19 Del. Admin. Code § 1342-A-7.0

Current through Register Vol. 27, No. 12, June 1, 2024

Section 1342-A-7.0 - Therapeutic Procedures - Operative

7.1 SURGICAL DECOMPRESSION is well-established, generally accepted, and widely used and includes open and endoscopic techniques. There is good evidence that surgery is more effective than splinting in producing long-term symptom relief and normalization of median nerve conduction velocity.

7.1.1 Endoscopic Techniques: have had a higher incidence of serious complications (up to 5%) compared to open techniques (less than 1%). The most commonly seen serious complications are incomplete transection of the transverse carpal ligament and inadvertent nerve or vessel injuries. The incidence of complications may be lower for surgeons who have extensive experience and familiarity with certain endoscopic techniques. Choice of technique should be left to the discretion of the surgeon.

7.1.2 Indications for Surgery: include positive history, abnormal electrodiagnostic studies, and/or failure of conservative management. Job modification should be considered prior to surgery. Please refer to the "Job Site Alteration" section for additional information on job modification.

7.1.3 Surgery as an Initial Therapy: Surgery should be considered as an initial therapy in situations where:

7.1.3.1 Median nerve trauma has occurred; "acute carpal tunnel syndrome", or

7.1.3.2 Electrodiagnostic evidence of moderate to severe neuropathy. EMG findings showing evidence of acute or chronic motor denervation suggest the possibility that irreversible damage may be occurring.

7.1.4 Surgery When Electrodiagnostic Testing is Normal: Surgery may be considered in cases where electrodiagnostic testing is normal. An opinion from a hand surgeon mayshouldmay be considered. The following criteria should be considered in deciding whether to proceed with surgery:

7.1.4.1 The patient experiences significant temporary relief following steroid injection into the carpal tunnel; or

7.1.4.2 The patient has failed 3-6 months of conservative treatment including work site change, if such changes are available; and

7.1.4.3 The patient's signs and symptoms are specific for carpal tunnel syndrome

7.1.5 Suggested parameters for return-to-work are:

Time Frame Activity Level

2 Days Return to Work with Restrictions on utilizing the affected extremity

2-3 Weeks Sedentary and non-repetitive work

4-6 Weeks Case-by-case basis

6-12 Weeks Heavy Labor, forceful and repetitive

Note: All return-to-work decisions are based upon clinical outcome.

7.2 NEUROLYSIS has not been proven advantageous for carpal tunnel syndrome. Internal neurolysis should never be done. Very few indications exist for external neurolysis.

7.3 TENOSYNOVECTOMY has not proven to be of benefit in primary carpal tunnel syndrome but occasionally can be beneficial in certain patients with co-existing or systemic disorders.

7.4 CONSIDERATIONS FOR REPEAT SURGERY The single most important factor in predicting symptomatic improvement following carpal tunnel release is the severity of preoperative neuropathy. Patients with moderate electrodiagnostic abnormalities have better results than those with either very severe or no abnormalities. Incomplete cutting of the transverse carpal ligament or iatrogenic injury to the median nerve are rare.

If median nerve symptoms do not improve following initial surgery or symptoms improve initially and then recur, but are unresponsive to non-operative therapy (see Section.F, Therapeutic Procedures, Non-Operative) consider the following:

7.4.1 Recurrent synovitis;

7.4.2 Repetitive work activities may be causing "dynamic" CTS;

7.4.3 Scarring;

7.4.4 Work-up of systemic diseases

A second opinion by a hand surgeon and new electodiagnosticelectrodiagnostic studies required if repeat surgery is contemplated. The decision to undertake repeat surgery must factor in all of the above possibilities. Results of surgery for recurrent carpal tunnel syndrome vary widely depending on the etiology of recurrent symptoms.

7.5 POST-OPERATIVE TREATMENT Considerations for post-operative therapy are:

7.5.1 Immobilization: There is some evidence showing that immediate mobilization of the wrist following surgery is associated with less scar pain and faster return to work. Final decisions regarding the need for splinting post-operatively should be left to the discretion of the treating physician based upon his/her understanding of the surgical technique used and the specific conditions of the patient.

7.5.2 Home Program: It is generally accepted that all patients should receive a home therapy protocol involving stretching, ROM, scar care, and resistive exercises. Patients should be encouraged to use the hand as much as possible for daily activities, allowing pain to guide their activities.

7.5.3 Supervised Therapy Program: may be helpful in patients who do not show functional improvements post-operatively, in patients with heavy or repetitive job activities and certain high-risk patients. The therapy program may include some of the generally accepted elements of soft tissue healing and return to function:

7.5.3.1 Soft tissue healing/remodeling: May be used after the incision has healed. It may include all of the following: evaluation, whirlpool, electrical stimulation, soft tissue mobilization, scar desensitivation, heat/cold application, splinting or edema control may be used as indicated. Following wound healing, ultrasound and iontophoresis with Sodium Chloride (NaCl) may be considered for soft tissue remodeling. Diathermy is a non-acceptable adjunct.

7.5.3.2 Return to function: Range of motion and stretching exercises, strengthening, activity of daily living adaptations, joint protection instruction, posture/body mechanics education; worksite modifications may be indicated.

. Time to produce effect: 2-4 weeks

. Frequency: 2-5 times/week

. Maximum duration: 36 visits

19 Del. Admin. Code § 1342-A-7.0

11 DE Reg. 1661 (06/01/08)
12 DE Reg. 67 (07/01/08)