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“Anesthesia for Endoscopic Carpal Tunnel Syndrome Release: A Comprehensive Systematic Review and Meta-Analysis of Local Versus Regional Versus General Anesthesia”

Open AccessPublished:November 23, 2022DOI:https://doi.org/10.1016/j.jpra.2022.11.002

      Abstract

      Background

      Worldwide, carpal tunnel syndrome (CTS) is the most common peripheral neuropathy due to compression. A minimally invasive endoscopic carpal tunnel release (ECTR) procedure is available to treat this condition. This study aims to identify and compare the different types of anesthesia in ECTR, particularly in terms of functional outcomes, patient satisfaction, and operative time.

      Methods

      PRISMA guideline was used to design and conduct this systematic review. MEDLINE, Cochrane, and EMBASE databases were searched systematically from inception to May 2022. For the search, MeSH terms such as endoscopic carpal tunnel release, general anesthesia, local anesthesia, and regional anesthesia were used.

      Results

      As a result of reviewing the literature, 198 publications were reviewed. After implanting our criteria, 12 studies were included. We included 14589 patients who underwent ECTR. Local anesthesia (LA) has a higher satisfaction rate and a shorter operative time than general anesthesia. LA had a mean operative time of 20.1 minutes, compared to 45 minutes and 51 minutes for regional anesthesia and general anesthesia. The number of patients with postoperative ECTR surgical complications was 2.7% (95%CI). After ECTR with LA, 95% of patients are back to their daily routine within six months.

      Conclusion

      All of the reported methods were effective, with LA being the most commonly used. Furthermore, it showed a shorter operative time and a higher satisfaction rate than other types of anesthesia. Due to the heterogeneity of the data, we recommend future randomized controlled trials to highlight the differences in anesthesia types used in ETCR.

      Level of evidence

      III, risk/prognostic study

      Keywords

      Introduction

      Carpal tunnel syndrome (CTS) is the most common nerve compression of the upper extremity
      • Thoma A.
      • Veltri K.
      • Haines T.
      • Duku E.
      A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression.
      . The estimated prevalence in the general population is 1.5% to 5%
      • Atroshi I.
      • Gummesson C.
      • Johnsson R.
      • Ornstein E.
      • Ranstam J.
      • Rosén I.
      Prevalence of carpal tunnel syndrome in a general population.
      . CTS is caused by compression of the median nerve in the osteofibrous canal located in the volar aspect of the wrist
      • Padua L.
      • Coraci D.
      • Erra C.
      • Pazzaglia C.
      • Paolasso I.
      • Loreti C.
      • Caliandro P.
      • Hobson-Webb L.D.
      Carpal tunnel syndrome: clinical features, diagnosis, and management.
      . Currently, there is no known cause for CTS. Several risk factors have been identified, including diabetes mellitus, excessive wrist extension or flexion, vibration exposure, and arthritis
      • Padua L.
      • Coraci D.
      • Erra C.
      • Pazzaglia C.
      • Paolasso I.
      • Loreti C.
      • Caliandro P.
      • Hobson-Webb L.D.
      Carpal tunnel syndrome: clinical features, diagnosis, and management.
      ,
      • Genova A.
      • Dix O.
      • Saefan A.
      • Thakur M.
      • Hassan A.
      Carpal Tunnel Syndrome: A Review of Literature.
      . CTS patients usually present with paresthesias and dysaesthesias that occur intermittently during the night and become more frequent during the day. Later, if left untreated, loss of feeling followed by weakness and atrophy of the thenar muscles will develop
      • Padua L.
      • Coraci D.
      • Erra C.
      • Pazzaglia C.
      • Paolasso I.
      • Loreti C.
      • Caliandro P.
      • Hobson-Webb L.D.
      Carpal tunnel syndrome: clinical features, diagnosis, and management.
      . Diagnosis of CTS is mainly clinically and via nerve conduction studies
      • Ibrahim I.
      • Khan W.S.
      • Goddard N.
      • Smitham P.
      Carpal tunnel syndrome: a review of the recent literature.
      . CTS can be treated conservatively or surgically; conservative treatments include corticosteroid injections, non-steroidal anti-inflammatory drugs (NSAIDs), vitamins B6 and B12, and hand splints
      • Zamborsky R.
      • Kokavec M.
      • Simko L.
      • Bohac M.
      Carpal Tunnel Syndrome: Symptoms, Causes and Treatment Options. Literature Reviev.
      .
      In contrast, surgical release of CTS is one of the most common procedures in the upper extremity; in the United States, up to 700,000 procedures are performed yearly using both open and endoscopic techniques. There are several types of surgical techniques for releasing the carpal tunnel: open carpal tunnel release (OCTR), mini-OCTR, and endoscopic carpal tunnel release (ECTR)
      • Zamborsky R.
      • Kokavec M.
      • Simko L.
      • Bohac M.
      Carpal Tunnel Syndrome: Symptoms, Causes and Treatment Options. Literature Reviev.
      • Via G.G.
      • Esterle A.R.
      • Awan H.M.
      • Jain S.A.
      • Goyal K.S.
      Comparison of Local-Only Anesthesia Versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release: A Randomized Trial.
      • Olaiya O.R.
      • Alagabi A.M.
      • Mbuagbaw L.
      • McRae M.H.
      Carpal Tunnel Release without a Tourniquet: A Systematic Review and Meta-Analysis.
      . In 1987, Okutsu introduced the endoscopic technique for releasing carpal tunnels
      • Okutsu I.
      • Ninomiya S.
      • Takatori Y.
      • Ugawa Y.
      Endoscopic management of carpal tunnel syndrome.
      . ECTR is preferable over OCTR in terms of recovery time, postoperative pain, higher satisfaction rates, and cost savings by moving procedures to outpatient facilities and using local anesthesia
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      ,
      • Li Y.
      • Luo W.
      • Wu G.
      • Cui S.
      • Zhang Z.
      • Gu X.
      Open versus endoscopic carpal tunnel release: a systematic review and meta-analysis of randomized controlled trials.
      .
      Various anesthesia options are available in ECTR, including general anesthesia, local anesthesia, intravenous regional anesthesia, and peripheral nerve blocks. Local anesthesia administration is quick and less time-consuming compared to other options. However, since the local anesthesia may increase the synovial layers' bulk and the amount of free fluid at the operation site, which may affect the visibility, it became of limited interest
      • Nabhan A.
      • Ishak B.
      • Al-Khayat J.
      • Steudel W.I.
      Endoscopic Carpal Tunnel Release using a modified application technique of local anesthesia: safety and effectiveness.
      ,
      • Wood S.H.
      • Logan A.M.
      A local anaesthetic technique for endoscopic carpal tunnel release.
      . There are no systematic reviews comparing outcomes of ECTR using local anesthesia versus other anesthesia options. In this study, we aim to compare local anesthesia with regional anesthesia and general anesthesia, particularly in terms of functional outcomes, patient satisfaction, operative time, perioperative pain, and complications.

      Methods and Materials

      Search Strategy

      We designed this systematic review using Cochrane review methods and utilized preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group PRISMA
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ,
      • Cumpston M.
      • Li T.
      • Page M.J.
      • Chandler J.
      • Welch V.A.
      • Higgins J.P.
      • Thomas J.
      Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions.
      . The following online databases were searched from inception to May 2022: MEDLINE, EMBASE, and Cochrane. They were searched using the following keywords to aid the search: (Carpal tunnel syndrome OR median nerve neuropathy OR CTS) AND (endoscopic carpal tunnel release OR endoscopic surgery OR closed carpal tunnel release) AND (general anesthesia OR local anesthesia OR WALANT OR wide-awake local anesthesia OR regional anesthesia). We strived to review available published literature that reported the results of identifying and comparing outcomes of ECTR using local anesthesia versus other options of anesthesia technique, particularly in terms of functional outcomes, patient satisfaction, operative time, perioperative pain, and complications. The International Prospective Register of Systematic Reviews was utilized in this review on February 17 and identified as (CRD42022352677)
      • Cumpston M.
      • Li T.
      • Page M.J.
      • Chandler J.
      • Welch V.A.
      • Higgins J.P.
      • Thomas J.
      Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions.
      . This article adheres to the guidelines in the Declaration of Helsinki in 1975. Ethical approval was waived due to the nature of the study.

      Screening and data extraction

      Initial screening of articles by title and abstract was conducted by two independent groups consisting of four authors each, and the fifth author resolved any conflict of inclusion in both groups using Rayyan software
      • Ouzzani M.
      • Hammady H.
      • Fedorowicz Z.
      • Elmagarmid A.
      Rayyan-a web and mobile app for systematic reviews.
      . Related articles underwent further analysis by full-text to ensure relevance and applicability. Inclusion of articles was limited to (1) published from inception up to May 2022; (2) reported in English; (3) adult male and female patients above 18 years old; (4) patients with confirmed CTS; (6) inclusion of an endoscopic carpal tunnel release treatment arm; (7) articles were case reports, case series or original articles.
      Meanwhile, studies were excluded if they met one or more of the following criteria: (1) language other than English; (2) reported a systematic review, economic analysis, animal or cadaveric studies; (3) non-endoscopic carpal tunnel release; (4) reported no outcome of interest. The level of evidence was assigned to each of the included articles, following the criteria described in the American Society of Plastic Surgeons' rating levels of evidence and grading recommendations
      • Sullivan D.
      • Chung K.C.
      • Eaves 3rd, F.F.
      • Rohrich R.J.
      The Level of Evidence Pyramid: Indicating Levels of Evidence in Plastic and Reconstructive Surgery Articles.
      .

      Data extraction

      Eligible articles underwent a full review with the primary interest of comparing regional vs. local vs. general anesthesia with regard to age and gender, major and minor surgery-related complications, major and minor anesthesia-related complications, symptom recurrences, reoperations, main presenting complaints, duration of presenting complaints, the total time needed to return to work or daily activities, satisfaction, postoperative pain, functional outcomes, and satisfaction. Pinch/grip strength, sensation (two-point discrimination, monofilament), operating time. In cases where we were unable to extract the full data from an article, we contacted the corresponding authors of the published articles. We did not receive a response from them, however.

      Bias assessment

      The methodological index for the non-randomized studies (MINORS) assessment tool was used to assess the methodological quality and synthesis of non-randomized control trials, prospective cohorts, and comparative studies. It is a validated 12-item tool designed to check the quality of non-randomized surgical studies
      • Slim K.
      • Nini E.
      • Forestier D.
      • Kwiatkowski F.
      • Panis Y.
      • Chipponi J.
      Methodological index for non-randomized studies (minors): development and validation of a new instrument.
      . The Randomized controlled trial studies were assessed for bias using the Cochrane risk-of-bias tool for randomized trials (RoB 2)
      • Sterne J.
      • Savović J.
      • Page M.J.
      • Elbers R.G.
      • Blencowe N.S.
      • Boutron I.
      • Cates C.J.
      • Cheng H.Y.
      • Corbett M.S.
      • Eldridge S.M.
      • Emberson J.R.
      • Hernán M.A.
      • Hopewell S.
      • Hróbjartsson A.
      • Junqueira D.R.
      • Jüni P.
      • Kirkham J.J.
      • Lasserson T.
      • Li T.
      • McAleenan A.
      • Higgins J.
      RoB 2: a revised tool for assessing risk of bias in randomised trials.
      . Randomization, allocation concealment, participant and employee blinding, observer blinding, incomplete data, and selective reporting were all evaluated, and each study category was given a "low risk," "high risk," or "some concern" rating. Two independent reviewers simultaneously evaluated the bias risk.

      Statistical Analysis

      The analysis was performed for the outcomes which were reported in three studies or more. To estimate the pooled prevalence of surgical complications, we used the inverse variance method with a restricted maximum-likelihood estimator for tau2 and continuity correction of 0.5 in studies with zero cell frequencies. A random-effects model was employed in the instance of significant heterogeneity (I2 > 50%); otherwise, a fixed-effects model was used. Publication bias was assessed using funnel plots and Egger's test. Statistical significance was deemed at p < 0.05. The analysis was performed using RStudio (version 4.1.1). 

      Results

      Literature findings

      This systematic review found 198 published articles, including 121 articles from EMBASE, 65 from MEDLINE, and 12 from the Cochrane library. After removing duplicates, 135 articles remained for review. We initially retrieved 16 full-text publications. We included data from 12 studies in the present systematic review (Figure 1), and 11 studies included in the meta-analysis
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      ,
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      • Aultman H.
      • Roth C.A.
      • Curran J.
      • Angeles J.
      • Mass D.
      • Wolf J.M.
      • Mica M.C.
      Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice.
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      • Tuzuner T.
      Median and ulnar nerve block for endoscopic carpal tunnel release.
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      • Wellington I.
      • Cusano A.
      • Ferreira J.V.
      • Parrino A.
      WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release.
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      • Foster B.D.
      • Sivasundaram L.
      • Heckmann N.
      • Cohen J.R.
      • Pannell W.C.
      • Wang J.C.
      • Ghiassi A.
      Surgical Approach and Anesthetic Modality for Carpal Tunnel Release: A Nationwide Database Study With Health Care Cost Implications.
      . These studies were published between 2001 and 2021. Six studies were published in European countries
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      ,
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      • Tuzuner T.
      Median and ulnar nerve block for endoscopic carpal tunnel release.
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      ,
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      , and the remaining studies were published in the United States. Two randomized clinical trials were included
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      ,
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      , while three studies were retrospective investigations
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      ,
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      ,
      • Wellington I.
      • Cusano A.
      • Ferreira J.V.
      • Parrino A.
      WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release.
      , and the remainder were prospective cohort studies. For the following reasons, four articles were excluded: reported no outcome of interest (n = 3), and insufficient data were available (n = 1). Table 1 lists the features of each article included.
      Figure 1
      Figure 1PRISMA flow chart for the systematic review.
      Table 1Characteristics of the included studies and surgeries.
      AuthorsCountryStudy DesignPatientsOperative characteristicsLevel of evidence
      Groups (E/O)Sample sizeAge rangeGender (M/F)Type of anesthesiaSurgical techniqueOperative time (minutes)
      Allam et al. 2020
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      USAP138/0138NANALAECTRNAII
      Aultman et al. 2020
      • Aultman H.
      • Roth C.A.
      • Curran J.
      • Angeles J.
      • Mass D.
      • Wolf J.M.
      • Mica M.C.
      Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice.
      USAP50/439326-7829/34LA with sedation versus WALANT onlyECTRNAII
      Chalidis et al. 2013
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      GreeceP85/08529-7923/62LASingle-port31.2 meanII
      Delaunay et al. 2001
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      USAR273/0273N/A68/205LAECTR (undefined)N/A tourniquet was inflated for 12.6 ± 5.4 minII
      Ly et al. 2019
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      SwitzerlandP24/02439-924/16LA (WALANT)Single-port14(7-25)II
      Nabhan et al. 2011
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      GermanyRCT43/04341-6918/26LA versus RAECTRL.A Group 28 ± 3.5 minutes

      IVRA Group 45 ± 3.9 minutes
      II
      Sørensen et al. 2012
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      DenmarkRCT38/03831-765/14LA versus RAECTR7.3 (SD 3.3) minutesI
      Tulipan et al. 2018
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      USAP156/0156n/a26/36single-portn/aII
      Tuzuner et al. 2006
      • Tuzuner T.
      Median and ulnar nerve block for endoscopic carpal tunnel release.
      TurkeyP21/02133-595/16RA (Median and ulnar nerve block)2-portal chow techniqueNAII
      Tüzüner et al. 2005
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      TurkeyR10/01035-582/8LATwo-portal Chow techniqueN/AII
      Wellington et al. 2021
      • Wellington I.
      • Cusano A.
      • Ferreira J.V.
      • Parrino A.
      WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release.
      USAR156/0156MT: (36.4-55.8)

      LT: (42.2-70.4)

      WALANT: (37.7-69.3)
      NALA (WALANT)ECTRWALANT: 10 minutes

      MT: 11 minutes

      LT 11 minutes
      II
      Foster et al, 2017
      • Foster B.D.
      • Sivasundaram L.
      • Heckmann N.
      • Cohen J.R.
      • Pannell W.C.
      • Wang J.C.
      • Ghiassi A.
      Surgical Approach and Anesthetic Modality for Carpal Tunnel Release: A Nationwide Database Study With Health Care Cost Implications.
      TurkeyR2238/ 7273223830-704409/9497GA, LA, RA
      E: endoscopic surgeries; O: open surgeries; M: male; F: female; ECTR: endoscopic carpal tunnel; P: prospective; R: retrospective; RCT: randomized clinical trials; LA: Local anesthesia; GA: General anesthesia; RA: Regional anesthesia; WALANT: wide awake local anesthesia no torniquet

      Study characteristics

      A total of 87481 patients were reviewed in all the studies, with sample sizes ranging from 10 to 86687 patients. The majority of patients underwent open CTR procedures (n= 72892, 83.32%), whereas only 14589 patients (16.67%) underwent endoscopic surgeries. The study included 14589 patients who had undergone ECTR. The age ranged from 26-92 years old. In all included studies, women were the majority (n = 9914/1450, 68.35%); in two articles, gender was not mentioned
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      ,
      • Wellington I.
      • Cusano A.
      • Ferreira J.V.
      • Parrino A.
      WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release.
      . In seven articles, local anesthesia was administered
      • Nabhan A.
      • Ishak B.
      • Al-Khayat J.
      • Steudel W.I.
      Endoscopic Carpal Tunnel Release using a modified application technique of local anesthesia: safety and effectiveness.
      ,
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      ,
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      ,
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      ,
      • Wellington I.
      • Cusano A.
      • Ferreira J.V.
      • Parrino A.
      WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release.
      , two articles compared local anesthesia with regional anesthesia
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      ,
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      , one article used only regional anesthesia (median and ulnar nerve block)
      • Tuzuner T.
      Median and ulnar nerve block for endoscopic carpal tunnel release.
      , one article used local anesthesia with sedation versus WALANT only
      • Aultman H.
      • Roth C.A.
      • Curran J.
      • Angeles J.
      • Mass D.
      • Wolf J.M.
      • Mica M.C.
      Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice.
      , and one article compared general anesthesia or regional anesthesia versus local anesthesia
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      . Regarding the clinical and operative characteristics, the duration of presenting complaints of CTS was presented in two studies
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      ,
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      , with a mean duration of 43.3 months. In a study by Chalidis et al.
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      and a range of 4-48 months in a study of Ly et al.
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      .
      For the hand laterality affected by CTS, only four articles mentioned the hand laterality of their patients
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      ,
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      ,
      • Tuzuner T.
      Median and ulnar nerve block for endoscopic carpal tunnel release.
      ,
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      . As a whole, the right hand was more affected (n=138/235, 58.72%) than the left hand (n=97/235, 41.27%). Three articles described the endoscopic carpal tunnel syndrome release method using a single port technique
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      ,
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      ,
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      , and two articles described the two-port chow method
      • Tuzuner T.
      Median and ulnar nerve block for endoscopic carpal tunnel release.
      ,
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      . The rest of the articles didn't mention their endoscopic technique. A mean operative time of 20.1 minutes was achieved for local anesthesia, 45 minutes was achieved for regional anesthesia, and 51 minutes was achieved for general anesthesia.
      Regarding patients' satisfaction, the rates of high satisfaction levels were generally higher in local anesthesia
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      ,
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      , 88.0% in another study
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      , and 91.7% in a third study
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      . Other patients' and operative characteristics are listed in Table 2. The outcomes of surgeries and follow-up are demonstrated in Table 2. Postoperative surgical complications were prevalent among 2.7% of patients (95%CI, 1.00 to 7.41, Figure 2). The pooled estimate showed a significant heterogeneity (I2 = 77.53, ph <0.0001). More details about the types of these surgical complications are listed in Table 2. Anesthesia-related complications were reported in two studies. In a study by Delaunay et al.
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      , among 273 patients who underwent ECTR under local anesthesia, 41 (15.02%) experienced mild pain. In an RCT carried out by Nabhan et al.,
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      additional local anesthetic agents were required by 3/43 patients (6.98%) due to severe pain (Table 2). However, we could not conclude a pooled estimate of the prevalence of pain or other anesthesia-related complications due to the small number of studies concerned with such a type of complication.
      Table 2Surgical and functional outcomes after carpal tunnel syndrome surgeries.
      AuthorsSurgical complicationsAnesthesia-related complicationsFollow-up intervalPatient satisfactionPostoperative pain
      Allam et al. 2020
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      Infection:6, neuropraxia:2, wound dehiscence:2, nerve laceration:0NANANANA
      Aultman et al. 2020
      • Aultman H.
      • Roth C.A.
      • Curran J.
      • Angeles J.
      • Mass D.
      • Wolf J.M.
      • Mica M.C.
      Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice.
      NANANAE(walant:7.26, mac:6.2)Walant: H:6.2, Average:4, L:2.6. MAC: H:6,8, Average:5.8, L:3.3
      Chalidis et al. 2013
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      NoneNA12 mNA0.7 ± 1.4 (0–5)
      Delaunay et al. 2001
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      None41 had mild painNANANA
      Ly et al. 2019
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      7 Incomplete visualization, 1 ConversionNA3 m22 very good, 1 somewhat painful, 1 very unpleasantNA
      Nabhan et al. 2011
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      1 patient complained of mild pain when the endoscope was inserted and required additional prilocaine.3 patients from group of LA required additional LA because of severe pain in the hand when the endoscope was inserted, One of these 3 patients also required sedation with 30 mg propofol for tourniquet pain.NA6 months after the operation 88% of patients are satisfied6 months after the operation, 11% of patients felt pain
      Sørensen et al. 2012
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      NoneNANA19 satisfiedSignificantly less pain than others
      Tulipan et al. 2018
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      noneNA3 m53 happy, 2 not happy, 7 lost follow up4.81
      Tuzuner et al. 2006
      • Tuzuner T.
      Median and ulnar nerve block for endoscopic carpal tunnel release.
      NoneNANANA3 (14.2%) required further anesthesia
      Tüzüner et al. 2005
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      One patient developed neuropraxia in the third and forth fingers postoperatively.NA12 mNAEarly postoperative pain was observed in two wrists, appearing 10 days and two months after surgery, respectively.
      Wellington et al. 2021
      • Wellington I.
      • Cusano A.
      • Ferreira J.V.
      • Parrino A.
      WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release.
      Superficial infections:3 (2 LT, 1 WALANT), Aseptic Flexor Tenosynovitis: 2 (2 MT)NANANANA
      Foster et al, 2017
      • Foster B.D.
      • Sivasundaram L.
      • Heckmann N.
      • Cohen J.R.
      • Pannell W.C.
      • Wang J.C.
      • Ghiassi A.
      Surgical Approach and Anesthetic Modality for Carpal Tunnel Release: A Nationwide Database Study With Health Care Cost Implications.
      NANANANANA
      IVRA: intravenous regional anesthesia; LA: local anesthesia; WALANT: wide-awake, local anesthesia, no tourniquet; LT: local anesthesia with tourniquet; MT: monitored anesthesia care with tourniquet
      Figure 2
      Figure 2A forest plot showing the prevalence of post-surgery complications in included studies.
      Regarding other outcomes, the proportion of reoperation was mentioned in one study
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      ، where two patients out of 138 (1.45%) underwent repeated surgery. Follow-up intervals were three months in two studies
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      ,
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      and one year in the other two studies
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      ,
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      . According to one study
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      , 95% of patients returned to their daily activities within six months of undergoing a local anesthetic operation. Set al.
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      reported that the mean pinch/grip strength postoperatively was 6.64 ± 1.23 (Table 2). None of the patients developed symptoms of recurrence.

      Publication Bias

      Assessment of publication bias showed asymmetry in the funnel plot because small-sized articles were more likely to report prevalence rates lower than the mean pooled estimate. This was corroborated in the analysis of Egger's test, where the test value was -2.36 (95%CI, -4.22 to -0.49) with a p-value of 0.034 (Figure 3).
      Figure 3
      Figure 3A funnel plot depicting the risk of publication bias.

      Quality Assessment and Risk of Bias

      The authors assessed randomized control trials, prospective and retrospective cohort included in the study. Two reviewers (AAB and AAL) evaluated the risk of bias separately and concurrently. 10 non-randomized studies were assessed by MINORS tool
      • Slim K.
      • Nini E.
      • Forestier D.
      • Kwiatkowski F.
      • Panis Y.
      • Chipponi J.
      Methodological index for non-randomized studies (minors): development and validation of a new instrument.
      . And two RCTs were assessed using Cochrane risk-of-bias tool for randomized trials (RoB 2)
      • Sterne J.
      • Savović J.
      • Page M.J.
      • Elbers R.G.
      • Blencowe N.S.
      • Boutron I.
      • Cates C.J.
      • Cheng H.Y.
      • Corbett M.S.
      • Eldridge S.M.
      • Emberson J.R.
      • Hernán M.A.
      • Hopewell S.
      • Hróbjartsson A.
      • Junqueira D.R.
      • Jüni P.
      • Kirkham J.J.
      • Lasserson T.
      • Li T.
      • McAleenan A.
      • Higgins J.
      RoB 2: a revised tool for assessing risk of bias in randomised trials.
      . The findings of both reviewers were the same, regardless of whether the material appeared biased. The non-randomized studies considered had MINORs of at least 60%. There were four comparative studies, and they scored an average of 15.25 (range 4-24). The sex non-comparative studies had an average score of 7.5 (range 3-16). Table 3 and 4 summarizes the MINORs instrument assessment. The two RCTs show a high risk of bias in selection and performance with a low risk in other factors (Figure 4,5).
      Table 3MINORS instrument assessment for non-randomized comparative studies (N=4)
      ItemTulipan 2018Aultman 2020Foster 2017Wellington, 2021
      A clearly stated aim2222
      Inclusion of consecutive patients2000
      Prospective collection of data2200
      Endpoints appropriate to the aim of the study2200
      Unbiased assessment of the study endpoint2202
      Follow-up period appropriate to the aim of the study2100
      Loss to follow-up less than 5%2100
      Prospective calculation of the study size2202
      An adequate control group2222
      Contemporary groups2202
      Baseline equivalence of groups2202
      Adequate statistical analyses2201
      Total score2420413
      Table 4MINORS instrument assessment for non-randomized non-comparative (studies (N=6)
      ItemDelaunay, 2001V. Ly, 2019Tuzuner, 2006Chalidis, 2013Alla, 2020TÜZÜNER, 2005
      A clearly stated aim121221
      Inclusion of consecutive patients200200
      Prospective collection of data020200
      Endpoints appropriate to the aim of the study111202
      Unbiased assessment of the study endpoint111211
      Follow-up period appropriate to the aim of the study020202
      Loss to follow-up less than 5%020200
      Prospective calculation of the study size020200
      Total score51231636
      Figure 5
      Figure 5An overview of the bias risk assessment for the included RCT studies.

      Discussion

      The median nerve is the most common nerve compression in the upper extremities
      • Thoma A.
      • Veltri K.
      • Haines T.
      • Duku E.
      A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression.
      . It is estimated that 1.5% to 5% of the general population is affected, with a higher incidence among females
      • Atroshi I.
      • Gummesson C.
      • Johnsson R.
      • Ornstein E.
      • Ranstam J.
      • Rosén I.
      Prevalence of carpal tunnel syndrome in a general population.
      . Carpal tunnel syndrome occurs when the median nerve is compressed in the osteofibrous canal located in the volar aspect of the wrist. In late 1989, Chow et al.
      • Nabhan A.
      • Ishak B.
      • Al-Khayat J.
      • Steudel W.I.
      Endoscopic Carpal Tunnel Release using a modified application technique of local anesthesia: safety and effectiveness.
      and Okutsu et al.
      • Wood S.H.
      • Logan A.M.
      A local anaesthetic technique for endoscopic carpal tunnel release.
      introduced the use of endoscopy in the release of median nerve compression, which demonstrated high superiority over the traditional technique of carpal tunnel release in terms of postoperative outcome, procedure time, satisfaction, and everyday functional recovery
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group PRISMA
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      . There are many options for anesthesia in ECTR, including general anesthesia, local anesthesia, intravenous regional anesthesia, and peripheral nerve blocks. Here, we compare local anesthesia with regional anesthesia and general anesthesia, particularly regarding patient satisfaction, operative time, pain, and complications.
      We screened a total of 87481 patients, but only those who underwent ECTR (16.67%) were assessed and evaluated. There is no doubt that open CTR is the procedure of choice for treating median nerve compression, and the study's findings show that 83.32% of the reviewed studies used open CTR
      • Atroshi I.
      • Gummesson C.
      • Johnsson R.
      • Ornstein E.
      • Ranstam J.
      • Rosén I.
      Prevalence of carpal tunnel syndrome in a general population.
      . Despite this, we believe that ECTR will have a bright future in managing CTS
      • Li Y.
      • Luo W.
      • Wu G.
      • Cui S.
      • Zhang Z.
      • Gu X.
      Open versus endoscopic carpal tunnel release: a systematic review and meta-analysis of randomized controlled trials.
      .
      Based on our systematic review, the most common anesthesia technique for ECTR was local anesthesia
      • Nabhan A.
      • Ishak B.
      • Al-Khayat J.
      • Steudel W.I.
      Endoscopic Carpal Tunnel Release using a modified application technique of local anesthesia: safety and effectiveness.
      ,
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      ,
      • Chalidis B.E.
      • Dimitriou C.G.
      One portal simultaneous bilateral endoscopic carpal tunnel release under local anaesthesia. Do the results justify the effort?.
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      ,
      • Tuzuner T.
      • Ozturan K.
      • Subasi M.
      • Karaca E.
      The use of local anesthesia in endoscopic release of the carpal tunnel.
      ,
      • Wellington I.
      • Cusano A.
      • Ferreira J.V.
      • Parrino A.
      WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release.
      , which was mentioned in 7 articles, followed by local anesthesia with regional anesthesia administration
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      ,
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      . Based on the results of our study, local anesthesia has a higher satisfaction rate and a shorter operative time than general anesthesia. A mean operative time of 20.1 minutes was achieved with local anesthesia, compared to 45 minutes and 51 minutes with regional anesthesia and general anesthesia, respectively. Generally, local anesthesia was associated with higher rates of patient satisfaction
      • Tulipan J.E.
      • Kim N.
      • Ilyas A.M.
      • Matzon J.L.
      Endoscopic Carpal Tunnel Release with and without Sedation.
      ,
      • Sørensen A.M.
      • Dalsgaard J.
      • Hansen T.B.
      Local anaesthesia versus intravenous regional anaesthesia in endoscopic carpal tunnel release: a randomized controlled trial.
      , 88% in another study
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      , and 91.7% in a third study
      • Ly T.V.
      • Urban V.
      • Meuli-Simmen C.
      • Pasternak I.
      Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia.
      . However, comparing the satisfaction rate to other types of anesthesia was impossible due to insufficient data. We found that only 2.7% developed postoperative complications, including infection, neuropraxia, and mild to severe pain. In a study by Nabhan et al.
      • Nabhan A.
      • Steudel W.I.
      • Dedeman L.
      • Al-Khayat J.
      • Ishak B.
      Subcutaneous local anesthesia versus intravenous regional anesthesia for endoscopic carpal tunnel release: a randomized controlled trial.
      , three patients out of 273 required sedation due to severe pain, which was explained by the long operative time of 28-45 minutes. A study by Allam et al.
      • Allam O.
      • Park K.E.
      • Carney M.
      • Kim S.
      • Craig M.
      • Thomson J.G.
      • Prsic A.
      Safety of Endoscopic Carpal Tunnel Release Performed Under Local Anesthesia.
      reported that ECTR under local anesthesia had the highest rate of surgical complications. Six patients developed surgical site infections, two patients had neuropraxia, and two had wound dehiscence. The article did not provide enough information or explanation for the high rate of complications. Delaunay et al.
      • Delaunay L.
      • Chelly J.E.
      Blocks at the wrist provide effective anesthesia for carpal tunnel release.
      , however, reported 15% of patients experienced mild pain and none required additional anesthetic injections, and postoperative evaluations revealed no surgical or anesthetic complications. Based on the high satisfaction rate reported in the included studies, we believe that ECTR under local anesthesia is highly safe with a lower risk of complications. The surgical technique was reported in five studies; three used single-port endoscopy, and only seven operations had incomplete visualization, which led to further delays. Two studies used double-portal endoscopy. Even though the author didn't report any visualization problems during the procedure, they considered the limited view as one of the limitations of ECTR. Nonetheless, both techniques showed to be safe and preferable for postoperative pinch/grip and recovery.

      Limitations and future recommendations

      To our knowledge, this is the first systematic review and meta-analysis that compares different anesthetic techniques in ECTR. This study has several strengths, including the review of the current literature without a timeframe, the strict inclusion and exclusion criteria, and the reporting format according to PRISMA guidelines. According to MINORs' assessment tool, all included studies scored a mean of 22.75 for possible bias. There are, however, several limitations to our study. Since the number of included articles is low, we were not able to obtain significant findings. In addition, some essential information was missing from the literature. Only five articles reported operation times, four reported patients' follow-ups, and only two reported the duration of presenting complaints or functional outcomes. Additionally, some confounding factors, such as operation time, presence of comorbidity, and surgeon experience, were not controlled in some of the included studies, which might have generated bias. The risk of bias was comprehensively assessed, but we recommend that future studies control all these variables. Moreover, the heterogeneity and lack of sufficient data made it impossible to conclude the best type of anesthesia for ECTR. Therefore, we recommend randomized controlled trials to compare local anesthesia, regional anesthesia, and general anesthesia to highlight the differences in functional outcomes, patient satisfaction, operative time, complications, and overall costs.

      Conclusion

      The main objective of our review and meta-analysis was to identify and compare the most suitable types of anesthesia for ECTR. Each of the reported methods was effective, with the most commonly used method being local anesthesia, which was reported in 7 of the 12 articles. Additionally, it showed a shorter operative time and a higher satisfaction rate than regional and general anesthesia. Hand surgeons can use the results of our study to choose an appropriate type of anesthesia for ECTR based on the results of our study. For future studies, we recommend randomized controlled trials to allow precise comparison of the advantages and disadvantages of each type of anesthesia.

      Statements and Declarations

      Funding

      The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

      Ethics approval

      This study was performed in line with the principles of the Declaration of Helsinki. Approval was waived due to the nature of the study.

      Competing Interests

      The authors have no relevant financial or non-financial interests to disclose.

      Conflict of interest

      The authors do not have any conflict of interest

      Acknowledgment

      This work was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.

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