This page is for my current patients only
此網頁只供我現時病人閱讀
Background 背景
There are 3 major nerves innervating the hand. One of them, called Median nerve, is traveling from palm side of the forearm, through a bony tunnel at wrist, to its destination, the thumb to ring finger. For some reasons when it is compressed at the tunnel, for example swelling of the tendons traveling together, or bone spur of the wrist bones, or thickening of the bounding ligament (transverse carpal ligament), then the nerve would be compressed. As a result, the compressed nerve will have impaired sensation and cause numbness. It might also cause weakness or even wasting of the thumb.
When Nerve Conduction Study confirmed nerve dysfunction and patient do not improve with conservative treatment, then surgical intervention would guarantee best outcome.
There are two methods to decompress the median nerve,
- Mini-open carpal tunnel release
By modifying traditional approach, a 3cm incision will be made along skin crease at palmar side of the wrist. The transverse carpal ligament is split under direct visualisation. It is a very safe and time honoured procedure. Because under direct visualisation, even anatomical variants, which is unexpected, can be safely operated.
- Endoscopic carpal tunnel release
By making a 1.5cm incision at wrist, an endoscope is past into the carpal tunnel. Again, the transverse carpal ligament is split under direct visualisation. However, since an endoscope had to be introduced into the tight and compromised carpal tunnel, this might cause temporary or even permanent injury to the nerve. Anatomical variants might also post higher risk of iatrogenic injury. While the wound is smaller, the cost increment from using the endoscope and additional time might need to be balanced.
我們的手由3條主要神經供應。其中一個叫做正中神經（Median nerve）。它從前臂手板一方穿過腕部一條由骨及韌帶組成的隧道（腕管 Carpal Tunnel），直達手掌及手指。如果由於某些原因，令它在通過這腕管時處被壓，例如，它旁的肌腱因發炎腫脹，或腕骨有骨刺增生，或上方的韌帶（腕橫韌帶 Transverse Carpal Ligament）增厚，那麼正中神經就會被壓。結果，受壓的神經會有麻痺感，嚴重的話還可能導致拇指無力甚至掌心雞髀位肌肉萎縮。
一旦經電神經測試證實神經功能受損，而保守治療無效，儘早進行手術鬆解將會有較理想的神經復原。
有兩種解壓正中神經的方法，
- 迷你開放式腕管鬆解
這是改進了的手術方法，醫生會沿著腕部掌側的皮膚皺紋打開一個3厘米的切口。在直接觀察下破開腕橫韌帶。這是一個非常安全的過程。因為在直視下，即使是解剖學上的畸變，也可以安全地施行手術。
- 內窺鏡腕管鬆解
醫生在腕部開一個1.5厘米的切口，將內窺鏡插入腕管。同樣，腕橫韌帶在直接觀察下被破開。但是，由於必須將內窺鏡插入已經十分緊逼的腕管中，因此可能會對神經造成短暫甚至永久的傷害。部份解剖學畸變也可能附帶更高的手術醫風險。雖然傷口較小，但必須平衡使用內窺鏡及額外手術時間所增加的費用。
Indication 適應症
Median Nerve compression due to 正中神經因以下問題受壓
- Thickened Transverse Carpal Ligament 手腕上方韌帶（腕橫韌帶）增厚
- Carpal bone bone spur 腕骨有骨刺增生
- Chronic swelling due to tendinosis of the tranversing flexor tendon 肌腱因慢性炎症而腫脹
- Tumour or ganglion 腫瘤或水瘤
- Urate Crystal 尿酸結晶
Preparation 預備
- Pre-op workup 手術前身體檢查
- Keep moving the hand to avoid stiffness 堅持多活動手指，避免僵化
- Do more deep breath 多深呼吸
- Continue usual medication on operative day 手術當天照常食藥
- No food or drink for 6 hours 手術前6小時禁食及禁喝水
- Admit to hospital 3 hours before surgery 手術前3小時到醫院
- Inform your relative despite surgery takes 10 minutes, you will return no earlier than 1 hour. 通知家人即使手術需15分鐘，但回病房可能是1小時後
Risk 風險
While all medical and nursing professionals endeavor to provide best and safest practice, complications still would occur.
General operative risks including heart attack, stroke, wound infection, wound hemorrhage, urinary tract infection, deep vein thrombosis, persistent swelling, pain, stiffness and redness related to reflex sympathetic dystrophy, scar pain and unsightly scar etc, is possibly encountered but extremely rare. Limb loss is a remote possibility.
Numbness over palm is not uncommon but usually resolves in weeks and seldom has consequence. Pain over wrist is uncommon and usually resolve with time.
Motor nerve injury is rarely occurred risk but it might cause weakness over thumb. Sensory nerve injury might cause loss of sensation over finger tips.
Anatomical variants also carry more risk.
Recurrence or persistent of symptom is around 1%, but this might be the natural course of the disease rather than complication.
儘管醫生和護士都會盡最大努力提供最佳和最安全的治療，但併發症仍會發生。
一般手術可能會遇到的風險，包括心臟病發作，中風，傷口感染，傷口出血，尿道感染，深層靜脈血栓形成，關於區域性神經紊亂相關的患肢持續性紅腫僵硬疼痛，傷口疼痛及外觀不理想等，這手術也不例外。嚴重案例可能需要截肢。
掌心麻痺雖並不罕見，但一般會於數星期後減消退而不留後遺症。手掌近手腕位置於用力時有痛十分常見，數週後通常會消失。
神經線損傷是很少遇上的風險。可能會引致指尖觸感受損以及拇指乏力。先天結構異常會有更高的風險。
持續病癥不改善或復發機率大概為1%，但這屬疾病的自然進程，不屬併發症。
Budget Estimation 預算費用
CPT code and RVU is as follows
- 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel, RVU 4.97
- 29848 Endoscopic carpal tunnel release, RVU 6.39
CPT碼和RVU如下
- 264721神經成形術和/或轉位； 腕管正中神經，RVU 6.39
- 29848內窺鏡腕管釋放，RVU 4.97
Estimation based on general ward as in Aug-2020,
- Surgeon fee $19,880 (Mini-Opne); $25,560 (Endoscopic)
- Anaesthetist fee $6,626 (Mini-Open); $8,520 (Endoscopic)
- Ward round $1,200/day
- Hospital charge $12,000 (Mini-Open); $17,000 (Endoscopic)
Total $39,707 (Mini-Open); $52,280 (Endoscopic) around
根據普通房於2020年8月進行的估算，
- 外科醫生費$19,880 (迷你開放式); $25,560 (內窺鏡)
- 麻醉師費$6,626 (迷你開放式); $8,520(內窺鏡)
- 巡房費$1,200
- 醫院費$12,000 (迷你開放式); $17,000 (內窺鏡)
總計$ $39,707 (迷你開放式); $52,280 (內窺鏡) 左右
Reference figures from private hospitals 醫院提供的參考數據
St Paul’s Hospital 聖保祿醫院
Median Charge 收費中位數 (Open release 開放式腕管鬆解)
- Doctors’ fee 醫生費 $18,000
- Hospital charge 醫院收費 $11,824
- Total 總費 $29,827
Cannosa Hospital 嘉諾撒醫院
Median Charge 收費中位數(Open release 開放式腕管鬆解)
- Doctors’ fee 醫生費 $15,800
- Hospital charge 醫院收費 $14,268
- Total 總費 $30,068
Baptist Hospital 浸會醫院
Median Charge 收費中位數 (Open release 開放式腕管鬆解)
- Doctors’ fee 醫生費 $18,977
- Hospital charge 醫院收費 $9,325
- Total 總費 $28,302
Adventist Hospital 港安醫院
Median Charge 收費中位數 (Open release 開放式腕管鬆解)
- Doctors’ fee 醫生費 $52,000
- Hospital charge 醫院收費 $14,070
- Total 總費 $66,070
Post-op care 術後照顧
- Control inflammation with regular usage of anti-inflammatory drug.
- If you feel the bandage is too tight, loosen it. There is a waterproof dressing underneath it. Do not remove the dressing.
- The wound is covered by a waterproof dressing. But because of the bandage and possible seepage of water via the skin crease, you should put the hand inside a sealed plastic bag when go for shower. Keep the dressing intact, there is no need to change it regularly.
- Moving the fingers are encouraged. Using the other hand to help the operated hand making full fist few times an hour. .
- Rest the wrist and do not lift heavy things.
- Always put the hand above chest. When you sleep, put a pillow further down your elbow to block it from getting straight. The hand will either lie on the pillow or on your chest. This will keep the hand always vertically above the chest and help swelling subside.
- 定時服藥，控制發炎
- 如果感覺繃帶太緊，請鬆開繃帶。 其下方有防水敷料。 不要去自己移除敷料。
- 傷口以防水敷料覆蓋。 但是由於表面的繃帶以及皮膚皺紋可能造成的滲水，因此在洗澡時，應將手放在密封的膠袋中（用保鮮紙繞好）。請保持敷料完整，無需定期更換。
- 多活動手指。 每小時用另一隻手協助患肢握拳。
- 保持手腕靜止，不要舉起重物。
- 盡量保持手放在高於胸口。 睡覺時，在肘部以下放一個枕頭，以防止其伸直。 手將自動放在枕頭上或胸口上。 這可保手始終垂直高於胸部，有助消腫。
Early Post-op Complication 手術後早期併發症
Notify surgeon in case you have
- Persistent fever of more than 37.5 Celcius
- Chills and rigor
- Wound pain despite rest
- Wound redness and swelling
- Purulent discharge from wound
- Calf pain
- Ankle swelling, progressive
- Sudden onset of shortness of breath
- Chest pain
如發現以下情況，要立即通知醫生
- 持續高燒（口探高於攝氏37.5度）
- 發冷打顫
- 無論運動或休息時，傷口痛楚都持續增加
- 傷口持續發紅腫脹
- 傷口有膿液
- 小腿愈見痛楚
- 小腿、腳踝和腿部腫脹持續增加
- 突發性的氣促
- 胸口突然疼痛
Rehabilitation after Day 14 手術後2週復健
Range of Motion Exercise:
- Rotation, Flexion-Extension, Lateral-Flexion:
Bent your elbow, rotate forearm in one direction to the extreme end, hold at end of range for 5 seconds, repeat 10 times for each directions
Repeat for Flexion and Extension (F/E ROM), and Lateral bending (ulnar radial deviation), also hold at end of range for 5 seconds, repeat 10 times for each directions.
Do not stretch it for additional range.
Thenar muscle strengthening:
- Thumb-little finger ring exercise
Make a ring with the thumb and little finger, for each hand, and loop the two rings together. Try to pull them apart. Hold for 10 seconds, then relax. Rest for 10 seconds. Repeat the whole set of exercises 10 times.
Caution on wrist care:
- Do not stretch, twist, or bend your wrist suddenly to avoid spraining your wrist.
- Avoid bending the wrist for more than 15 minutes. If need to work on phone, put it on table.
- You can start office work in 2 days after the operation, and do manual lifting no earlier than 6 weeks.
- Increase the amount of activity gradually and avoid strenuous exercise, especially weight lifting.
- Avoid excessive wrist fatigue within one year.
活動範圍運動:
- 彎曲肘部，將前臂向一個方向旋轉到活動範圍最末端，在範圍末端保持5秒鐘，每個方向重複10次
重複進行屈曲和伸展（F / E ROM）和橫向彎曲（向拇指或尾指側移），保持在活動範圍末端5秒鐘，每個方向重複10次。不要勉強伸展。
拇指肌力訓練：
- 小拇指指環鍛煉：
左右手都以拇指和小指環成一圈，然後將兩個環扣在一起。嘗試用點力試圖將它們拉開。保持10秒鐘，然後放鬆。休息10秒鐘。重複整套練習10次。
注意腕部護理：
- 不可突然伸張、扭轉、彎曲頸部，以免扭傷腕部。
- 避免彎曲手腕超過15分鐘。如果需要長時間用手機，請將電話放到枱面。
- 手術後2天可長時間坐辦公室工作，個半月後才可做體力勞動工作。
- 漸進式增加活動量，避免劇烈運動，尤其是舉重。
- 性生活手術後6周可恢復。
- 一年內避免手腕過度疲累。
Reference 參考文獻
- Isam Atroshi, Gert-Uno Larsson, et al. Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial. BMJ 2006 June 24. 332 (7556):1473
- Karl JW, Gancarczyk SM, Strauch RJ.
Complications of Carpal Tunnel Release Orthop Clin North Am. 2016 Apr;47(2):425-33. https://pubmed.ncbi.nlm.nih.gov/26772951/