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PENANGANAN CARPAL TUNNEL SYNDROME

I Gede Sandi Widarta Putra

1570121065

Artikel 1. Carpal Tunnel Syndrome: Current Review

ABSTRACT Carpal tunnel syndrome has been considered to be one of the most common disorders
ABSTRACT
Carpal tunnel syndrome has been considered to be one of the most common
disorders of the upper extremities and the most common and prevalent surgically
correctable compression neuropathy. The typical symptoms, produced by median
nerve compression at wrist, lead to pain which is classically nocturnal,
paresthesia, weakness in hand and digits in Median nerve distribution and may
lead to thenar atrophy in advanced cases. Although majority of cases are
idiopathic, various systemic disorders and occupational factors may also lead to
similar symptoms. The diagnosis is primarily clinical, based on detailed patient
history and physical examination which can be supported and confirmed by
electrophysiological studies. Treatment is prima rily symptomatic. Various
treatment modalities ranging from observation and nocturnal splinting to surgical
treatment, both open and endoscopic procedures, have been tried depending
primarily on the severity of involvement. Recent studies have shown both open
and endoscopic procedures to be equally effective with fewer complications with
endoscopic surgeries.
Ide Pokok:

Carpal tunnel syndrome merupakan kelainan bagian ektremitas atas yang disebabkan oleh kompresi neuropati. Gejala yang dihasilkan oleh kompresi saraf di pergelangan tangan yaitu nyeri dan lemahnya tangan dan jari dari distribusi saraf median. Diagnosis didasarkan pada riwayat terdahulu, latihan fisik dan studi elektrofisiologi. Pengobatan yang dilakukan yaitu dengan open and endoscopic procedures. KEYWORDS: Carpal Tunnel Syndrome, Diagnosis, Endoscopic Carpal Tunnel release, Entrapment Neuropathy, Median Nerve compression. Keyword : Carpal Tunnel Syndrome, diagnosis, Endoscopic Carpal Tunnel release, Saraf terjepit, tekanan median nerve.

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Paragraf 1 Carpal tunnel syndrome is one of the most common disorder of the upper extremities and the most prevalent compression neuropathy1. Brain (1947) and George Phalen (1950) have been responsible for the recognition of Carpal tunnel syndrome (CTS) as a disease entity; however the term ―Carpal tunnel syndrome‖ was first used by Kremer et al. in 1953. First ever Carpal tunnel release was performed by Herbert Galloway in 1924 and Phalen (1957) holds the credit for popularizing the use of steroids. Ide Pokok :

Carpal tunnel merupakan kelaianan pada ektremitas atas dan juga kompresi saraf. Carpal tunnel syndrome merupakan
Carpal tunnel merupakan kelaianan pada ektremitas atas dan juga kompresi
saraf. Carpal tunnel syndrome merupakan istilah yang pertama kali
digunakan oleh Kremer dan untuk penggunaan carpal tunnel release
pertama dilakukan oleh Herbert Galloway tahun 1924.
Paragraf 2
About 3% of US adults are affected, mostly between the ages of 40 and 60 years2.
Women are almost 3 times more likely than men to develop CTS1. The exact
epidemiology in Indian population is unknown. Various associated risk factors
include diabetes, hypothyroidism, rheumatoid arthritis, pregnancy, obesity, family
history, and trauma. A history of hand-related repetitive motions also increases the
risk3, 4. Occupations that require use of hand-operated vibratory tools or repeated
and forceful movements of the hand/wrist (such as assembly work and food
processing or packaging) have also been associated with CTS5.
Ide Pokok :

CTS kebanyakan terjadi pada usia 40 dan 60 tahun dan kebanyakan yang terkena yaitu wanita. Beberapa faktor risiko yang juga dapat menyebabkan terjadinya CTS yaitu diabetes, hyperparatiroid, pekerjaan dan lain sebagainya.

Paragraf 3 The carpal tunnel is defined as the space deep to the Transverse Carpal Ligament, which extends ulnarly from the hook of hamate and triquetrum to scaphoid and

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trapezium radially, and is bordered posteriorly by the carpal bones. The Carpal tunnel contains the median nerve and nine flexor tendons: the Flexor Digitorum Profundus (FDP) and Flexor Digitorum Superficialis (FDS) tendons to the index, middle, ring and small finger,along with the Flexor Pollicis Longus (FPL) tendon. Ide Pokok :

Carpal tunnel diartikan ruang yang dalam ke Transverse Carpal Ligament yang membentang di tulang carpal. Carpal tunnel terdiri dari median nerve dan sembilan tendon fleksor.

Paragraf 4 The Transverse carpal ligament (TCL) has a variable depth of 10 to13mm6 and
Paragraf 4
The Transverse carpal ligament (TCL) has a variable depth of 10 to13mm6 and a
normal pressure of 2.5 mmHg within the carpal tunne. Rydevik demonstrated that
external compression of 20-30mmHg induces a slower epineurium venule flow
which can progress to complete intraneural flow stasis if the pressure increases to
80mmHg. It has been observed that that the critical pressure level for microvessels
obliteration and consequent ischemia with total nerve conduction block is around
40-50mmHg. The Median nerve, lying most superficial within the canal, enters
the space in the midline or just radial to it and divides into terminal branches at
the distal end of the Transverse Carpal Ligament.
Ide Pokok :
TCL memiliki kedalaman 10 sampai 13 mm dan tekanan normal 2.5 mmHG
dalam carpal tunnel. Median nerve terletak paling dalam di dalam canal dan
bercabang-cabang dibagian distal dari TCL.

Pargraf 5 The unyielding nature of fibro-osseous tunnel makes Median nerve susceptible to compression. Aberrant muscles like Palmaris profundus, lumbricalis, and/or muscles bellies can further narrow the tunnel volume. Ide Pokok :

Median nerve memiliki sifat yang rentan mengalami kompresi karena terdapat otot-otot didalamnya.

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Figure 1

Gambar 1 menunjukan anatomi carpal tunnel, dimana nantinya anatomi ini berperan penting untuk digunakan dalam
Gambar 1 menunjukan anatomi carpal tunnel, dimana nantinya anatomi ini
berperan penting untuk digunakan dalam proses treatment dari carpal
tunnel syndrome.
Table 1
Tabel 1 menjelaskan penyebab dari carpal tunnel syndrome. Jadi carpal
tunnel syndrome penyebabnya ada 2 yaitu lokal dan sistemik. Penyebab
lokalnya dapat berupa bentuk akut, carpal canal stenosis, struktur yang
tidak normal serta lesi pada rongga dari carpal tunnel. Penyebab
sistemiknya berupa kehamilan, diabetes, kegemukan dan lain sebagainya.

Paragraf 6 The onset of symptoms can be either acute or insidious. Acute presentation is characterized by rapid and sustained increase in pressure within carpal tunnel which requires urgent decompression.

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Ide Pokok :

Gejala yang ditimbulkan akibat kompresi median nerve dapat berupa gejala akut dan ringan.

Paragraf 7 The causes for acute presentation include wrist trauma, infection, hematoma and high pressure injections. Most of the cases have an insidious presentation with chronic symptoms. Various anatomic factors which behave as space occupying lesions also play a role in the symptoms. Various systemic factors constrict the already slender space in carpal tunnel either by increasing the interstitial tissue pressure or causing pathological material deposition. Ide Pokok :

Penyebab dari gejala akut ada banyak yaitu luka pergelangan tangan, infeksi dan suntikan dengan dosis
Penyebab dari gejala akut ada banyak yaitu luka pergelangan tangan,
infeksi dan suntikan dengan dosis tinggi serta karena ada faktor yang
menyebabkan penyempitan rongga carpal tunnel.
Paragraf 8
Carpal Tunnel Syndrome complicates approximately 45% of pregnancies,
developing in third trimester which often improves with conservative treatment
postpartum10. Various retrospective studies have linked use of keyboards and
occupational vibratory exposure to CTS11.
Ide Pokok :
Carpal tunnel syndrome dapat mempersulit kehamilan tetapi dapat
membaik dengan postpartum konservatif treatment.

Paragraf 9 Carpal tunnel syndrome is primarily a clinical diagnosis. The most common complaint by patients is ―Nocturnal Acroparesthesia‖, which is a painful tingling sensation in the distribution of Median nerve, which may even disturb sleep. Patients are often awakened by numbness or tingling with an intense desire to shake out the affected hand (Flick sign12); however daytime paresthesias may

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also occur. Patients with severe CTS may have paradoxically less pain, because of increasing sensory loss13. Certain positions or activities may trigger paresthesias in daytime such as the act of sewing, pray position, holding the phone or a book while reading. Patients may not be able to exactly localize the paresthesias initially in a large number of cases, thus relating it to whole hand and back of the hand as well as to the palmar surface, but when subjected to provocative maneuvers to reproduce symptomatology, often localize paresthesias over the radial three fingers and to the radial side of the fourth finger. Chronic delayed presentations may be in form of numbness in fingers, grip weakness and reduced finger dexterity. In the late stages of the disease, examination may reveal sensory loss in Median nerve distribution; with sparing of Thenar eminence (sensory loss in the thenar eminence indicates a lesion proximal to the carpal tunnel, rather than CTS itself14). Weakness of thumb abduction and opposition may occur, along with Thenar eminence atrophy, in advanced stages22. Bilateral CTS is common; although the symptoms may be more in one hand. Ide Pokok :

Dari pemeriksaan diagnosis klinik, pasien mengeluhkan rasa sakit dan kesemuatan sebagai distribusi median nerve. Keluhan
Dari pemeriksaan diagnosis klinik, pasien mengeluhkan rasa sakit dan
kesemuatan sebagai distribusi median nerve. Keluhan biasanya muncul pada
malam hari yang dapat mengganggu tidur tetapi pada siang hari juga dapat
muncul keluhan tersebut.
Paragraf 10 dan 11
A detailed physical examination including cervical spine and neurological
examination of the upper limb should be done to exclude CTS mimics
Ide Pokok :

Pemeriksaaan fisik lengkap termasuk pemeriksaan tulang servikal dan juga saraf upper limb.

Paragraf 12 Various Provocative tests for CTS15 have been described Phalen’s Test

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When asked to hyper-flex the wrist and hold the position for 60 seconds to increase pressure on the median nerve, a positive test is indicated by the onset of pain or paresthesias. A meta-analysis found the sensitivity and specificity of a positive Phalen‘s sign to be 68% and 73%, respectively. Tinel’s test When the volar surface of the patient‘s wrist is tapped, either just proximal to or on top of the carpal tunnel, onset of pain or paresthesias in the Median nerve distribution indicates a positive result. This test is less sensitive than Phalen‘s maneuver, but has a similar specificity. The Median nerve (Durkan’s) compression test Pain or paresthesias develop within 30 seconds of applying pressure over the transverse carpal ligament. The Hand elevation test Pain or paresthesias develop when the patient raises both hands overhead for 60 seconds. Combining results of provocative maneuvers may increase sensitivity and specificity. Positive results in both the Phalen‘s and Median nerve compression tests, for example, have a collective sensitivity and specificity of 80% and 92%, respectively17. Ide Pokok :

and specificity of 80% and 92%, respectively17. Ide Pokok : Beberapa tes provocative untuk CTS Phalen’s

Beberapa tes provocative untuk CTS Phalen’s Test, dengan melakukan fleksi pergelangan tangan dan menahannya selama 60 detik untuk meningkatkan tekanan pada median nerve sehingga timub rasa nyeri, apabila hasilnya positif maka dapat dikatakan bahwa positif mengalami CTS Tinel Test, tes ini kurang sensitive dibandingkan dengan phalen’s test. Tes ini dilakukan dengan menekan pergelangan tangan, dan apabila nyeri maka hasilnya positif CTS. Durkan’s compreesion test, dengan memberikan tekanan pada transverse carpal ligament The hand elevation test, dengan mengangkat kedua tangan ke atas kepala selama 60 detik.

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Figure 2

Phalen’s test merupakan suatu tes yang digunakan untuk mengetahui adanya carpal tunnel syndrome. Phalen’s test
Phalen’s test merupakan suatu tes yang digunakan untuk mengetahui
adanya carpal tunnel syndrome. Phalen’s test dilakukan dengan
memfleksikan tangan untuk menjepit saraf median.
Figure 3
Tinel’s test merupakan tes yang digunakan untuk mengetahui adanya carpal
tunnel syndrome. Test ini dilakukan dengan menekan bagian pergelangan
tangan.

Paragraf 13 DIAGNOSTIC STUDIES Electrodiagnostic Testing (EDS)

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The goals of an electrodiagnostic examination are to localize the lesion; to show the involvement of motor, sensory fibers, or both; to define the physiologic basis (axonal loss, demyelination) and the severity of the lesion (degree of axonal loss, the continuity of axons), as well as the time course of the lesion (evidence of reinnervation or of ongoing axonal loss). Ide Pokok:

Tes elektrodiagnostik bertujuan untuk melokalisasi lesi untuk menentukan dasar fisiologis dan tingkat keparahan lesi.
Tes elektrodiagnostik bertujuan untuk melokalisasi lesi untuk menentukan
dasar fisiologis dan tingkat keparahan lesi.
Paragraf 14
The main objective of the neurophysiological assessment of a patient with
supposed CTS is to confirm the clinical suspicion of median nerve compression at
wrist suggested by history and clinical examination. Motor and sensory nerve
conduction velocity of the median nerve and other nerves along with the needle
EMG examination of one or several muscles also allows the diagnosis of other
coexisting diseases often associated with CTS such as radiculopathies,
plexopathies etc.
Ide Pokok :

Tujuan dari penilaian fisiologi pasien yaitu untuk mengkonfirmasi kecurigaan bahwa adanya kompresi pada median nerve. Pemeriksaan fisiologi lainnya yang berhubungan dengan CTS juga diperiksa seperti konduksi saraf motorik dan kecepatan saraf median. Paragraf 15 The neuro physiological studies may also allows quantification of the severity and the type of nerve lesion in the preoperative work-up of a CTS patient and may be of value in medicolegal cases if the patient has unsatisfactory improvement after the intervention. Ide Pokok :

Studi neuro fisiologi juga memungkinkan kuantifikasi tingkat keparan dan juga jenis lesi saraf sebelum operas CTS dilakukan.

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Paragraf 16 Results of the nerve conduction studies are compared to age-dependent normal values and to results from other nerves on either the same or the contralateral hand. In a 2002 systemic review, the sensitivity of NCS for CTS was 56% to 85% and the specificity was 94% to 99%18. Ide Pokok:

Hasil studi kondusksi saraf dibandingkan antara umur normal dan juga hasil dari saraf lainnya. Paragraf
Hasil studi kondusksi saraf dibandingkan antara umur normal dan juga
hasil dari saraf lainnya.
Paragraf 17
The American Academy of Orthopedic Surgeons (AAOS) recommends EDS
when CTS surgery is being considered and may also be used after surgery, to
verify neurologic improvement.
Ide Pokok :
AAOS merekomendasikan EDS agar bisa digunakan setelah operasi tidak
hanya ketika operasi sedang berlangsung.
Paragraf 18
Imaging
Routine radiographs are normal in majority of cases except those with post
traumatic or arthritic cause for CTS. MRI and ultrasonography may be helpful in
measuring differing canal size and to define pathology in uncommon cases like
fatty infiltration of median nerve, bursitis, and demonstration of neuroma or other
space occupying lesions.
Ide Pokok :

Radiografi seperti MRI dan USG yang rutin dilakukan dapat membantu ukuran kanal, infiltrasi lemak pada median nerve, bursitis dan juga lesi yang mendesak rongga.

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Table 2

Ide Pokok Tabel 2 menunjukan test diagnosis untuk mengetahui carpat tunnel syndrome. Dalam test diagnosis
Ide Pokok
Tabel 2 menunjukan test diagnosis untuk mengetahui carpat tunnel
syndrome. Dalam test diagnosis tersebut akan dibandingkan beberapa teknik
test. Perbandingan testnya meliputi performanya, bagian yang diukur,
hasilnya serta intepretasi dari hasilnya.
Paragraf 19
Imaging usually shows flattening of nerve at the level of hook of hamate. Imaging
methods can be of use in recurrent CTS after surgical release to look for real canal
widening, inflammation, incomplete resection of ligament, scarring etc. Thus,
AAOS does not currently recommend the routine use of ultrasound or MRI in the
diagnosis of CTS.
Ide Pokok:

AAOS tidak merekomendasika penggunaan MRI dan USG secara rutin tetapi hanya digunakan setelah operasi CTS.

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Table 3

Ide Pokok Ringkasan dari test elektrodiagnostik pada diagnosis carpal tunnel syndrome yaitu Laten pada Distal
Ide Pokok
Ringkasan dari test elektrodiagnostik pada diagnosis carpal tunnel syndrome
yaitu Laten pada Distal Median motor, perbedaan antara latency bermotor
distal dari Median dan ulnaris saraf, perbedaan antara latency Sensory
distal dari Median dan ulnaris saraf, perbedaan antara median dan ulnar
latency sensorik pada merangsang digit keempat dan rekaman dari
pergelangan tangan, perbedaan antara median dan latency sensorik radial
pada ibu jari dan pergelangan tangan dan perbedaan antara median dan
ulnaris latency sensorik.
Table 4

CTS mimics, terdapat memar pada saraf median, sindrom pronator, neoplasma intercranial, tumor puncoast, tumor saraf perifer, neuropathy ulnar, radial neuropathy dan neuropaty yang disebabkan oleh diabetes.

Paragraf 20

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MANAGEMENT Management options for CTS range from non-surgical measures to steroid injections to surgical carpal tunnel release including open as well as endoscopic methods which is determined by the clinical and electrophysiological severity of involvement, chronicity of symptoms and individual patient choices. Ide Pokok:

Pilihan penatalaksaana CTS dapat berupa tindaka non-surgical, injeksi steroid dan juga metode open endoskopik. Paragraf
Pilihan penatalaksaana CTS dapat berupa tindaka non-surgical, injeksi
steroid dan juga metode open endoskopik.
Paragraf 21
Non-surgical Measures
Multiple nonsurgical options are available, but the best evidence supports use of
splints, steroid injection, and oral steroids. Splinting or steroids alone may bring
longterm relief in mild to moderate cases19; in fact, about a third of mild cases
improve spontaneously20.
Ide Pokok :
Banyak pilihan yang tersedia dari tindakan non surgical tetapi
peneggunaaan splint, injeksi steroid dan oral steroid terbukti lebih baik.
Paragraf 22
Conservative therapy may also be useful in patients not willing for surgery or
cases of transient CTS (pediatric patients, pregnancy, hypothyroidism etc.).
Ide Pokok:
Pada kasus trancient tidak ingin melakukan operasi dan CTS dapat
digunakan konservatif terapi.

Paragraf 23 Most conservative treatments begin providing relief within 2 to 6 weeks and reach the maximal benefit at 3 months. Alternative management approach can be considered if there is no response after 6 weeks. Ide Pokok :

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Konservatif treatment mulai membantu meringankan dalam waktu 2 sampai 6 minggu dan maksimal sampai 3 bulan.

Paragraf 24 Wrist immobilisation during night and intermittently during day produces relief in up to 80% patients within days. Splints, particularly useful in patients who have a positive Phalen‘s test, work primarily by maintaining MCP joint in neutral position keeping the lumbricals out of tunnel. Studies have shown Splinting to be equally effective whether used continually or only at night. Splinting can relieve symptoms and improve functional status within 2 weeks with the effects lasting for 3 to 6 months, eliminating the need for surgery for some patients with mild CTS. Ide Pokok :

Imobilisasi pegelangan tangan dapat membantu pasien. Penggunaan splint pada kasus pasien positif Phalen’s dapat
Imobilisasi pegelangan tangan dapat membantu pasien. Penggunaan splint
pada kasus pasien positif Phalen’s dapat meringankan gejala dan
memperbaiki status fungsional.
Paragraf 25
Activity modification, an integral part of initial management, is aimed to avoid
repetitive strenuous activities. Ergonomic modifications at work place like
ergonomic keyboards are supposed to be helpful.
Ide Pokok:
Merubah aktivitas seperti merubah tempat kerja, keyboard supaya
ergonomis merupakan managemen awal untuk menghindari kejadian
berulang setelah sembuh.

Paragraf 26 Local corticosteroid injections for CTS have been utilized for years to alleviate symptoms. The effectiveness and duration of benefit from these injections have not been clearly defined along with very little information regarding the optimal corticosteroid to use, dosage, or location of the injection. The reappearance of symptoms after corticosteroid injection ranges from 8% to 100%. Patients with

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the most severe CTS are least benefited from steroid injections. Celiker22 compared steroid injections to NSAIDs and splinting in an unblinded, randomized trial. No statistical difference between corticosteroid injection alone versus NSAIDs and splinting was observed during the short follow-up periods. Local corticosteroid injections appear to be superior to oral steroids for up to 3 months. No studies show benefit from steroid injection greater than 3months. Ide Pokok:

Pemberian suntikan kortikostiroid untuk CTS telah digunakan selama bertahun-tahun namun efektivitas dan durasi manfaat
Pemberian suntikan kortikostiroid untuk CTS telah digunakan selama
bertahun-tahun namun efektivitas dan durasi manfaat dari suntikan ini
belum jelas. Ketika dibandingkan antara kortikosteroid injeksi dengan splint
tidak didapat perbedaan statistic.
Paragraf 27
Oral prednisone at a dose of 20 mg/d for 2 weeks improves symptoms and
function in patients with CTS, but is less effective than steroid injections23.
Treatment for 2 weeks is as effective as treatment for 4 weeks; the effects tend to
wane after 8 weeks in both cases.
Ide Pokok:
Penggunaan prednisone oral pada pasien CTS memiliki efektifitas lebih
rendah dibandingkan steroid injeksi,.

Paragraf 28 Surgical Measures Patients with severe CTS i.e. with findings such as thenar atrophy, diminished hand function, and median nerve denervation should be referred for surgery without delay. This recommendation is based on expert opinion, however, as most clinical trials comparing surgical vs nonsurgical treatment exclude those with severe CTS24. Ide Pokok:

Tindakan Bedah

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Pasien dengan CTR parah seperti thenar atrophy, menurunnya fungsi tangan dan denervasi median nerve lebih dianjurkan untuk melakukan operasi tanpa penundaan.

Paragraf 29 Carpal tunnel release has been performed by various methods including open method, limited open method and endoscopic methods. The different methods have their own drawbacks and benefits. The primary aim of all these methods is to limit the post-operative weakness and recurrence rates and avoid complications. The postoperative weakness due to tendon subluxations following release of carpal ligament (so- called Volar wrist pulley) is a major post-operative concern. Ide Pokok:

Telah banyak metode yang digunakan untuk Carpal Tunnel Release dan dari setiap metode yang digunakan
Telah banyak metode yang digunakan untuk Carpal Tunnel Release dan dari
setiap metode yang digunakan pasti memiliki kekurangan dan kelebihan
masing-masing. Sebenarnya tujuan utama dari semua metode adalah
menghindari komplikasi pasca operasi.
Paragraf 30
Traditionally, the open release is performed through wrist-palm incision, which
involves deep dissection releasing palmar fascia and carpal ligment longitudinally.
With the improved understanding, early diagnosis and increased need for aesthetic
surgery ‗palm-only‘ incision technique has evolved whereby incision is given
only in the region of palm.
Ide Pokok:

Dulunya open release dilakukan dengan menyayat pergelangan tangan dimana nantinya ini akan melibatkan diseksi palmar fascia dan carpal ligament longitudinally, namun meningkatnya pemahaman berkembang pula teknik ‘palm-only’.

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Paragraf 31 Limited open carpal tunnel release: Using a ‗palmonly‘ mini incision (<2 cms) distal end of carpal ligament is released under direct vision followed by proximal release using variously designed guides Ide Pokok:

Limited open carpal tunnel release menggunakan sayatan kecil kurang dari 2

cm. Paragraf 32 Endoscopic technique: Endoscopic technique overcomes complications associated with open techniques like
cm.
Paragraf 32
Endoscopic technique: Endoscopic technique overcomes complications
associated with open techniques like scar tenderness, prolonged healing time,
pillar pain and weakened grip strength. However, it is not advised in patients with
wrist stiffness, proliferative synovitis and space occupying lesions that obliterate
the view of canal. When all the treatment modalities for CTS are compared, it has
been found that surgical treatment for CTS is more effective than conservative
method or injection technique26. Especially with long term benefit, the surgical
technique has been found to be superior to injection method which gives only
short term relief. No significant difference in the outcome has been found
comparing endoscopic to open carpal tunnel release. Active motion exercises of
the wrist and fingers should be encouraged post-operatively in all patients as wrist
immobilization following carpal tunnel release has not been found to be any
benefit.
Ide Pokok:

Teknik endoskopik mengatasi komplikasi terkait metode open seperti bekas luka, nyeri dan melemahnya kekuatan menggenggam. Penggunaan teknik ini juga lebih efektif dibandingkan dengan metode konservatif atau teknik injeksi. Tetapi teknik ini tidak dianjurkan untuk pasien dengan kekakuan pergelangan tangan, sinovitis proliferatif dan juga lesi.

Paragraf 33 A Cochrane database review27 was done recently to assess the effectiveness and safety, and more specifically, in relieving symptoms, producing functional

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recovery (return to work and return to daily activities) and reducing complication rates, of the endoscopic techniques of carpal tunnel release compared to any other surgical intervention for the treatment of CTS. In this review, with support from low quality evidence only, it was found that Open Carpal Tunnel Release(OCTR) and Endoscopic Carpal Tunnel Release(ECTR) for carpal tunnel syndrome are about as effective as each other in relieving symptoms and improving functional status, although there may be a functionally significant benefit of ECTR over OCTR in improvement in grip strength. ECTR appears to be associated with fewer minor complications compared to OCTR, but no difference in the rates of major complications was observed. Return to work was observed to be faster after endoscopic release, by eight days on average. Ide Pokok:

Sebuah database Cochrame menilai efektifitas, keamanan, meringakan gejala, pemulihan fungsi dan menurunkan jumlah
Sebuah database Cochrame menilai efektifitas, keamanan, meringakan
gejala, pemulihan fungsi dan menurunkan jumlah komplikasi dengan
membandingkan antara endoskopik carpal tunnel release dengan teknik
bedah lainnya dalam treatment dari CTS. Dari database tersebut didapat
bahwa OCTR dan ECTR, keduanya efektif dalam meringankan gejala dan
meningkatkan status fungsional walaupun ECTR memiliki kelebihan seperti
meningkatkan kemampuan menggenggam dan juga dengan sedikit
komplikasi.

Paragraf 34 Complications associated with carpal tunnel release are mostly minor e.g. a painful or hypertrophic scar, stiffness, swelling, and pain or tenderness on either side of the incisionand resolve within a few months. Other commonly encountered complications may be injuries to motor and/ or palmar cutaneous branch of median nerve, pillar pain, injury to superficial palmar arch, incomplete carpal tunnel release, tendon adhesions, infection, wound hematoma, finger stiffness, reflex sympathetic dystrophy, weak grip strength and recurrence. The most common complication following open carpal tunnel release surgery is pillar pain followed by laceration of the palmar cutaneous branch of median nerve. Incomplete release is the most frequently reported complication of endoscopic

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release. Patients can expect significant symptomatic improvement within 1week of surgery, and most patients return to normal activities in 2 weeks. Evidence suggests that from 3% to 19% of patients may have persistent or recurrent symptoms even after carpal tunnel release, with up to 12% requiring surgical revision28. Recurrent carpal tunnel syndrome has been reported to occur in 7-20% patients29. Revision surgery involves neurolysis of median nerve, fat or muscle transfer and vein wrapping, however the results are not satisfying. Ide Pokok:

Komplikasi yang berkaitan dengan carpal tunnel release yaitu pembengkakan, nyeri, kekakuan, bengkak dan lain-lain, namun
Komplikasi yang berkaitan dengan carpal tunnel release yaitu
pembengkakan, nyeri, kekakuan, bengkak dan lain-lain, namun komplikasi
tersebut dapat diatasi dalam beberapa buan. Setelah tahap pemulihan dari
operasi tidak menutup kemungkinan untuk gejala CTS itu dapat muncul
kembali
Paragraf 35
Carpal tunnel syndrome, the most common and prevalent surgically correctable
compression neuropathy, is caused by median nerve compression at wrist. The
diagnosis is primarily clinical, based on detailed patient history and physical
examination and confirmed by electrophysiological studies. Treatment options
available range from conservative measures such as splinting and steroids to
surgical release, which may be open or by endoscopic route.
Ide Pokok:
Carpal tunnel syndrome disebabkan oleh adanya kompresi pada median
nerve. Diagnosis dapat diambil dari riwayat penyakit sebelumnya,
pemeriksaan fisik dan studi elektrofisiologi. Pengobatan dari CTS ini
bervariasi terdapat tindakan konservatif seperti splinting dan steroid untul
bedah.

Artikel 2. Current Approaches for Carpal Tunnel Syndrome With advancement in biomechanical and biological research on idiopathic carpal tunnel syndrome, the insight on the pathophysiology of carpal tunnel syndrome has gained much clinical relevance. Open carpal tunnel release is still a gold

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standard procedure for carpal tunnel syndrome, which has evolved into mini-open procedure with development of new devices. Endoscopic carpal tunnel release has become popular in recent practice of hand surgery with an advantage of early recovery of hand function with minimal morbidity. However, endoscopic carpal tunnel release has its own limitation such as long learning curve with obvious surgical risk reported in the literature. In this review article, various treatment protocols for idiopathic carpal tunnel syndrome are presented with special highlight on endoscopic carpal tunnel release, which is gaining popularity in current practice. IdePokok:

Dengan kemajuan dalam penelitian biomekanik dan biologi Carpal Tunnel Syndrome, pengetahuan mengenai patofisiologi dari
Dengan kemajuan dalam penelitian biomekanik dan biologi Carpal Tunnel
Syndrome, pengetahuan mengenai patofisiologi dari CTS telah banyak
memperoleh relevansi klinis. Hal ini terbukti dengan berkembangnya
prosedur Open Carpal Tunnel Release menjadi mini open prosedur.
Endoscopic Carpal Tunnel Release menjadi sangat populer dalam operasi
bagian tangan dengan pemulihan fungsi tangan lebih cepat dan morbidity
yang rendah.
Keywords: Carpal tunnel syndrome, Open, Endoscopic, Release
Kata Kunci : Carpal Tunnel Syndrome, Open, Endoskopik, Release
Paragraf 1
Carpal tunnel syndrome (CTS), the most common form of entrapment neuropathy
in upper extremity, is estimated to occur in 3.8% of the general population. On the
basis of clinical examinations and nerve conduction studies, it has been
approximated that one in every five subjects who complain of symptoms such as
pain, numbness, and a tingling sensation in the hands could have CTS
Ide pokok :

Carpal Tunnel syndrome (CTS), terjadi akibat terjepitnya saraf ektremitas atas. Dari pemeriksaan CTS pasien mengeluhkan gejala seperti nyeri, bengkak dan rasa tertusuk pada tangannya.

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Paragraf 2 According to the biomechanical and histological findings, the most characteristic histological finding is noninflammatory fibrosis and thickening of the subsynovial connective tissue. The hypothesis says surgical trauma to the synovium and the flexor tendons within the carpal tunnel associated with aging process or repetitive/forceful movement could lead to degeneration, thus as the volume of the carpal tunnel contents increases, median nerve within the tunnel is compressed and eventually resulted in CTS. Ide pokok :

Secara histology ditemukan noninflamatory fibrosis dan penebalan pada jaringan subsynovial. Dalam suatu hipotesis
Secara histology ditemukan noninflamatory fibrosis dan penebalan pada
jaringan subsynovial. Dalam suatu hipotesis dikatakan bahwa trauma bedah
synovium dan tendon fleksor carpal tunnel berhubungan dengan proses
penuan, jumlah dari kandungan carpal tunnel meningkat, saraf median
dengan tunnel mengalami tekanan sehingga menyebabkan CTS.
Paragraf 3
Conservative Treatment
When the pathophysiology of idiopathic CTS remained unclear, definitive
treatment strategies have not been established. However, in recent practice,
treatment should be selected considering the various factors, such as the stage of
the disease, the severity of the symptoms, or the patient's preference. Splinting,
local injection of corticosteroids into the carpal tunnel, and oral corticosteroid
treatment have proven effective in some cases.
Ide Pokok :

Pengobatan CTS harus mempertimbangkan beberapa faktor seperti tingkat penyakit, kerasnya gejala, atau preferensi pasien. Splinting, pemberian kortiokosteroid secara injeksi lokal ke dalam carpal tunnel dan dengan pengobata oral kortikosteroid terbukti efektif dalam kasus yang sama.

Pargraf 4 The rationale for wrist splint is based on observations that CTS symptoms improve with rest and aggravate with activity. Subsequent research has suggested

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that the therapeutic effect of wrist splinting arises from minimizing carpal tunnel pressure. Ide Pokok :

Berdasarkan observasi didapat bahwa gejala CTS dapat disembuhkan dengan istirahat dan diperparah dengan adanya aktivitas. Peneliti menganjurkan pengobatan dari splint pergelangan tangan dengan mengurangi tekanan pada carpal tunnel.

Paragraf 5 Corticosteroid treatment is effective in reducing inflammation and edema of synovium and tendons,
Paragraf 5
Corticosteroid treatment is effective in reducing inflammation and edema of
synovium and tendons, it also has harmful effect on tenocyte function by reducing
collagen and proteoglycan synthesis. This eventually reduces the mechanical
strength of the tendon and leading to further degeneration.4) The effect of
corticosteroids or local anesthetic agents on the peripheral nerve fibers or epin-
erium cells reported traumatic epineural injury, axonal degeneration and
intrafascial syrinx created by hydrostatic pressure.5) Further research is required
to clarify the appropriate injection method and the optimum preparation, dose, and
volume of corticosteroid.
Ide pokok :
Kortikostiroid memiliki manfaat untuk mengurangi inflamsi dan edema dari
sinovium dan tendon tetapi kortikostiroid juga memiliki efek yang
berbahaya pada fungsi tenosit dengan menurunkan sintesis kolagen dan
proteoglikan. Efek yang timbul dari anastesi local pada serabut saraf perifer
dapat menyebabkan trauma epineural, degenerasi akson dan intrafascial
syrinx.

Paragraf 6 When conservative treatment fails, surgical treatment is considered. Despite the equivocal nature of CTS etiology, simple decompression of the median nerve by division of the transverse carpal ligament (TCL) is the treatment of choice and is considered to yield excellent results in 75% of the patients Ide Pokok :

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Surgical treatment digunakan ketika conservative treatment gagal. Surgical treatment yaitu treatment dengan megurangi tekanan pada saraf median dan membagi transverse carpal ligament (TCL) .

Paragraf 7 In the recent literature, surgical treatment has been reported to be more effective than splinting7) and other conservative treatment.8) Carpal tunnel release (CTR) with TCL division is accepted as the most reliable procedure for relieving symptoms. The TCL can be divided by various surgical techniques, including conventional open carpal tunnel release (OCTR), mini-OCTR, and endoscopic carpal tunnel release (ECTR). OCTR is generally accepted method,9) and reported high success rate with minimal complication, although in worst scenario, some wound-related symptoms may persist for 2 years postoperatively.10) This surgery is indicated and feasible for CTS with any type of pathology, such as CTS due to any space occupying lesion, deformity or even in revision surgeries. Ide Pokok :

Surgical treatment tercatat lebih efektif dibandingakan dengan splinting dan juga conservative treatment lainnya. Carpal
Surgical treatment tercatat lebih efektif dibandingakan dengan splinting dan
juga conservative treatment lainnya. Carpal tunnel release (CTR) dengan
membagi TCL diterima sebagai prosedur yang banyak dipercaya dalam
menghilangkan gejala CTS. TCL dapat dibagi dalam beberapa surgical
teknik seperti conventional open carpal tunnel release (OCTR), mini OCTR
dan endoscopic carpal tunnel release (ECTR). OCTR merupaka teknik yang
umum digunakan dan tercatat memiliki keberhasilan dengan angka yang
tinggi dengan tingakat komplikasi yang minimal.

Paragraf 8 ECTR has gained popularity since their introduction two decades ago as single portal surgery by Okutsu et al.11) and two portal technique by Chow.12) Okutsu et al.13) developed their procedure with special tube like instrument to visualize whole TCL and it was transected under endoscopic assistance. At first, visualizing the dorsal aspect of the TCL by using endoscopy seemed highly innovative, attractive approach (Table 1, Fig. 1).

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Ide Pokok : ECTR yang awalnya diperkenalkan sebagai single portal surgery oleh Okutsu et al, selanjutnya oleh Chow digunakan two portal technique. Okutsu et al mengembangkangkan prosedur ECTR dengan membuat instrument kusus seperti tabung yang akan dimasukan dibawah endoscopic.

Table 1

Catatan komplikasi terkait penggunaan pertama ECTR. Incomplete release dengan jumlah total 183, SPA injury (superficial
Catatan komplikasi terkait penggunaan pertama ECTR. Incomplete release
dengan jumlah total 183, SPA injury (superficial palmar arch) dengan
jumlah 7, ulnar nerve injury dengan jumlah 1, median nerve injury dengan
jumlah 2 dan persentase total complication rate dengan jumlah 36%.
Fig 1

Memperlihatkan teknik surgical treatment untuk mempermudah dalam pelaksanaan treatment dengan diberikan huruf yaitu exit sebagai pintu keluar cannula, KL (Kaplan line), dan TCL (transverse carpal ligament) serta menggunakan alat visualisasi yaitu endoscopik. Paragraf 9

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Authors‘ preferred technique: anatomy principle based ECTR procedure

1. Local anesthetics for instant feedback from the patient during surgery: We

use Ropivacaine 7.5 mg/mL, 10 mL in total: 4 mL was administered in the proximal direction under the subcutaneous fascia, 2 mL subcutaneoulsy in the distal wrist crease, and 4 mL subcutaneously in the palm.15) 2. Robust anatomic land marks to avoid potential damage of normal structure: A line is drawn for the planned incision that is a transverse incision on the distal wrist crease starting from the radial border of the palmaris longus (PL) extending ulnarly for 1.5 cm. If the PL is absent, a 1.5-cm incision centered on the

line drawn from the ulnar border of the middle finger is used. The PL tendon
line drawn from the ulnar border of the middle finger is used. The PL tendon is
the dissected and retracted radially to protect the palmar cutaneous branch of the
median nerve exposing the deep fascia of the forearm (Table 2, Fig. 2).16)
3. Good endoscopic visualization and tapping the TCL with probe: Blunt
dissection is performed to the proximal edge of the TCL. A elevator is used to
clean the undersurface of the ligament to provide a good view with the endoscope.
By palpating palm and watching it with endoscopy or inserting a needle from the
palm into the canal, 4 cm distal to the transverse wrist crease, the end of the TCL
is marked (Fig. 3).
4. Transecting the TCL: The probe knife is used to make the first cut, distally
to proximally. The distal border of the TCL should be saved at this stage. The
scope is switched into proximally and retrograde knife is brought in and the
second cut to release complete TCL (Fig. 4).
Ide Pokok :
Prosedur ECTR
1. Pemberian anastesi local dengan menggunakan ropivacaine 7.5 mg/ml
2. Menandai bagian anatomi yang sehat untuk menghindari bahaya
potensi kerusakan struktur normal

3. Pandangan endoskopik bagus dan TCL dibuka lalu digunakan sebuah alat pengankat untuk membersihkan bagian bawah ligament agar diperoleh hasil yang bagus ketika dilihat menggunakan endoskopi. Ketika sudah jelas masukan needle dari telapak tangan ke

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canal, 4 cm ke lipatan transversal pergelangan tangan dan terakhir TCL telah ditandai.

4. Proses transecting TCL menggunakan pisau.

Table 2

Dasar-dasar untuk mencegah komplikasi selama ECTR yaitu mengetahui anatomi topografi dari pintu masuk dan keluar,
Dasar-dasar untuk mencegah komplikasi selama ECTR yaitu mengetahui
anatomi topografi dari pintu masuk dan keluar, manipulasi instrumen luar
dari lapisan tendon, bersihkan jarak antara TCL dan cannula.
Fig 2
Permukaan bagian bawah dari Transvese Carpal Ligament.
Fig 3
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Triangular blade, sebuah pisau segitiga yang digunakan untuk mengangkat permukaan bawah dari ligament sehingga dapat melihat dengan jelas bagian dalamnya.

Fig 4

Retrograde knife, sebuah alat yang digunakan untuk proses memotong TCL. Jadi probe knife digunakan untuk
Retrograde knife, sebuah alat yang digunakan untuk proses memotong TCL.
Jadi probe knife digunakan untuk potongan pertama TCL, selanjutnya
untuk pemotongan TCL yang kedua menggunakan retrograde knife
Paragraf 10
Clinical results of ECTR
ECTR, either by single or dual-portal technique, can yield almost same clinical
results comparable with those of OCTR. Unless iatrogenic nerve injury is
counted, ECTR provides good symptom resolution, less scar and pillar pain,
providing better physical findings and electrophysiologic recovery.
Ide Pokok:
ECTR, baik dengan single portal maupun two portal keduanya dapat
menghasilkan perbandingan hasil klinik yang sama dengan OCTR.

Paragraf 11 ECTR is useful for achieving median nerve decompression, its effectiveness in comparison with the minimally invasive OCTR for restoring function of the affected hand early after treatment is still under debate. The grip strength temporarily decreases after ECTR because of postoperative pain over the incision site, which is the case after any CTR procedure. Because of the ambiguity in the

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definition of ‗resuming daily activities,‘ the average time required to resume daily activities or work after ECTR could not be addressed and compared directly. However, by using limited skin incision for ECTR, we expect the intact subcutaneous fatty tissue and palmar fascia will help for decreasing postoperative pain. Ide Pokok :

Efektifitas dari ECTR dibandingkan dengan OCTR dalam pemulihan fungsi setelah pengobatan masih menjadi perdebatan.
Efektifitas dari ECTR dibandingkan dengan OCTR dalam pemulihan fungsi
setelah pengobatan masih menjadi perdebatan. Setelah melakukan operasi
ECTR kemampuan menggenggam menjadi menurun diakibatkan oleh rasa
sakit dibagian yang diiris sebelumnya.
Paragraf 12
The benefit of ECTR over OCTR is that by dividing the TCL from below, the
overlying skin and muscle are preserved, potentially improving postoperative
morbidity, facilitating an earlier return to work, and preserving grip strength. The
rate of major nerve, vessel, or tendon injury was shown to be lower in ECTR
group, at 0.19% compared with 0.49% for the OCTR group. Similarly, Boecksyns
and Sorensen20) reported a rate of 0.3% for irreversible nerve damage in the
ECTR group, and 0.2% for the CTR group.
Ide pokok :
Keuntungan ECTR melebihi OCTR dikarenakan TCL dipecah dari bawah
sehingga kulit dan otot terlindungi, berpotensi memperbaiki kerusakan
setelah operasi, mempercepat kembali bekerja dan memulihkan kekuatan
tangan menggenggam.

Paragraf 13 On the other hand, CTR had more wound problems such as infection, hypertrophic scar, and scar tenderness. Thoma and colleagues demonstrated a benefit of ECTR with respect to scar tenderness. ECTR also provides a faster recovery to operated patients for the first 2 weeks, with faster relief of pain and faster improvement in functional abilities. But at 1 year, both open and endoscopic techniques seem to be equivalently efficient (Table 3).

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Ide pokok :

Baik ECTR maupun OCTR merupakan teknik yang sama-sama efisien, tetapi hanya waktu dalam proses penyembuhannya berbeda. ECTR mampu memulihkan dengan cepat pasien pascaoperasi.

Table 3

Dalam penggunaan teknik ECTR juga memiliki kelebihan dan kekuranga. Kelebihan dari teknik ini yaitu pemulihan
Dalam penggunaan teknik ECTR juga memiliki kelebihan dan kekuranga.
Kelebihan dari teknik ini yaitu pemulihan bergerak lebih cepat, saraf tidak
tergores dan lain sebagainya, adapun kekurangan dari teknik ini yaitu
dibutuhkan kemampuan kusus, harga dari alat endoscopic juga tidak murah
dan lain sebagainya.
Table 4
endoscopic juga tidak murah dan lain sebagainya. Table 4 Dari 708 pembedahan pada ECTR didapat bahwa

Dari 708 pembedahan pada ECTR didapat bahwa yang mengalami komplikasi pada median nerve sebanyak 100 orang, yang mengalami palmar

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cut branch sebanyak 17, yang mengalami ulnar nerve injury sebanyak 88, yang mengalami digital nerve injury sebanyak 77, yang mengalami tendon injury sebanyak 69, yang mengalami superficial palmar arch sebanyak 86 dan yang mengalami ulnar artery injuri sebanyak 34. Sedangakan, dari 616 pembedahan pada OCTR didapat yang mengalami komplikasi pada median nerve sebanyak 147 orang, yang mengalami palmar cut branch sebanyak 117, yang mengalami ulnar nerve injury sebanyak 29, yang mengalami digital nerve injury sebanyak 54, yang mengalami tendon injury sebanyak 19, yang mengalami superficial palmar arch sebanyak 21 dan yang mengalami ulnar artery injuri sebanyak 11.

Pargraf 14 Practicing ECTR could result in a few disastrous complications such as transection of
Pargraf 14
Practicing ECTR could result in a few disastrous complications such as
transection of the median nerve, flexor tendons, superficial palmar arch or even
the ulnar nerve, mostly because of technical errors (Table 4).
Ide Pokok:
Kesalahan dalam menggunakan teknik ECTR dapat menyebabkan
terjadinya komplikasi ringan. Komplikasi ini terjadi akibat terpotongnya
median nerve, tendon flexor dan ulnar nerve.

Pargraf 15 These complications usually could be avoided by adhering some principles to the recommended procedure: (1) the TCL should not be cut if soft tissue obstructs surgical view; and (2) very low threshold to conversion to open procedure if the surgeon encounters any difficulty introducing the cannula or achieving proper working space and good visualization just as like any endoscopic surgery (Table 2). Careful physical examination and preoperative ultrasonography or magnetic resonance imaging may be useful to detect space-occupying lesion for CTS. Ide Pokok :

Komplikasi yang terjadi dapat dihindari dengan mengikuti prosedur yang dianjurkan. Komplikasi juga dapat dihindari dengan melakukan

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pemeriksaan fisik sebelum operasi dan juga melakukan USG untuk mengetahui terdapat lesi.

Pargaraf 16 Anatomic variations should be always kept in mind considering ECTR. Reported prevalence of anatomic variations encountered in elective CTR was 31 anomalies in total out of 526 CTR (5.7%). These included aberrant muscle/tendon variation, anomalies of the median nerve or its palmar cutaneous or motor branches, and anomaly of the ulnar nerve crossing the carpal tunnel incision. Ide Pokok :

Dari keseluruhan jumlah variasi anatomi CTR yaitu 526, tercatat 31 mengalami anomaly (abnormalitas). Termasuk didalamnya
Dari keseluruhan jumlah variasi anatomi CTR yaitu 526, tercatat 31
mengalami anomaly (abnormalitas). Termasuk didalamnya yaitu
ketidaknormalan otot/tendon, anomaly median nerve dan anomaly ulnar
nerve.
Paragraf 17
Another potential limitation of ECTR-namely is related to the cannula (diameter
5.5 mm in Chow's technique) within the limited space of carpal tunnel which has
already preceding pathologies in. As stated earlier, the pressure in the carpal
tunnel was measured 5–85 mmHg in idiopathic CTS , which is greater than non-
symptomatic population measured 3–6 mmHg.
Ide Pokok :
Cannula dan ruang yang terbatas dari carpal tunnel berpotensi menjadi
penghambat ECTR. Tekanan ruang dari carpal tunnel yang normalnya 3 -6
mmHg mengalami tekanan yang lebih besar yaitu 5-85 mmHg.

Pargraf 18 ECTR is advised not to attempt without clear understanding of the anatomy of the target space because potential complications are mostly related to the technical pitfalls and anatomic variations.

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Ide Pokok :

Penggunaan ECTR tidak dianjurkan untuk dicoba-coba karena berpotensi menyebabkan komplikasi.

Paragraf 19 The current concepts of CTS and the role of ECTR in current surgical procedures were reviewed. ECTR is a useful technique for achieving median nerve decompression. However, there is lack of evidence-based clinical data to support ECTR provides superior clinical results to OCTR in terms of early recovery of hand function. Principle-based ECTR procedure, however provides few complica- tions with successful clinical outcome so far. New treatment strategies can be established for CTS of different pathologies based on these clinical experiences. Ide Pokok :

ECTR memiliki keunggulan lebih tinggi dibandingkan dengan OCTR baik dari pemulihan fungsi tangan dan juga
ECTR memiliki keunggulan lebih tinggi dibandingkan dengan OCTR baik
dari pemulihan fungsi tangan dan juga komplikasi yang rendah.

Kesimpulan Artikel 1 & 2 Carpal tunnel syndrome merupakan kelainan bagian ektremitas atas yang disebabkan oleh kompresi neuropati. CTS kebanyakan terjadi pada usia 40 dan 60 tahun dan kebanyakan yang terkena yaitu wanita. Gejala yang ditimbulkan, pasien mengeluhkan rasa sakit, nyeri dan kesemuatan. Untuk mengetahui gejala dari CTS dapat dilakukan beberapa tes seperti Phalen’s test, Tinel test, durkan compression test dan the hand elevation test. Penanganan dari CTS ini dapat berupa tindakan non-surgical dan tindakan surgical. Tindakan surgical bisa berupa conservative dan juga injeksi kortikostiroid sedangkan tindakan surgical berupa OCTR dan ECTR. Dimana, ECTR merupakan teknik yang banyak digunakan sekarang ini karena memiliki beberapa kelebihan serta sedikit kekurangan.

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DAFTAR PUSTAKA

1. Sardana V, Ojha P. (2016). Carpal Tunnel Syndrome : Current Review. International Journal of Medical Research Professionals , pp: 814.

2.

Kim P, Lee H, Kim T, Jeon I. (2014). Current Approaches for Carpal Tunnel Syndrome. The Korean Orthopaedic Association , pp :2537.

. The Korean Orthopaedic Association , pp :253 – 7. I G e d e S