WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release

Abstract

Background

This study sought to investigate complication rates/perioperative metrics after endoscopic carpal tunnel release (eCTR) via wide-awake, local anesthesia, no tourniquet (WALANT) versus sedation or local anesthesia with a tourniquet.

Methods

Patients aged 18 years or older who underwent an eCTR between April 28, 2018, and December 31, 2019, by 1 of 2 fellowship-trained surgeons at our single institution were retrospectively reviewed. Patients were divided into 3 groups: monitored anesthesia care with tourniquet (MT), local anesthesia with tourniquet (LT), and WALANT.

Results

Inclusion criteria were met by 156 cases; 53 (34%) were performed under MT, 25 (16%) under LT, and 78 (50%) under WALANT. The MT group (46.1 ± 9.7) was statistically younger compared with LT (56.3 ± 14.1, P = .007) and WALANT groups (53.5 ± 15.8, P = .008), F(2, 153) = 6.465, P = .002. Wide-awake, local anesthesia, no tourniquet had decreased procedural times (10 minutes, SD: 2) compared with MT (11 minutes, SD: 2) and LT (11 minutes, SD: 2), F(2, 153) = 5.732, P = .004). Trends favored WALANT over MT and LT for average operating room time (20 minutes, SD: 3 vs 32 minutes, SD: 6 vs 23 minutes, SD: 3, respectively, F(2, 153) = 101.1, P < .001), postanesthesia care unit time (12 minutes, SD: 7 vs 1:12 minutes, SD: 26 vs 20 minutes, SD: 22, respectively, F(2, 153) =171.1, P < .001), and door-to-door time (1:37 minutes, SD: 21 vs 2:51 minutes, SD: 40 vs 1:46 minutes, SD: 33, respectively, F(2, 153) = 109.3, P < .001). There were no differences in complication rates.

Conclusions

Our data suggest favorable trends for patients undergoing eCTR via WALANT versus MT versus LT.

Keywords

endoscopic carpal tunnel carpal tunnel syndrome WALANT wide-awake surgery

Introduction

Carpal tunnel syndrome is the most common peripheral compression neuropathy and 1 of the most frequent disorders of the hand, affecting 4.9% to 7.1% of the population.^1,2 Carpal tunnel release (CTR) is the mainstay surgical treatment for median nerve compression refractory to conservative management. As such, it is among the most common hand procedures performed yearly, with a 38% increase from 360 000 cases in 1996 to 577 000 in 2006.³ The traditional, gold standard CTR was performed via a larger, open incision within the palm. However, recently, the endoscopic carpal tunnel release (eCTR), in which a small endoscope with an attached blade is used to release the transverse carpal ligament under direct visualization, has become increasingly popular. When compared with open CTR, eCTR has shown similar ligament release and complication rates without subjecting patients to larger surgical incisions.^4,5 Furthermore, eCTR decreases postoperative scar tenderness and increases grip and pinch strength postoperatively.⁶

Recently, there has been increasing interest in performing certain hand procedures with only local anesthesia rather than with global sedation.^7,8 Specifically, the use of wide-awake, local anesthesia, with no tourniquet (WALANT) is a described technique shown to reduce postoperative pain, operating time, and cost when compared with traditional methods using sedation and tourniquets.^3,7,9,10,11 First described by Bezuhly et al¹² for an extensor indicis proprius-to-extensor pollicis longus tendon transfer, WALANT has since been applied to other surgical procedures, including CTR, with patients reporting similar overall satisfaction and Quick Disabilities of Arm, Shoulder, and Hand (qDASH) scores compared with anesthesia by way of sedation.^13,14,15 This approach is characterized by the use of larger volumes of local anesthetic with epinephrine delivered into the operative field and digits without the use of a tourniquet or formal sedation, regional, or general anesthesia. This concept poses a lower cost burden to the health care system, particularly relevant, given the current shift toward delivering cost-effective, quality care.^7,9,16 Still, while WALANT has been shown to have similar patient satisfaction rates compared with sedation for eCTR,¹⁷ it is not without its own limitations. Specifically, a recent study found that while WALANT in eCTR did have a high patient satisfaction, approximately 33% of these cases were deemed technically demanding by the performing surgeon due to impaired visualization.¹⁸

There have been a multitude of studies that suggest similar complication rates between open CTR and eCTRs, and several others that compare WALANT with general sedation. However, this study investigates the complication rates and perioperative outcomes after eCTR performed via WALANT versus sedation or local anesthesia with a tourniquet. Specifically, the objectives of this study were to compare eCTR via WALANT versus tourniquet with or without sedation for the following metrics: (1) preoperative, intraoperative, and postoperative timing; (2) rates of nerve injury, neuropraxia, ischemia, and infection; and (3) reoperation rates due to incomplete transverse carpal ligament release.

Methods

Approval of our institutional review board was obtained. A retrospective chart review was carried out for all patients aged 18 years and older who underwent an eCTR between April 28, 2018, and December 31, 2019 by 1 of the 2 fellowship-trained surgeons. Patients were identified via Current Procedural Terminology code 29848 (eCTR). Revision procedures were not considered individual cases but rather as outcome measures. Endoscopic carpal tunnel releases on the contralateral side performed at a different date were treated as separate cases. Cases with a concomitant procedure performed at the time of eCTR were excluded, as were cases with no patient follow-up. Demographic data including age, sex, and body mass index (BMI) were collected, as were diabetes mellitus, cardiac history, and smoking status. Collected surgical metrics included laterality, anesthesia type, tourniquet use, antibiotic use, duration of surgery, time spent in operating room, postoperative postanesthesia care unit (PACU) time, and total “door to door” time. Time spent in the operating room was defined as the time from patient entering the physical operating room to when they exited for the PACU. “Door to door” time was defined as the time between patients being brought to preoperative holding area to when they physically left the hospital. Adverse outcomes were recorded, such as need for revision surgery, deep infection (defined as a surgical site infection necessitating a return to the operating room for a formal washout), superficial infection (defined as a surgical site infection that resolved with oral antibiotics), neuropraxia, other nerve injury, ischemia, and other complications related to index procedure.

Patients were evaluated as 1 of the 3 groups: monitored anesthesia care (MAC) with tourniquet (MT), local anesthesia with tourniquet (LT), and WALANT. Data were analyzed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, New York: IBM Corp). χ² testing with the Fisher exact test was used to analyze categorical variables among the 3 surgical groups. Analysis of variance was used for numeric variables and, when significant, Tukey honestly significant difference post hoc testing was used to determine significance among the groups. An independent samples t test was used to compare tourniquet time between patients receiving MAC sedation and local anesthetic.

Results

Our retrospective review identified 172 eCTRs (132 patients) performed by 1 of the 2 fellowship-trained hand surgeons at our single institution between April 28, 2018, and December 31, 2019. Of these, 156 cases met inclusion criteria; 53 (34%) eCTRs were performed under MT, 25 (16%) under LT, and 78 (50%) under WALANT. There was a significant difference in age, F(2, 153) = 6.465, P = .002, among the groups, with the MT group (46.1 ± 9.7) having overall younger patients compared with both LT (56.3 ± 14.1, P = .007) and WALANT groups (53.5 ± 15.8, P = .008). However, no significant differences were appreciated regarding sex, BMI, diabetes status, current smoking status, and cardiac morbidity status (Table 1). When looking at the average tourniquet time stratified by anesthesia type, patients in the MAC group had significantly longer tourniquet times compared with the local group (MAC: 11.1 minutes, SD: 2.3 vs Local: 9.1 minutes, SD: 3.3; P = .004) (Table 2).

Table 1.

Analysis of Demographics of Patients Undergoing eCTR Based on Surgical Method.

	MAC + tourniquet	Local + tourniquet	WALANT	P value
N (%)	53 (34)	25 (16)	78 (50)
Age, y (SD)	46.1 (9.7)	56.3 (14.1)	53.5 (15.8)	.002
Sex (%)
Male	24 (45)	16 (64)	86 (55)	.188
Female	29 (55)	9 (36)	70 (45)	.188
BMI (SD)	32.9 (6.2)	33.0 (11.1)	31.6 (7.2)	.534
Diabetes (%)
Yes	3 (6)	0 (0)	8 (10)	.270
No	50 (94)	25 (0)	70 (90)	.270
Current smoker (%)
Yes	16 (30)	3 (12)	12 (15)	.086
No	37 (70)	22 (88)	66 (85)	.086
Cardiac comorbidities (%)
Yes	2 (4)	1 (4)	5 (6)	.885
No	51 (96)	24 (96)	73 (94)	.885

Note. Comparison of patient characteristics based on surgical method. There is no significant difference between sex, BMI, diabetes status, current smoking status, and cardiac morbidity status among the groups. There was a significant difference in age, F(2, 153) = 6.465, P = .002, among the groups, with the MT group (46.1 ± 9.7) having overall younger patients compared with both LT (56.3 ± 14.1, P = .007) and WALANT groups (53.5 ± 15.8, P = .008). eCTR = endoscopic carpal tunnel release; MAC = monitored anesthesia care; WALANT = wide-awake, local anesthesia, no tourniquet; BMI = body mass index; MT = monitored anesthesia care with tourniquet; LT = local anesthesia with tourniquet.

P < 0.05 indicates statistical significance.

Table 2.

Tourniquet Time by Anesthesia Type.

	Anesthesia type	Mean (SD)	P value
Tourniquet time (min)	MAC	11.1 (2.3)	.004
Tourniquet time (min)	Local	9.1 (3.3)	.004

Note. Comparison of tourniquet time based on anesthesia type. Tourniquet time for the MAC group (11.1, SD = 2.3) was significantly longer than that for the local group (9.1, SD = 3.3); t(76) = 3.007, P = .004. MAC = monitored anesthesia care.

P < 0.05 indicates statistical significance.

A comparison of surgical timing was made among surgical groups (Table 3). Tukey post hoc testing showed a statistically significant difference in average procedure time among the groups, with decreased times seen in the WALANT group (10 minutes, SD: 2) compared with the MT (11 minutes, SD: 2) and LT (11 minutes, SD: 2), F(2, 153) = 5.732, P = .004 (Figure 1a). Similar trends favoring WALANT over MT and LT were seen with respect to average operating room time (20 minutes, SD: 3 vs 32 minutes, SD: 6 vs 23 minutes, SD: 3, respectively, F(2, 153) = 101.1, P < .001) (Figure 1b), PACU time (12 minutes, SD: 7 vs 1:12 minutes, SD: 26 vs 20 minutes, SD: 22, respectively, F(2, 153) = 171.1, P < .001) (Figure 1c), and door-to-door time (1:37 minutes, SD: 21 vs 2:51 minutes, SD: 40 vs 1:46 minutes, SD: 33, respectively, F(2, 153) = 109.3, P < .001) (Figure 1d).

Table 3.

Comparison of Surgical Timing by Surgical Method.

	N	Mean	SD	95% CI		P value
	N	Mean	SD	Lower	Upper	P value
Procedure time (min)
MAC + Tourniquet	53	0:11	0:02	0:10	0:12	.004
Local + Tourniquet	25	0:11	0:02	0:10	0:12
WALANT	78	0:10	0:02	0:09	0:11
OR time (min)
MAC + Tourniquet	53	0:32	0:06	0:30	0:34	.000
Local + Tourniquet	25	0:23	0:03	0:22	0:22
WALANT	78	0:20	0:03	0:19	0:26
PACU time (min)
MAC + Tourniquet	53	1:12	0:26	1:04	1:19	.000
Local + Tourniquet	25	0:20	0:22	0:11	0:29
WALANT	78	0:12	0:07	0:10	0:13
Door-to-door time (min)
MAC + Tourniquet	53	2:51	0:40	2:40	3:02	.000
Local + Tourniquet	25	1:46	0:33	1:32	2:00
WALANT	78	1:37	0:21	1:32	1:42

Note. Comparison of surgical timing among surgical groups. Analysis of variance testing shows a significant difference between procedure time among the groups, F(2, 153) = 5.732, P = .004, as well as significant differences in OR time, F(2, 153) = 101.1, P < .001, PACU time, F(2, 153) = 171.1, P < .001, and door-to-door time, F(2, 153) = 109.3, P < .001. CI = confidence interval; MAC = monitored anesthesia care; WALANT = wide-awake, local anesthesia, no tourniquet; OR = operating room; PACU = postanesthesia care unit.

There were 2 cases of superficial infections in the LT group, and 1 in the WALANT group; however, this did not reach statistical significance (P = .067) (Table 4). Intraoperative antibiotics were used in 8 patients, all of which were in the MT group. There were 2 cases of aseptic flexor tenosynovitis (“other complication”) seen in the MT group, which also did not reach statistical significance (P = .248). No cases of neuropraxia, nerve injury, deep infection, or ischemia were observed in any of the groups.

Table 4.

Prevalence of Complications by Surgical Method.

	MAC + tourniquet (%)	Local + tourniquet (%)	WALANT (%)	P value
Superficial infections
Yes	0 (0)	2 (8)	1 (1)	.067
No	53 (100)	23 (92)	77 (99)	.067
Other complications
Yes	2 (4)	0 (0)	0 (0)	.248
No	51 (96)	25 (100)	78 (100)	.248

Note. Comparison of postoperative adverse outcomes among surgical groups. There were 2 cases of superficial infections in the LT group and 1 in the WALANT group; however, this was not a significant difference. There were 2 cases of “other” complications in the MT group, both were aseptic flexor tenosynovitis. This also was not a significant difference. No cases of neuropraxia, other nerve injury, deep infection, or ischemia were observed in any of the groups. MAC = monitored anesthesia care; WALANT = wide-awake, local anesthesia, no tourniquet; LT = local anesthesia with tourniquet; MT = monitored anesthesia care with tourniquet.

Discussion

Our study demonstrates favorable results with WALANT eCTR compared with MT and LT groups, particularly regarding total operating room, PACU, and door-to-door times. While there were also statistically significant decreases in procedure time in the WALANT group compared with the other treatment arms, it does not reach clinical significance. The prevalence of superficial infections and other complications, including neuropraxia, nerve injury, deep infection, or ischemia, was statistically similar among groups.

Carpal tunnel release is 1 of the most commonly performed surgical procedures.¹⁹ Owing to this high volume, determining ways to streamline this surgery to minimize cost and maximize patient outcomes/satisfaction can help mitigate the burden to our overall health care system. Several efforts have been made to do so, including employing less-invasive surgical techniques, using portable hand tables to decrease turnover time, and foregoing postoperative splinting.²⁰ A shift toward simplifying perioperative anesthesia^21,22 has also been proposed. In their survey-based study of 716 American Society of Surgeons of the Hand providers, Munns and Awan²³ found that 43% of respondents used intravenous sedation during CTR, 18% Bier block, and 8% local anesthesia with the patient wide awake. This overall trend away from general anesthesia has allowed WALANT to recently gain increased popularity due to its patient satisfaction rates⁹ and cost-effectiveness.¹⁵ Furthermore, this technique does not require preoperative testing or perioperative monitoring, has shorter postoperative anesthesia recovery times, and eliminates the need for a tourniquet, which has been associated with mechanical pain and nerve damage.^24-28

Numerous studies have published on the outcomes as they pertain to patients undergoing open CTR via varying forms of anesthesia. In their prospective study of 230 patients undergoing open CTR (81 WALANT, 149 MAC), Tulipan et al¹⁵ reported no difference in the reoperation rate and patient satisfaction levels between the groups. Disability and symptom scores did not statistically differ at 2 weeks and 3 months, nor did average postoperative qDASH, Levine-Katz, and Visual Analog Scale pain scales. Similarly, in their randomized controlled trial comparing 37 wrists that underwent an open carpal tunnel decompression under local anesthesia and tourniquet versus 36 wrists wide-awake without a tourniquet but with a local anesthetic mixture containing adrenaline, Iqbal et al²⁶ reported that patients who underwent CTR with a tourniquet experienced significantly greater pain; however, pain and hand function improved similarly across both groups. This was further validated per Davison et al¹³ in their prospectively collected, multicenter study of 100 consecutive CTRs performed with only lidocaine and epinephrine versus 100 consecutive CTRs performed with intravenous sedation. Patients treated with intravenous sedation had double the length of stay, on average, in the postoperative recovery unit; were more likely to require preoperative workup in the form of blood work, electrocardiograms, and/or chest radiographs; and were more likely to require narcotic use postoperatively. Furthermore, in 1 of the largest retrospective samples published to date (304 CTRs performed on 246 patients; n = 90 CTRs with tourniquet, n = 214 CTRs without), Sasor et al²⁹ showed no major differences in postoperative outcomes between those undergoing wide-awake, open CTR with or without tourniquet use. Finally, in 50 consecutive cases of open carpal tunnel decompression randomized to traditional arm tourniquet versus infiltration of adrenaline and local anesthetic solution, Ralte et al³⁰ found that tourniquet use was associated with more pain and discomfort. Consistent with other published studies, no significant difference was observed regarding the ease of the surgeon to perform the procedure, as evidenced by the similar procedure durations and occurrences of technical difficulties. There, too, were no perceived outcome differences at 6 weeks as per the Michigan Hand Outcomes Questionnaire.

The clinical benefits of WALANT use have also been appreciated outside the realm of open CTR, particularly in smaller hand surgical procedures such as trigger finger release, ganglion cyst excision, or de Quervain release. Several studies cite improvements in mean visual analog scores and operative time,³¹ as well as increased patient comfort and less total blood loss when compared with the conventional technique. These promising results support WALANT use, and also point to the fact that epinephrine is safe and effective in the digits—contrary to traditional popular belief.

Endoscopic carpal tunnel release has evolved significantly since initially described by Okutsu in 1987.³² Thus, understanding the role of WALANT in the setting of eCTR is of paramount importance. Shin et al,³³ in their survey-based study of 123 members of the American Association for Hand Surgery, found that 34% of respondents favored a standard open (extensile) incision and 20% preferred an endoscopic incision. Still, more contemporary data suggest a quicker return to work,³⁴ increased grip and pinch strength, improved hand dexterity, superior scar sensitivity in the first 3 months postoperatively, improved symptom severity and functional status scores, and higher subjective satisfaction³⁵ for endoscopic compared with open release. Nonetheless, skepticism surrounding eCTR still exists. It is thought that the limited visualization may subject patients to increased risk for deleterious complications such as nerve/arterial injury. However, these claims have not been strongly supported in the literature. In a large meta-analysis evaluating complications in 22 327 endoscopic and 55 669 open cases, open CTR had a statistically significant increase in the incidence of structural damage to nerves, arteries, or tendons (0.49% vs 0.19%), although transient neuropraxias were more common with eCTR.³⁶

One of the most powerful differences displayed in this study pertains to the statistical decrease in time spent in the operating room, PACU, and overall door-to-door time, as this may have a direct role on patient satisfaction and overall cost. For our cohort, the timing and delivery of local anesthetic varied depending on anesthesia type. For WALANT, the senior authors inject in the preoperative area, just before going into the room with the prior scheduled patient to allow for approximately 25 minutes to pass for the epinephrine to have an effect. Conversely, for local + tourniquet or local + MAC, local anesthetic is injected in the operating room, just after induction and before prepping the patient. Each injection typically takes 1 to 2 minutes to perform. A cross-sectional and longitudinal analysis of 302 California hospitals in 2014 estimated the mean cost of operating room time to be between $36 and $37 per minute, depending on whether the procedure was performed in the inpatient ($37.45) or ambulatory ($36.14) settings.³⁷ Of this $36 to $37 per minute cost, $20 to $21 was attributed to direct costs, $13 to $14 to wages and benefits, and $2.50 to $3.50 to nonbillable surgical supplies. Anesthesia costs, in particular, were $3.42 per minute, on average. Given that surgical care accounts for nearly one-third of all US health care spending,³⁸ and that the operating room is the second most expensive part of surgical care,³⁹ finding ways to bring down this cost is critical. Applying these findings to our data set suggests that a 12-minute difference in mean time spent in the operating room between groups could generate significant cost savings, especially considering how common eCTRs are performed. This is particularly important considering that a 12-minute difference, based on our data, is more than the average time required to perform an eCTR for all 3 treatment modalities. Furthermore, our study found that patients in the MT group stayed 6 times longer in the PACU, on average, compared with their WALANT counterparts. Longer time in the PACU translates to increased need for nursing and staffing resources and decreased space for other patients. How this translates to cost savings, however, is still not as well understood.

This study describes the complications and perioperative metrics as they pertain to patients undergoing eCTR via WALANT versus sedation with tourniquet use versus LT. Still, it is not without its own limitations. Complication rates in carpal tunnel surgery are generally very low. An a priori power analysis was not performed. As such, it is possible that the study was not sufficiently powered to detect differences in complication rates. Direct comparisons between those patients who received antibiotics versus those who did not were avoided, so as to avoid making conclusions on small sample sizes. Generally speaking, the authors do not give antibiotics for soft tissue procedures less than 1 hour in duration. Although very rare, in some instances, select anesthesiologists at our institution administer antibiotics to MAC patients out of habit or without surgeon confirmation, which may explain the discrepancy in our cohort. Furthermore, the retrospective design subjects study outcomes to selection bias, in that it is possible that patients who underwent WALANT were less anxious at baseline and thus more likely to have postoperative success, for example. In general, the senior authors will perform their CTRs under local anesthesia, unless as part of an additional larger procedure. Monitored anesthesia care is generally reserved for patients with carpal tunnel disease with a severe phobia of needles and/or general anxiety of being awake during the procedure. For patients with larger BMIs or extensive medical comorbidities, for example, stronger recommendations are made for local so as to avoid any potential risks from anesthesia. Still, regardless of type, a shared decision-making process that caters to the patients’ desires and preferences is recommended. Future research in the form of prospective, randomized controlled trials is warranted to determine the full effects of WALANT versus sedation/tourniquet on patient-reported outcomes and satisfaction.

Footnotes

Ethical Approval

This study was approved by our institutional review board.

Statement of Human and Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Statement of Informed Consent

Informed consent was not required per our institutional review board (Reference No. 20x-154-1) for purposes of this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Antonio Cusano

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