In reply: In discussing our article (1), Segal criticizes the incision at the wrist as being too small for the average surgeon. The trained neurosurgeon should be able to judge for him- or herself what kind of incision to use, depending on his or her level of experience and his or her comfort with a particular type of incision. The incision described in our article can be made longer; it can be extended at both ends to convert into a modified S-shaped incision or its radial end can be extended downward for 1 to 2 cm. Slight obliquity of the incision can facilitate the exposure. The anomalies of the motor branch and the cutaneous nerve supply to the palm to which Segal referred had been carefully scrutinized. Pertinent references were cited in our article. We pointed out that the cutaneous branches are avoided by placing the incision medial to the palmaris longus tendon, while the motor branch is safeguarded by making the incision in the ligament under vision and staying distally near the medial edge of the carpal tunnel.
Unfortunately, while dwelling on the wrist incision, Segal missed the point of the article. What we hoped to emphasize was that procedures for carpal tunnel surgery must take into account the known sequelae of surgery. The modification we proposed for that purpose is based on our concept of the pathogenesis of carpal tunnel syndrome, known anatomic criteria, and the potential spread of various incisions to prevent undue gaping of the ligament.
Sequelae of carpal tunnel surgery are well documented in many reports. Pain, weakness of the wrist, and other more enigmatic complications, such as reflex sympathetic dystrophy, remain a challenge. Segal states that he has not encountered any complications in his 500 cases and further states that nearly all incisions are painful and that pain after carpal tunnel surgery may be solely related to the patient's genetic propensity for wound healing. This statement is unfair to patients who have legitimate complaints and does no service to those who try to learn and help others learn by reporting the bad as well as the good results. Progress with this procedure can be made only if we face up to the recognized sequelae of carpal tunnel surgery. (The remarks about the endoscopic procedure are off the subject and are left to proponents of endoscopic surgery for their comments.)
Adel F. Abdullah
1. Abdullah AF, Wolber PH, Ditto EW III: Sequelae of carpal tunnel surgery: Rationale for the design of a surgical approach.Neurosurgery