALINT is the sort of hole-in-one concept, where you give a single poke and that's all that the patient will feel. And so I use a 30-gauge, one-inch needle for my initial puncture. And so it's a very, obviously a very small needle that patients will barely feel. And then the other thing that I do is use lidocaine with epinephrine, but I also use sodium bicarbonate. And the literature's, I think, a little bit hazy, I guess, on the benefits of adding sodium bicarbonate. But sort of for what it's worth, my anecdotal experience is that sodium bicarbonate really does take quite a bit of the sting out of the local anesthesia. And so for even your most anxious patients, if you're using, in my experience, 30-gauge needles plus sodium bicarbonate, then you can really make the procedure, I want to say, virtually painless for the local anesthesia administration. And then you can add in the freezing spray, I guess, because it has a certain benefit psychologically for patients, thinking, well, he's frozen, so it should hurt less. And I think going along with that, the sodium bicarbonate, one of the problems with local anesthesia is just the rate at which you inject. And if you inject very, very quickly, then patients get a real significant pressure sensation. And so injecting slowly, and one of the things about using small needles is that you're sort of forced to inject slowly because there can only be so much flow through smaller needles. So using smaller needles in my experience has really been helpful. Probably I'll need to have one of these guys do my CMC arthroplasty down the road. But for patient comfort, it really makes a big difference. My technique involves just raising a skin wheel right at the incision. So my first poke will be just only to the palmaris longus, and I'll raise a little skin wheel. And then through that skin wheel, then I'll do a puncture through the fascia at the distal wrist crease, and then inject about five to six cc's into the carpal tunnel. And that will sort of bathe the nerve in local anesthesia. And then I'll proceed through my skin wheel to inject into the palm, and then provide another cc or two into the palm. I found that if you just do a nerve block, some patients will actually have discomfort when the blade is raised and the transverse carpal ligament is incised. So I found that doing an additional small injection into the palm to actually anesthetize the transverse carpal ligament makes a difference. And I think those are sort of the highlights of my approach. Just to sort of discuss what might potentially be different about mine than our other two presenters is that because I go distal, there will be more fluid in the carpal tunnel than the approaches that you're going to see from my colleagues. And so that is potentially one of the disadvantages of this approach. I've sort of learned to be able to do the operation with a little bit of fluid. And so for me, it's a look that looks normal, and the operation is straightforward to do that way. One of the things I like about it is that you go right to the source. You're injecting the nerve right as it comes into the carpal tunnel. And so you're going to get very, very good anesthesia there. And I think the final note that all three of us will make is that you really have to inject these patients early, which is something that Don Lalante has talked about. The reason why the anesthesia is so good is you inject 20 to 30 minutes ahead of time, and that really gives it time to work. And so what I'll do is I'll see a patient in the holding room, I'll inject them, and then I'll come back in 20 minutes and check with them and ask them, do you have dense numbness? Are the thumb index and middle finger densely numb? And if they say, well, no, I can still kind of feel some things, then I'll go and give them a little more. So what I'm shooting for is really dense, dense numbness in the median nerve distribution. And when you have dense numbness in the median nerve distribution, then the pressure from the carpal tunnel blade is eliminated. And again, that's one of the problems with the MAC anesthesia is you don't have enough time for it to work, so the local to work. So you don't get the dense nerve block. And then when the blade comes in, then the patients will feel the pressure sensation on the nerve and will become disinhibited. So I think to reemphasize what Don Lalonde has told us over and over again, these patients really need to be blocked and then checked to make sure that they have anticoat anesthesia. So anyway, that's just a quick overview of how I do this, and I'll move on here to Randy, and he'll go over his technique. Thanks, Mike. So I think what you'll probably pick up is that while there are differences in how we do things, there's probably more alike in concept and principle than anything. So I made the switch about three and a half years ago, and I'm almost at the point where if somebody wants to go to sleep for it, I'll send them to somebody to put them to sleep. It works that well. And my technique is a little bit different than Mike's in that I think we're similar, and we raise this wheel of anesthesia at and just proximal to our planned incision. And that is, you know, you feel the initial poke. I use a 27-gauge needle at that point. And that after two or three seconds, I check with them all the time. What's your number? What's your number? And I tell them my goal is to keep you three at a ten at the worst or below. And if somebody says four, I'll slow down or stop. I mean, I take it that seriously. And oftentimes, they'll tell me zero, and they're kind of laughing about it because they're a little bit nervous. So once that's in, I do pause, talk to them a little bit about the surgery, and I'm looking for a little bit of a proximal blockade, talk about discharge instructions, and take about 30 seconds. And that initial proximal wheel gives you a little bit of a basis of a block. It's not a true block, but it is effective. And then I advance into the subcutaneous areas of the palm with another five milliliters. So it's ten total, and it is absolutely, I've never done it, but it is absolutely a block that I could convert to an open if I wanted to. I could do an open wide awake open easily and painlessly with that blockade. And so my colleagues that do opens want me to teach them the technique just to get numb. And so, you know, it works either way, but I have not found the need to ever abort doing it. A little comment on the Bicarb. So I do these in my office, purely local wide awake in the spirit of Don LaLonde and the Walnut movement. But when I go to the surgical centers, I still do them wide awake, but the surgical center doesn't get me sodium bicarbonate. So I actually have an anecdotal study going on, and I don't tell the patients either way. And I can tell you unequivocally it makes a difference. It makes a difference in two ways. The Bicarb takes the sting or the burn away, and I don't hype it when I'm in the office, and I don't talk about not having it when I'm in the surgical center. And I can tell, I'll hear things, oh, it's burning, it's burning, and I'll slow my injection down if they're saying that. The other thing is the Bicarb deionizes the lidocaine, and so it actually has a quicker anesthetic effect that actually lasts longer. So it really makes a difference. So I, you know, despite, I think there is some mishmash a little bit in the literature, but anecdotally, I can tell you that it does make a big difference. In terms of, I think those are probably the ways we're different and mostly the same. I think you have some comments on that too, Bill? Sure. I think you have your video next. We'll see if this, we're going to go through the actual injection technique. If we get that link running, here comes the tech help. Hey, Randy, Bill, while we're waiting, let's just quickly talk about local anesthesia. Do you guys ever use Marcane for this? No. And why not? Don't need it. You know, it's just the reliability of lidocaine, the cost, and the effectiveness and the safety. You know, it's, as Don LaLonde says, we've got five billion examples of safe use of lidocaine in our dentist's offices over the last 60 years, so it's a proven safety profile, so there's just no reason to not use it. And Bill? Yeah, for the same reasons, you know, the lidocaine works great. There is some concern for neurotoxicity if you get too close to the nerve with Marcane, so if I'm doing even a carpal tunnel steroid injection, I don't use Marcane for those either, but for all my other injections, I do, and it just hasn't been necessary for this, and I almost never need to supplement after that 30, you know, 40-minute wait time for this. My comment quickly is that I've found that patients just don't like it, they just don't like to be numb that long. Yeah. They would rather have the pain than the numbness. Sure, yeah. And I don't, yeah, for the same reasons. Well, occasionally, too, we'll do bilaterals, and, you know, one of the high points of the local world is that you can drive yourself in, drive yourself home, and oh, it's a little bit numb when they walk out with two numb, meaty nerves that are going to be driving there. So if I do bilaterals, we usually have a person drive them in, so. Yeah. Let's talk about another question. Size of needles make a difference? For sure. Are you guys gonna go with my 30-gauge? I don't know if my CMC joint can support a 30-gauge. 27, I'd, you know, very, very rarely have patients complain of pain from the needle itself. I do use the ethylene chloride, the cold spray, which I think it may be more of a placebo effect than not, but, you know, I don't think the response I've gotten has warranted going slower, or with smaller, I mean. Randy, do you use the cold spray? I do not. I do not. I tell them the numbing's in the injection, so that usually works. Yeah. So this is a recent, this is just, this is myself in the office doing a local anesthesia, and it's got a carpal tunnel. I do them the same every time, even though we've literally done thousands of them over the years. I mark my landmarks, Kaplan's cardinal line, the longitudinal line is the radial aspect of the ring ray, and then there's the transverse incision, as Mike alluded to. It's, it ends up being fairly central. I've shifted mine as I've moved to the local anesthesia. Slightly radial to where it used to be, but I think you can use sort of the radial border of Palmaris longus if there is one, and extend it ulnarly. I used to go strictly FCU, two, but not all, or shy of Palmaris longus, so it was a more ulnar incision. So here, back to the discussion on the 30, that's a 27 gauge. I pinched that skin tightly, which provides a little bit of distraction to the nerves, and and it also pulls the skin away from the fascia, and it allows that initial injection to be purely in the sub-Q without posing any risk of going past the fascia and into the nerve, or at least near the nerve. That is an unhappy moment for patient and surgeon alike. So at this point, I'm talking to them. You can see that this is not sped up or slowed down. This is real time, and we started with 12, and I'm at 10 and a half at that point. So what I prefer at this point, despite, it looks like there's a lot of movement, most of the movement's with my left hand, and if I see my wheel going somewhere that I don't like, I simply massage the local back where I want it, rather than redirect the needle, which is a more uncomfortable experience for the patient. At this point, we're talking, this patient's a real patient, wide awake. We're talking about life. We're talking about what to expect afterward, and I do that little thing where I'm sort of projecting where I want the tip of my needle to roughly end up close to Kaplan's cardinal line. This is a shallow angle. At that injection, that is almost universally a pain of zero when that injection goes in, and I'm staying very shallow. I'm below the palmar skin, but I'm very much superficial to the deep palmar fascia, and you can see we're still only at 7, so this is not a slam dunk in terms of, you don't rush this process. This process doesn't work for anybody if the patient's having an unpleasant experience at this point. So you do advance slowly. You try to keep your anesthesia in front of the tip of where your needle would be by a half centimeter or so, and it truly, having done hundreds this way, at this point, most people say they might feel a little pressure, but they don't feel pain. They don't feel burning. They don't feel sharpness. They don't feel paresthesias at all, and you can see a nice, healthy, blanched area of skin forming, and that's for two reasons at this point. Some of it is the pure distension of the local anesthesia causing some of that blanching. I don't think there's a true epinephrine effect that quickly, but by the time you're done, you're getting a combination of the pressure from the fluid causing the blanching and then actually the epinephrine effect, and we're almost done here, and then when I'm done at this point, this person will have 30 minutes to sit up, read a book, watch their Netflix. Some people want to go out to the lobby and hang out with their spouse or family if they brought someone. Some people close their eyes and take a nap, but they're all, they're prepared for that, and that 30 minutes is critical. When we go back to work on them, there's no swelling, there's no distension, there's no fluid visible, looking at the anatomy, and there's, I never see the local when I'm operating. So that is, that's the beginning, the end of the injection process. I'm just gonna make a quick comment and then a question for you. So the difference between Randy's technique and my technique is, Randy is, tell me if I'm incorrect, is superficial to the fascia and then into the palm. I'll raise a superficial skin wheel and then I'm gonna actually pop to the fascia and inject into the carpal tunnel. So Randy's technique probably will be drier than mine because he is superficial to fascia. Exactly, exactly. And I, when I first made the transition, I did try some blocks. I think Bill does a more proximal block. I did a little bit of that, kind of a little bit of the things that I was reading and just through trial and error, experimentation, I've settled on this and this works really well. I don't have any obfuscation of my view. I don't have, and it's a very comfortable injection. It's not particularly quick. So it does take me some time. Like you, when I'm doing these at the surgical center, I just, I just try to stay a patient ahead. So, so whatever the case is, I try to a patient ahead. So sometimes it's longer, it's an hour sometimes, but it's, it's always a minimum of 30 minutes. I don't do a recheck and I don't add and I just trust. So far, so good. And my technique is sort of a combination of both of these. So again, I'm Bill Pienka from Fort Worth, Texas. I started a couple years ago taking all my carpal tunnels into the office. At first they were all mini opens, now almost always endoscopic, but the injection technique is the same regardless of technique. And the thing that I do that's a little bit different is I use a higher volume. I'm using 20 cc's of lidocaine with the sodium bicarb and I'm doing a subfascial median nerve block about five centimeters proximal to the incision. And the reason I like doing that is twofold. One, I'm injecting eight or so cc's more proximal and you're getting a dense median nerve block then. So the other injections when you go more distal, whether it's into the palm or at the incision site, the patients really aren't feeling them, feeling that at that point because that LIDO has already started to kick in from the median nerve block proximally. The other thing that I really like about it is when you inject that volume, it floats the fascia off the nerve and actually makes your approach a little bit easier, but it keeps your endoscopic visualization dry because you're taking the fluid around the nerve more proximal. And then distally, I'm going just sort of superficial to the transverse carpal ligament again for when that blade comes through and you sort of get the fat falling through that area there as being anesthetized by that as well. As far as doing it in the office under a local technique, I think there's lots of benefits that have been touched on before, but I want to emphasize a few of them is it's dramatically cheaper for the patients. My office is not affiliated with a hospital. So there's not a facility fee that they're paying for. They're not paying for anesthesia. So that takes over half of the cost of the procedure away for the patients, which they've been very, very grateful for. It is way more convenient. They don't need to come NPO. There's no risk that we're going to convert to a general anesthesia because we're in the office. That's not an option. So I tell them come from breakfast, bring coffee to wait in the waiting room. I have had more patients than I ever expected come on their lunch break to have their surgery and go back to work, which is really something, you know, you're not going to get with any other technique. I love the opportunity to have the patients awake while I'm doing the procedure. It makes them an active participant in their care. If they see what you're doing, you can counsel them and discuss with them. You know, when I first talked to Don LaWanda about doing this, that was the big thing. He said, you know, you counsel your patient the entire time you're doing the procedure. Talk about their post-operative plan, talk about their follow-up, talk about their restrictions, and they just have a much better experience knowing sort of what to expect, why your restrictions are what they are. And then as soon as you're done, you put your bandage on and they walk out. There's no recovery room. There's nothing. So it really limits their time in my office to no more than an hour and a half or so. And when I'm injecting them, I generally wait a little bit longer. I try to get to 45 minutes. I am not the world's most patient person, so sometimes that can be difficult. But I've found the longer I wait, the more time that epinephrine has to set up. The better your visualization is. So, again, things that are different for mine, I inject eight cc's, more proximal. I do the very similar just subcutaneous injection at the incision site. And then I actually I find it's a little bit easier to get that low angle injection to get the superficial stuff. If I come from the palm at the distal aspect of the transverse carpal ligament and inject in a retrograde fashion. So that's how I've been doing it. And I have a little video here, hopefully, that will play showing my technique. Necessary, not necessary? No tourniquet. And how is visualization in terms of bleeding, lack of bleeding, whatever? I have had zero issues. The epinephrine, I mean, wait in the 30 minutes, certainly the epinephrine is having a good hemostatic effect at that point. But there's no question that the initial incision and the initial dissection, there's more blood than with a tourniquet. I won't ever argue that. The difference is it's just not that much. I mean, you see a little bit of, part of it is because you haven't exsanguinated. So even if there's no active venous bleeding, you haven't exsanguinated, so you have residual blood parked in those veins, even if things are pretty well clamped down from the epinephrine. But what I have found is, you know, you just have that one case where it's just pristine and perfect the whole time, you thank the patient for being a good patient, but every now and then you get somebody who's got a decent venous network, right, where your incision is and you try to work around it. You'll get one that's just kind of leaking, and we've done it enough times. I do them with the residents or I do them with our PA, and my PA knows enough now, she'll just reach, she'll just readjust her skin hook and kind of, she sees where it's coming from and she puts it right where that vein is and it immediately, we sponge and it immediately stops. Okay, so no cautery for you? No cautery. Same, no cautery. It does take a little bit of adjustment period, and I think I think the thing that I noticed the most is that the tissue doesn't bleed, but in patients that have a lot of synovium in there, even if you clear it off well, you can still sort of see the red tinge to the synovium through the scope. And I do have a video of the visualization on one of my patients in doing this that you can see. Everything's just a little pinker than it would be with a tourniquet, but your visualization is still totally adequate to get a safe view and a good view to complete this procedure. One thing I've noticed is that the transverse carpal ligament doesn't bleed when you cut it. Right. No. Yeah. No. Right. So here's my injection technique. So, wiping with alcohol. And then I start proximally. You can see it's a much bigger syringe than you saw previously. And this is a straight vertical injection to get through the fascia. So you can feel a pop with the needle as you get in. And then I'm putting about eight cc's. And this is generally not painful. It's not a very sensitive area. So once the needle's in, I can inject this one a little bit faster. And that's just sort of bathing the nerve. What are your landmarks for that injection? So I literally go right where my incision would be, and I go five centimeters proximal to that. Okay. Just right off Palmaris. Just ulnar to Palmaris. And then I'm going right to the incision site. And this is just subcutaneous. Raise a wheel. And then, as was mentioned before, I try to keep the local in front of the needle tip as I inject down just a little bit here. The patient didn't like that as much as you can see there. And that's why I've gone retrograde more, is I've found that that one tends to be a little harder to stay on top of the ligament in my hands. And I have the patient straighten their fingers out and then come from that intersection of Kaplan's cardinal line, sort of heading more proximally to get my subcutaneous anesthesia. And so twice I've engaged you at all? It is. Twice. Do you always have them sitting up? Yes. So I do all mine lying down for obvious vasovagal reasons. I think most people, this is fine. I would always be a little bit nervous to get that person gets wobbly and they're sitting up and you got a needle in their palm and no one there to catch them. But yeah, I'll do it just like Randy does. I'll have the patient lying flat and I'll put their hand on my knee and then I'll inject them there. So I sort of have control with them resting at a level that's good for me. Yeah, and I'll just, I'll be sitting in a chair when I inject them. Then here's just a quick slide showing the visualization for one of these patients. So you can see it is more pink than you get in the operating room, but you can clearly see the transverse carpal ligament there. It's a dry view despite having injected through around the median nerve. You do occasionally get a bubble or two, but. and able to complete it. You can see even after cutting there's no active bleeding or anything like that. Anybody have any questions before we get down to demonstrate on the cadaver? I do not, no. I hope not. For me, I have them leave their bandage on. So I close these with a subcutaneous monocryl and just put some Steri-Strips over the incision. They wear their bandage and keep it dry for five days. Then they remove it at home even before they come back and see me and can wash and shower like normal. I ask them to limit their lift into about two pounds for four weeks, knowing that that's really just for pain control. Their incision will be well healed before that. But what I've found is that pillar pain tends to last a lot longer in patients that get back to activities sooner. And I just tell them, listen, if you have childcare needs or work duties or, you know, life responsibilities that require you to do things beforehand, go for it. Just know that it's gonna hurt for longer. And I remind them of that every time I see them, that we had that discussion if they, you know, went back to their construction job or whatever. Similar, I do a monocryl Steri-Strips. I also put a Tegaderm over with a tiny gauze. And they can shower immediately with the Tegaderm as long as the edges are intact. So they can shower immediately. They can shower the next day. I put an Acewrap on top of that for two reasons. One, I like a little compression. Two is people, if they do spot a little bit and you're looking through a clear dressing and it's a white gauze, even if it's two drops of blood, for some people it's a dramatic moment. So the Acewrap at least hides that from them. And then after three days, they peel the Tegaderm off. The gauze comes with it. They shower normally. And I say, you know, you put a band-aid on it or nothing and the Steri-Strips fall off on their own. And then activity-wise, I tell them there's no formal restrictions. I say, if you do something and it hurts, you're not doing any harm. You're just making yourself sore. So I kind of let them go. I do counsel my laborers, my heavy mechanics, carpenters, tool and die, folks that realistically you're not going to feel like that type of work for at least a couple weeks because of the pillar pain. And I said that your priority in the next two weeks is to get your incision healed. After that, you know, you'll heal. And everyone has pillar pain, but some people it's gone by two weeks. Sometimes people have it for six or eight weeks, but it always goes away. My post-op protocol is similar to Randy's. I'll use a, I actually close the nylon just because it's less reactive. And then we'll cover with the gauze and an opsite. And then I'll just tell the patients if something hurts, don't do it. If it doesn't hurt, you're okay to do it. If you do something that hurts, you're just going to hurt more. But I think one thing that I've come to realize is that a lot of patients really have significant economic pressures. And so I don't want to tell them, well, you can't work for two weeks because that might mean you're not going to pay your mortgage or feed your kids. And so I think patients do what they're going to do. And this way you, because they're not going to hurt anything, you at least make them not feel guilty about it, you know, that they're somehow not following your instructions. One thing that I've found is that for welders specifically, they tend to wear, they wear gloves and they really sweat a lot. And so I've, I really encourage them to change dressing frequently, keep the thing dry. As far as showering, a couple of days, you know. Revisions. I do, I don't do revisions endoscopically. So if somebody's had an open or an endoscopic prior, I will do those open. I used to, that's how I was trained. And about 10 years into practice after a day of doing three or four opens in a row on somebody who had had a previous either open or endo 15, 20 years prior, I made the comment to whoever I was working with, like these look exactly like it's never been done before. And so kind of made the decision to try doing endoscopics for revisions at that point and carefully and obviously not trying to be a cowboy. But, um, I have found that it, that I have had no issues whatsoever doing revisions with the endoscopic. Um, I, my threshold is very low to switch from an open if I had to, I just haven't had to. And I've, I've been very happy with that and haven't had any complications and they've gotten better. So I kind of use, um, uh, the duration of time since their index procedure. And it was 10 years, it's kind of shrinking to five years. If somebody is having recurrence symptoms or if they never got better from their original carpal tunnel, that to me, that's an open and I want to kind of see, I want to, I want to see what's going on in there. Yeah. And same for me. I know Tom Trumbull had published an article years ago about doing revisions with endo and, you know, had great results, but like Bill, I don't do revisions just for comfort level reasons, rheumatoids, if I think I have fulminant synovitis. And then as Randy said, if you have someone who just simply didn't get better from the first go around, that's probably not a bad idea. Dr. Wong. Yeah. Yeah. I mean, I don't have any, there's no reaction. So the only time, you know, when you're doing your dissection, as you know, you're really not, you're not, I mean, you're trying to avoid the nerve at all costs in terms of just spreading with your scissors or your retraction. So you're really, you're aware of it, you know where it is, and you're working owner to it. But when you get in that tight canal, there's, you know, you're, with your blunt part of your instrument, you're filling up volume in a tight space. So there's a pressure phenomenon that people would experience with that nerve. But I do not have, I have not had, at least since I've switched to that technique, I've not had somebody tell me that was painful. Every once in a while, somebody will kind of make a comment like, that feels tight. And it is, because it is tight, but they're not, and I'll specifically ask them, do you have pain? They say, no, it just, I can feel it, something's tight in there. But they do not acknowledge pain or paresthesias or electrical or burning or tingling. That's a good question. I would say probably, I don't know, maybe 1 out of every 200, maybe 1 out of 150. I'm using a 30-gauge needle, not that anyone wants to have any needle poked near your median nerve, but I think a 30-gauge needle would be the most minimal amount of trauma that you could do, you know. And if you move slowly, then I always tell patients, if you feel any tingling or you feel anything at all, just let me know and I'll redirect. But Les makes a great point. I mean, one of the advantages Randy has is that he's just not near the nerve. Yeah. I don't think I, with that proximal where I'm actually going down with the intention of blocking the nerve, I try to keep that more ulnar. It's ulnar to palmaris to keep me safe from that. I can't think of an occasion where I've had a patient, you know, say, oh, I can feel that electrical sensation. I was actually getting it more around the incision as I was trying to inject towards the palm, which is why I started coming the other way and sort of injected less at the incision site because I was having that experience there. For sure, for sure. In the early, when I was first trying to figure it out, I would try to do a block and I would do it on like Bill closer to where we're working, partially because of timing, I just wanted that block to set up faster. I don't know that I hit it ever, but even getting in the ballpark in some fluid pressure, I would get a pretty good reaction and I didn't like that. So that's when I started playing around with different options and settle on what I do. But I think if you got really good at it, which clearly Bill and Mike are, I think you can be very good at that block without one out of 200 is, and it's probably not even that high quite honestly. So, but it's not, you don't want, I mean, the whole point is that what we're trying to accomplish is a better procedure, a better, safer, more comfortable procedure and so it's incumbent on us to do the thing that is the most comfortable and we have the most confidence in. One, I think just one comment I would make is one of my priorities is just to really have a dense, dense block because I found that the pressure is what can really bother patients, and so that's why I've sort of persisted in doing an actual median nerve block, which I guess is sort of more akin to Bill, because pressure on the median nerve, I think patients have found uncomfortable. But it sounds like Randy, you really haven't had that issue. I don't, and I'm obsessive about talking to the patient about what they're feeling. I mean, my staff get just, I mean, I say the same things over and over and over. What's your number? What's your number? I'm just obsessive about it being a really, really good experience and even when I ask, when I even, sometimes they don't say anything, but you'll kind of see this body shift and I'll say, what's going on? Are you just adjusting your shoulders or is something bothering you? And I'll look at them and they have a smile on their face and they can tell like, I don't really know what I'm feeling. It feels weird, but it's not unpleasant. It's not a negative feeling. And so I've been very happy with that technique. So I guess my experience is that if they have a dense median nerve block, they just don't feel anything. So you can put the scope in. It can be a super tight, you know, carpal tunnel and they will have no pressure sensation at all. I mean, they're just that densely blocked. And that's my experience as well. And that's what I want. I want the patient and, you know, I think as long as they're not feeling that pressure or feeling any discomfort, it's going to be a pleasant experience regardless of the injection procedure that you use. I do like having that dense block though. And I think it helps, you know, for post-operative pain quite a bit as well. And maybe they get a little bit longer relief if the nerve itself is blocked. But again, having only done a nerve block and not doing the sub-Q, I can't really directly compare them myself. I think any way you look at it, it hurts less than getting an IV start. And none of us get those. So, I mean, in the end of the day, there's no question. It is a globally a more painless experience than the traditional. So we should do our demonstration here. Bill, do you want to go ahead and start because you're the most proximal. You can kind of show us where you start with your proximal. Yeah. So. Can I ask one more question? Of course. I used to do that with a dense block and I did the other day. I'm just going to repeat the question so everyone can hear it. The question was, he used to use a dense median nerve block but is wondering whether having a less dense median nerve block might signal to patients if there's any concern about getting near the nerve or... With the scope. Right. With the scope. Exactly. So, does having that responsiveness of having a less dense block make the procedure safer, I think, is that accurate? Yeah. I don't, I guess I would say I don't want them to have, I don't want to rely on that feedback. I think that the principles of the procedure itself in terms of the actual release are such that I'm not, I mean, when the patient's asleep, you never had that feedback at all. And so, I don't know that that feedback from the patient makes it safer. It's a little bit different than, for example, a needle aponeurotomy where you are heavily coaching the patient to respond to paresthesias and you're using tiny amounts of local and you're trying to avoid a conduction block. But with this, we never got that feedback with, you know, tourniquets and sedation. So I don't want, I don't want, I mean, yes, if the person reacts, I'm going to stop what we're doing. I just haven't had that experience. So I guess my answer is I haven't had the experience where a patient was bothered by the actual release at all other than, you know, saying it felt maybe a little weird but not a bad feeling. So I don't, I don't need that feedback personally. So looking at my technique here, and I've sort of marked out sort of the end of your transverse carpal ligament where I would make my incision here. And then this dot is where I would start with my median nerve block. And I'm just ulnar to palmaris, and this is a straight in injection. I would have my cold spray, and I can feel a pop as I get through the fascia. You generally don't get much of a wheel here, and then this is an 8 to 10 cc injection slowly at that level. So once I pull out at that point, then I'm going to come down to the incision, and I'm not going to inject here because I'd like them to sort of show their techniques. But I do a subcutaneous injection of about four cc's at the incision site. And then I'll come from the distal most aspect and inject in a retrograde fashion. And again, I have the patient straighten their fingers out so I can get a real low angle here to get between the skin and the transverse carpal ligament as I fill up the sort of the subcutaneous area right superficial to the. So my fluid is injected about five centimeters proximal to my incision. So I showed a video demonstrating it. I don't get the fluid in the carpal canal. So my visualization, other than being a little more pink because I'm not using a tourniquet, really is not affected by my injection technique. So does injecting sub-q get down into the area we're releasing the nerve? Not in my experience, no. Because it's superficial to the transverse carpal ligament. So I still have a dry view of the undersurface because your local is superficial to it. So we watched the video earlier, but just to reiterate some of those things. This incision is pretty comparable to what I would do. And I usually start a couple millimeters proximal, and I bunch up this skin. I always have the patient lying down, the arms on a hand table, so in the same position they are when they're gonna have their surgery. And we use a much smaller needle than this, but this is what we get. And that most people have a nice little redundancy in their skin here, and I just pinch it between my fingers, and I just try to pop through. I'm gonna get a little less pushback from the specimen here. I'm just below the skin, and so you can immediately start to see that wheel rise. And then I'd rather move my needle around. If I don't like where it's going, I just start to massage where the fluid is going. And what I want to ultimately see is distension proximal to the incision. I want it to envelop the incision, and I want it to go distal to my incision. So that was about 5 cc's. And so I'm looking for sort of a halo, you know, kind of right around, you know, just completely encompassing the incision. At this point I stop. This is a deliberate pause, and that lidocaine is actively numbing that area. Talk about the surgery, talk about life, talk about post-op instructions. Just by yourself 30 seconds. And then come in, and I kind of lay my needle. I've used an inch and a half needle in the office, and I look at Kaplan's cardinal line, and I want to be pretty close to that with the tip of my needle. I don't have to be right up to it, a little bit shy. And then I look at where the needle and the hub have a junction, and that's about where I want to start. To Bill's point, I have them just slightly extended, which allows us to stay in that sub-Q without getting deep. And truly this, at this point, this injection is, I ask, and people will, they don't even know that I've injected them again. And so I start injecting here, and we just, we just go, I'll have to do it left-handed, and we just go a little extension, and we just work our way slowly. And this is gonna be faster for demonstration purposes, but I just, I'm looking at the palm, I'm feeling the palm, and I just want to see that skin getting tight and taut, where I want them taut. Like I said, it would be absolutely accessible for an open carpal tunnel if I wanted to, I just haven't found the need to do that. We just work our way in, and I know when that hub, oh there I came through, so when that hub is, is close to the skin, I know I'm as far distal as I need to be. At any point, if they start feeling discomfort at all, even a one or two, I just either slow down or I back up and pause. So for me it's five there and five in the sub-Q in the palm. And I'll just quickly show what I do here, and then we can actually do the release, again sort of a big needle, but so I'll pick a point between the palm eris and the FCU, kind of halfway between, make a small poke with, again with, I'll use a 30 gauge needle, raise a subcutaneous wheel right across like this, so a subcutaneous wheel just like that, and then I'll let that work for a second, and then just, you know, right out of Green's textbook for how to do a steroid injection to the, you know, for the carpal tunnel, go in about a 45 degree angle, midway between the two, just feel myself poke right through the fascia, and this is just some extent, there's what, you know, Les was talking about is can you injure the nerve? I think if you have a good tactile sense, just right when you pop through the nerve, if you start injecting, you're sort of pushing the nerve away, and using a 30 gauge needle, so it's just a very, very small needle, and then of course just your anatomy, I mean you know your anatomy and you're well owner to the nerve, and then I'll usually put in about eight to ten cc's total in this area, about a cc or two in the sub-Q, and maybe about between five and eight into the carpal tunnel, and then just like Randy and Bill, then I'll just come into the palm like that and inject subcutaneously, and I think we may have time just to do a release quickly here. I didn't want to inject into the carpal tunnel on mine, just so you guys can see how the dryer look looks, so Randy, do you want to go ahead and do a release here? Sure. Yeah. Yes. Yeah, without question, yes, so you know how it is, you sort of started to do a technique, and this is just the way you decided to do it, because there wasn't a lot of a lot of people to tell you how to do it, and so I just got used to being able to operate with a little more fluid around there, as some are are wet, I guess a little wet, some are remarkably dry for the amount of fluid they inject into the into the, you know, carpal tunnel. Like I say, my objective has always been to get a dense, medium nerve block, and so that's why I've injected there, but the downside, compared to the techniques of Bill and Randy, is that you're going to have more fluid. It's just a view that I've gotten used to seeing. So we'll make this incision a little bit bigger than we normally would. Do we have any little gauze? You can just use the side of the, yeah. So this, just come and grab this, just get your hands out of the way. Longitudinal spreading. I'm not sure if this specimen has a, has a palmaris. That looks like, that looks like palmaris right there, which you won't be able to see. Yeah. So we'll kind of bypass the, so palmaris is right, a little muscle in here, right there. Do you have a couple of rag nails, Bill? Yeah, that might be helpful. Grab one. Do you want to come sideways? You get that a little bit deeper, right? There you go. So I think we're actually through the lateral area. Yeah, I think you are. So here we are, this is deep. We'll just work distal. Normally you do a little proximal release, but I think what we want to see is. I think to show how much fluid there is in the canal, or lack of fluid. So I use a skin hook here. I don't know if you guys do the same. One thing, just to comment as a little bit of a disclaimer, is that sometimes the cadavers get pretty wet, just as they thaw. So you may see more fluid. So I hang on to this one. I put my own or two fingers on my, my line that I drew overlying the carpal tunnel, and that gives me palpatory feedback from, from the, from both this elevator, the synovial elevator. So what we're doing is you're, you're directing upward towards the roof, and you're just trying to peel the synovium. This should be, again, a painless experience for the patient. And we'll just see. I'm not quite sure what that's gonna look like, but. Yeah, I usually have a PA or a resident, and they're sitting across from me with skin hooks, but at this point. So, so there's a lot of synovium in here that I think is not gonna be your typical. Sometimes you can use the, let me just get in and see if we're in the right plane. So, actually, our focus is a little bit, but that's, we'll see if we adjust our focus a little bit. So, so as it was taught to me, sometimes the distal edge is a little bit tricky to see, but you're seeing the transversely oriented fibers. So if you can't totally make out that distal edge, I pull back about a centimeter, deploy the blade, do a five or so millimeter release, and you can see I didn't do a good job clearing the synovium on this cadaver. And then at that point, you can, it starts to become very clear where the distal edge, and there's a little more natural tension in a living specimen that will kind of spring open. But at a certain point, it becomes very obvious you're at the end of the ligament. Once you've documented that, then it's all the way out. What I find is very helpful to visualize that distal aspect is I actually will take, since my assistant is holding the retractors, I'll have my, so if it were doing a left hand here, I'd have my right hand, and I put my thumb right in the mid portion of the palm, and I actually bounce it. So when you see the fat bouncing, you know that that's distal to the distal-most edge of the transverse carpal ligament, because the ligament will prevent that bounce. So that sort of gives you a nice distinction to make sure that you're getting complete release distally without going too far to, for example, get into the palmar arches, which was mentioned before. I think one of the things that's impressive about this demonstration is, because I actually did inject into the carpal tunnel, I was showing how I did it, this is basically a reflection of Randy and Bill's technique, and you can see really how dry it was even for a cadaver. Usually cadavers are pretty wet. Do you guys always sit in the axillary and do them right-left? I do. Yeah, same for me. As a fellow, they wanted us to always use our dominant hand, and I found that the rotation of the supination of the forearm, or the hand, made it a little more annoying, so I sit always in the axillary. Yeah, me too. I find it really disorienting when I'm trying to teach a resident. I have to stop and think, which is right or wrong, so. It depends on where their point of constriction is, so I think sometimes when you do, or more often that I see people have, you know, had this done somewhere else, they say they never got better after the procedure. My fear is always, did you have an incomplete release, and that's some of the criticism, which I believe is unwarranted of the endoscopic, is that you're more likely to have an incomplete release. I think I'm more likely to get a complete release with bouncing my thumb on that distal aspect, because it really makes a clear distinction of where the transverse carpal ligament ends, but I think, you know, usually it's not that tight. I don't think that that's usually the constriction point, but if it is, then, you know, that could be a reason that your patients don't get better after a carpal tunnel release if you don't complete it. Instead of the U, I always look for the U. In terms, I tell everybody after we're done, that is a huge advantage, in my opinion, to the endoscopic over the open, is not only do you get visual feedback, as Dr. Wong was alluding to, you can see, you can see as clear as day, and doing that partial release, coming back a little bit, and then going, a lot of times I'll just go a tick at a time, and you'll see white fiber, white fiber, white fiber, and there'll be that last tick, and you can just, and all of a sudden, you can't even see anything in your view, because it's totally draped to the side. So you're lifting up, so you're driving the nose of the device palmerward, so you're pushing up against that roof, plus I always have my assistant fully extend and retro-pulse their thumb, and the hand's flat, and so that adds to the tension on the ligament, and you can, and by doing a little bit of that not quite distal release, things don't open up, but then you go advance one tick at a time, and it'll just pop open, I mean, it's very clear. And then when I drop the blade, I come back to the axle of where I left, deploy it fully, come out, try to make a field goal on my two-prong skin hook, and then I go back, and usually to just double-check on one side, I just want to see one leaflet from proximal to distal, I want to see it floppy, I want to see it fall right into the, I always teach this, like the cameras, you're in a canoe, or a bow of a skinny boat, and I want that leaflet to fall right into the bow of that boat, and I know if it's flopping down inside of there, I know that it's loose and uncut, but the other thing is, when you're going in, and obviously we do lots of them, and you get a feel, some are tighter than others. I mean, some, you know, some you're like, oh, you're kind of working, but you have to be controlled with your hand, and your hand is always in contact with the form, and it's a very, very controlled, but it is a muscle-y effort to get it in there. When you go back into that double-check, it's all, there's all kinds of room, where it slips right in there, and so you don't get that. You don't get that feedback doing an open. You get visual feedback, but you don't get that actual, tactile feedback that, ten seconds ago, I tried to insert the same size instrument, and I could barely fit it in, and now I can put it in there, and I can wheel it around, and there's all the room in the world. So you get, you get a lot more feedback. As you get better at them, and do more of them, I have found, you know, the fingers in the palm, those, you know, I'll sometimes do a release, and I'll feel a good release, and I can see it separated, and I'll see a few little fibers, and every now and then, I'll push down with my fingers in the palm, and go get those. That probably doesn't make a bit of difference, but you start to do things like that over time, but I really enjoy, I like that sense that I just was in the very space that we're trying to decompress, and it was tight, and now I'm back in it, and it's wide open, and so I can look at that patient with confidence, like, I know you're totally decompressed. And I add to that even a little bit more. I go back in after I do my visual check with the scope. I'll take the dilator back in, point it up towards the skin, and I pull it back, and I tell the residents, you know, see if you can pluck any guitar strings, because if you are pulling, pulling, pulling, one, you can tell it's open, because the dilator easily slides in, but as I'm pulling back, if there's a band that's still there that could be a constriction point, you can feel it with the tip of that dilator, and then we'll go back in and get it. Very rarely do we need to, but I check it on everybody as a sort of third safety check. I don't think it matters. I wouldn't start with a patient that has a needle phobia that they say, no, you know, if they, if you say, hey, we can do this with you awake, I just have to inject you and numb it up. If they have a sort of a negative initial response to that, probably not the best one to start with. After, you know, a few of them, you know, those people, you say, listen, you know, trust me on this. This is gonna be a more positive experience for you, and now that's not even something I take into consideration, but it's starting. If you have somebody that's real nervous, that's probably not one that's gonna make you comfortable with the procedure. Are you speaking specifically of sedation versus local or open versus endo? Yeah, yeah, for sure. A low anxiety, somebody who's excited about it. I mean, you know, when you bring it up, in the old days, I would give options. Now I say, this is an operation we do under local, and most of the time patients are there. They know that about my practice, and that's why they're there, so it's an easy conversation, but in the early days, if if they're anxious at all, that's not the person, and then I would say the only other person from a technical standpoint is the giant hand, like the the six guy with just giant bear paws. Like, that's not probably a great one to do. I mean, you can do them for sure eventually, but it's just, you know, it's a little small, a little easier. And just my quick answer is that if you have a dense median nerve block, then the canal size becomes really less important, so even the super tight ones, if they're just densely blocked, you can slowly dilate it up. You can leave the coequal in for a while, just to sort of stretch things out, so I don't think size of canal really makes a big difference in terms of local versus sedation, as long as, in my experience, you have a dense block. And my experience with giant hands, actually, is I think that giant hands are much easier to do endoscopically than wading through, you know, six inches of palmar skin, so I actually, when I see my giant hands, I'm really happy that I'm doing them endoscopically. I think they're much easier. Do you hedge your incision distal? I'm sorry? Do you hedge your incision distal on those giant hands? Yeah, a little bit, yeah, I think so, yeah. I'm sometimes afraid that it won't reach. It won't reach, yeah, yeah, yeah, yeah. But, like, to try to do a mini open on a giant hand versus an endoscope, it's like literally night and day difference how much easier and more straightforward it is, yeah. Okay, great. Well, thanks everyone for coming. We're all around if you have any additional questions. Okay, so I guess time here, we're wrapping, but if people want to work on specimens, we've got plenty. We'll be back here at the same location at noon? 3.05 at noon. Room 305. So people stay now and work on specimens if they want? No. We're getting kicked out. Getting kicked out, okay, great. You don't have to go home, but you can't stay here.

local anesthesia

endoscopic carpal tunnel release

patient cooperation

risk of disinhibition

OR turnovers

recovery room stays

office settings

techniques

dense nerve block

WAL-ANT anesthesia