Study Results Indicate Most CTR Patients Preferred to Be Wide Awake During Surgery

By: Maureen Leahy

Study highlights potential benefits of local-only anesthesia technique

According to study data presented on Tuesday, patients undergoing staged bilateral carpal tunnel release (CTR) were equally satisfied with their outcomes regardless of which method of anesthesia—local-only or local plus sedation—was used. However, 59 percent of the patients preferred to undergo surgery while being wide awake with local-only anesthesia.

The study, conducted at The Ohio State University Wexner Medical Center Hand and Upper Extremity Center, was presented by Kanu Goyal, MD. He said that while patients were equally very satisfied with their CTRs done under either local-only anesthesia or local anesthesia with sedation, of the 27 patients who completed the study, 16 preferred local-only anesthesia, nine preferred sedation, and two were indifferent.  

Prospective, randomized control trial

The study involved 48 adult patients scheduled to undergo staged bilateral CTR. All patients had agreed to receive both methods of anesthesia and to have the two surgeries performed by the same surgeon, utilizing the same surgical technique. The study excluded patients younger than 18 years, older than 89 years, and those who were not able to provide consent. Additional exclusion criteria were the following:

  • prior history of CTR
  • allergy to local anesthetic
  • medical condition prohibiting sedation (eg, COPD, lung cancer, sickle cell disease, liver disease, kidney disease)
  • any other contraindication to sedation
  • unwillingness to participate
  • inability to have the same surgeon for both procedures, or utilizing different surgical techniques
  • current imprisonment/incarceration

All surgeries were performed by one of three board-certified orthopaedic surgeons. Each patient was randomly assigned to receive either local-only anesthesia or local anesthesia plus sedation for the first CTR. The other protocol was used in the second surgery; patients could choose which wrist would be operated on first.

For each patient, both surgeries were completed within a four-week timeframe. Per the individual surgeon’s preference, the same surgical technique (open or endoscopic) was used on both wrists.

Local-only anesthesia surgeries were performed using the WALANT (Wide Awake, Local Anesthetic, and No Tourniquet) protocol. The authors note that the reported benefits of the WALANT method include safety, efficacy, low-complication rates, high patient satisfaction, overall reasonable pain tolerance by patients, decreased costs, minimal preadmission testing, and no patient fasting.

For the local-only procedures, patients were anesthetized with 10 mL to 20 mL of 1 percent lidocaine with 1:100,000 epinephrine and 8.4 percent bicarbonate, compounded in a 4:1 ratio. For surgeries performed under sedation, the treating surgeon administered 10 mL of 1 percent lidocaine with 1:100,000 epinephrine in the operating room after confirmation by anesthesia staff that the patient was sedated. All CTR procedures with sedation utilized a tourniquet.

The findings

The authors collected subjective and objective measures pre- and postoperatively from patients for both surgeries. Primary outcome measures included patient satisfaction with each procedure and patient anesthesia preference. Secondary outcomes included, but were not limited to, the Beck Anxiety Inventory, QuickDASH, surgical times and costs, pain assessment, and surgeon comfort.

Overall, 27 patients (59 percent female; average age, 55 years) completed the study. At final follow-up (six weeks after the second surgery), 26 patients (96 percent) reported they were equally highly satisfied with the outcome achieved with either method of anesthesia. However, statistical analysis revealed that wide-awake CTR with local-only anesthesia was preferred by 59 percent of patients (95 percent confidence interval [CI] = 41 percent–78 percent) and sedation was preferred by 33 percent of patients (95 percent CI = 16 percent–51 percent).

AND-2018-03-07-007_image01

Fig. 1 Patient anesthesia preference at final follow-up based on surgical technique.

Courtesy of Kanu Goyal, MD

Additional findings included the following:

  • no statistically significant difference in a scaled comparison of worst postoperative pain between local-only anesthesia surgery versus sedation during surgery
  • no statistically significant differences in postoperative pain between the endoscopic (n = 8) and open (n = 19) cohorts
  • no statistically significant differences in anesthesia preference between the endoscopic and open cohorts (Fig. 1)
  • no statistically significant differences in mean total surgical costs or surgeon comfort between the two methods of anesthesia

 “The results of our study show that patients do well and are highly satisfied with a carpal tunnel release regardless of being wide awake or sedated,” said Dr. Goyal. “However, more patients preferred being wide awake than sedated, suggesting that surgeons may want to start offering wide-awake surgery as an option to their patients for simple procedures that can be performed under the WALANT technique.”  

References for the studies cited may be found in the online version of this article, available at www.aaos.org/News/DailyEdition2018.

Dr. Goyal’s co-authors of “Comparison of Local Only Anesthesia versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release” are Garrhett Via, BS; Andrew Esterle, MD; Hisham Awan, MD; and Sonu A. Jain, MD.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org.

References

Benson, L. S., Bare, A. A., Nagle, D. J., Harder, V. S., Williams, C. S., & Visotsky, J. L. (September 01, 2006). Complications of Endoscopic and Open Carpal Tunnel Release. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 22, 9, 919.

Agee, J. M., Peimer, C. A., Pyrek, J. D., & Walsh, W. E. (January 1, 1995). Endoscopic carpal tunnel release: a prospective study of complications and surgical experience. The Journal of Hand Surgery, 20, 2, 165-71.

Becker, S. J., Makanji, H. S., & Ring, D. (January 1, 2012). Expected and actual improvement of symptoms with carpal tunnel release. The Journal of Hand Surgery, 37, 7, 1324-9.

Lalonde, D., Bell, M., Benoit, P., Sparkes, G., Denkler, K., & Chang, P. (January 1, 2005). A Multicenter Prospective Study of 3,110 Consecutive Cases of Elective Epinephrine Use in the Fingers and Hand: The Dalhousie Project Clinical Phase. The Journal of Hand Surgery, 30, 5, 1061-1067.

Chatterjee, A., McCarthy, J. E., Montagne, S. A., Leong, K., & Kerrigan, C. L. (January 1, 2011). A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States. Annals of Plastic Surgery, 66, 3, 245-8.

Teo, I., Lam, W., Muthayya, P., Steele, K., Alexander, S., & Miller, G. (November 1, 2013). Patients' perspective of wide-awake hand surgery—100 consecutive cases. The Journal of Hand Surgery: European Volume, 38, 9, 992-999.

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