









































Educated Hand Publishing 
LLC “T he Science Behind the Art” 
Volume 6- No. 1 2018

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 1

Regional Anesthesia for Bilateral Carpal Tunnel Release

Debra S. Varela, DNP, CRNA1

Johanna Newman, DNAP, CRNA2

Jorge A. Valdes, DNP, CRNA3

Affiliation:
1.  Literature Review was conducted as partial fulfillment for the degree of Doctor of Nursing Practice in Anesthesiology through Barry University in Miami Florida and 
practicing CRNA at a critical access hospital in rural North Central Arkansas

2.  CRNA Clinician at Anesco North Broward in Fort Lauderdale, FL

3.  Clinical Assistant Professor of Anesthesiology at Florida International University in the College of Nursing Health Sciences 

Funding/Conflict of Interest Disclosure:  None 

KEYWORDS:  carpal tunnel syndrome, median nerve block, local anesthesia, lidocaine, epinephrine

INTRODUCTION
 Carpal tunnel syndrome (CTS) interferes with a patient’s quality of life and has significant financial implications for patients, 
their employers, and the US health care system.1,2 CTS involves compression of the median nerve and is the most common 
nerve entrapment neuropathy with a prevalence of 3% to 5% in the general population.1 Because the average age at the time of 
diagnosis is 45 to 60 years, CTS affects people in the workforce.1 CTS is responsible for an average of 28 days away from work 
according to 2015 data from the Bureau of Labor Statistics.1,2 A reported 56% to 87% of those presenting with median nerve 
compression symptoms are diagnosed with bilateral involvement, especially patients with diabetes, hypothyroidism, obesity, and 
inflammatory arthritis.1,3,4 Carpal tunnel release (CTR) surgery incurs an estimated health care cost of $2 billion annually in 
the United States,5 with more than 500,000 persons undergoing CTR surgery every year.6

Patients diagnosed with bilateral carpal tunnel syndrome (BCTS) are faced with the decision to undergo surgical intervention 
in a staged unilateral approach or a simultaneous bilateral approach. Studies have shown that bilateral carpal tunnel release 
(BCTR) is overwhelmingly more cost-effective and time-efficient than a staged unilateral approach.1,5,6 Bilateral hand 
procedures limit certain regional anesthesia techniques typically employed for unilateral upper extremity procedures, however, 
requiring reconsideration of more effective anesthesia options.7-9

Abstract
Carpal tunnel syndrome is the most common nerve entrapment neuropathy, and over 60% of diagnosed patients pres-
ent with bilateral median nerve involvement. Bilateral upper extremity surgery presents unique anesthesia challenges, yet 
surgeons are increasingly interested in performing simultaneous bilateral carpal tunnel release (BCTR) procedures. The 
regional anesthesia techniques traditionally used for unilateral hand procedures are impractical for bilateral procedures, and 
general anesthesia is expensive and incurs added risk. A cost-effective and efficient anesthesia plan for BCTR is therefore 
needed. We conducted a literature search to support the administration of an efficient and safe anesthesia technique for 
BCTR utilizing local infiltration and median nerve block. Electronic searches were conducted to identify current pertinent 
information published in anesthesia, hand surgery, and plastic surgery journals within the past 5 years. The information 
gathered was assimilated to make an evidence-based recommendation for a BCTR anesthesia technique. BCTR is a more 
cost-effective and time-efficient treatment for bilateral carpal tunnel syndrome than a staged unilateral approach. Local 
anesthesia with median nerve block with or without sedation is a cost-efficient and safe anesthesia strategy for BCTR..

AEJ
Volume 6 - No.1 2018



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METHODS
Electronic searches were conducted through MEDLINE 
(National Library of Medicine), CINAHL (EBSCO), and 
PUBMED (National Library of Medicine) for current pertinent 
information published in the anesthesia, hand surgery, and 
plastic surgery literature. The search was limited to 2012 through 
2016, with the exception of large, multicenter landmark studies. 
Search sensitivity was increased by using the Boolean operators 
“OR” and “AND” to combine search categories. The words and 
phrases searched included the following: bilateral carpal tunnel 
syndrome/release, bilateral versus staged unilateral carpal tunnel 
release, median nerve block, regional anesthesia for bilateral hand 
procedures, local anesthesia with epinephrine and hand surgery, 
buffering of local anesthetics, general anesthesia versus regional 
anesthesia: cost and safety, anxiety and anesthesia, sedation, and 
monitored anesthesia care.
REVIEW OF THE LITERATURE
Bilateral Carpal Tunnel Release Versus Staged Unilateral 
Release
Surgical treatment of BCTS can be addressed in a simultaneous 
approach or a staged unilateral approach.1,4-6 The cost- and 
time-effectiveness of BCTR compared with staged unilateral 
carpal tunnel release (SCTR) has been well documented. A study 
evaluating cost-effectiveness published in November 2016 in the 
Journal of the American Academy of Orthopedic Surgeons showed 
BCTR to have a higher total effectiveness and lower cost than 
SCTR.6 A cost and time comparison study between SCTR and 
BCTR was also performed by Elfar et al,5 who reported a 22% 
increase in total amount billed including fees for the physician, 
facility, and anesthesia in the SCTR group compared with the 
BCTR group. The average total operating room time for SCTR 
procedures was 66 minutes compared with 40 minutes for BCTR 
procedures.5 Additionally, patients undergoing BCTR missed 
an average of 22 days from work, compared with 46 days for 
patients undergoing a staged unilateral approach.5 Physicians also 
benefit from the simultaneous BCTR option by requiring fewer 
postoperative visits (3.46 for SCTR vs 1.45 for BCTR), with 
higher remuneration per hour.4

The primary reason patients report choosing SCTR over BCTR 
is concern for independent postoperative self-care, whereas 
patients choosing BCTR over SCTR reported wanting to 
avoid 2 surgical procedures.1 A prospective cohort study by 
Osei et al1 conducted postoperative surveys of both SCTR and 
BCTR patients to compare self-care ability. The results revealed 
increased difficulty with household chores only during the first 
2 postoperative days in the BCTR group, but no significant 
difference in personal hygiene performance between the groups.1

Anesthesia Considerations for BCTR
Bilateral hand procedures limit the use of certain regional 
anesthesia techniques typically used for unilateral upper 
extremity procedures, such as brachial plexus block (BPB) and 
intravenous regional blocks (IVRBs).7,8 Local anesthesia toxicity 
and tourniquet pain are potential complications with these 
techniques.7-9 Postoperative concerns with these methods include 
bilateral motor blockade with BPB, and the lack of analgesia 
provided with IVRB following deflation of the tourniquet.7-9 

Anesthesia techniques practical for consideration for BCTR are 

general anesthesia, local anesthesia, and median nerve block with 
or without sedation.7-9

Both open and endoscopic surgical techniques for BCTR are 
considered minimally invasive procedures according to the clinical 
practice guidelines of the American Association of Orthopedic 
Surgeons.3 A pneumatic tourniquet for hemostasis has 
traditionally been used for this procedure, necessitating anesthesia 
management for tourniquet pain.10,11 Negating the noxious 
stimuli of a tourniquet eliminates the need for general anesthesia 
or heavy sedation, thus avoiding their associated risks and 
expense.10-12 Costly preoperative testing may also be eliminated if 
general anesthesia is not indicated.10,11 Regional techniques and 
local anesthesia alternatives result in less postoperative pain and a 
shorter recovery room stay than general anesthesia.13

Within the past 10 years, wide acceptance of the use of 
epinephrine for hemostasis has been published in the hand 
surgery literature. A large multicenter prospective study 
conducted between 2002 and 2004 through Dalhousie University 
in Canada reviewed 3110 consecutive cases in which epinephrine 
was electively injected into the hand with no incidence of tissue 
loss.12 The long-held belief that epinephrine in finger and hand 
surgery is contraindicated was dispelled.10-12 The acceptance of 
epinephrine-containing local anesthetics in hand surgery enables 
local infiltration and median nerve block as an effective, safe 
anesthetic technique for BCTR.10,11

Sedation and Patient Anxiety
In 2 separate patient satisfaction studies comparing patients 
undergoing CTR under local anesthesia only to local anesthesia 
with sedation, one by Rozanski et al14 and the other by Davison 
et al,15 the investigators found no difference in overall satisfaction 
with their procedure, with 93% of patients reporting satisfaction 
with whichever technique they received. A preponderance of 
available literature supporting the use of a local anesthesia only 
technique termed “wide awake local anesthesia no tourniquet” 
(WALANT) has been published by Lalonde et al.10-12,15 
Comparison studies conducted by Lalonde’s group evaluating 
patient satisfaction between nonsedation and sedation techniques 
showed no significant differences in satisfaction; however, surgical 
conditions and local anesthesia techniques were not standardized 
between the groups.15 In the study conducted by Rozanski et 
al14 to specifically evaluate pain perception on injection and 
during the procedure between sedation and nonsedation groups, 
significantly higher pain on injection and during the surgery 
was reported in the local anesthesia only groups. Despite these 
findings, the authors supported the use of local anesthesia only 
owing to the reduced need for a thorough preoperative workup, 
intravenous access, intraoperative monitoring, and recovery room 
time compared with the sedation technique.14,15 Studies designed 
to evaluate patient satisfaction, anxiety, and comfort with equal 
surgical and local anesthesia techniques between sedated and 
nonsedated patients were not available in the reviewed literature.
Patient anxiety related to regional anesthesia has been reported as 
primarily related to fear of pain, awareness, and not knowing what 
to expect.16-18 Preoperative consultation with patients describing 
the procedure, medical equipment, terminology, and postoperative 
expectations has been identified as a means to greatly decrease 
anxiety in regional anesthesia patients.16-18 The patient’s health 
status, as well as acceptance of increased pain during the injection 



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Volume 6 - No. 1 2018 Page 3

and procedure, are factors in proposing this regional anesthesia 
plan with or without sedation.14,15

Comparison of Injection Technique
Two local anesthesia injection techniques have been described 
for carpal tunnel decompression procedures: the Altissimi and 
Mancini technique, in which a local anesthetic is infiltrated into 
the carpal tunnel to anesthetize the median nerve as well as 
subcutaneously for surgical analgesia, and the Gale technique, 
which involves only superficial infiltration without a median 
nerve block.19,20 A randomized controlled single-blinded trial 
reported in the Journal of Hand Surgery by Patil et al20 evaluated 
analgesic levels between the 2 techniques for patients undergoing 
BCTR in a staged unilateral sequence separated by 4 to 8 weeks. 
The Gale technique was used on one hand, and the Altissimi 
and Mancini on the other.20 Of the 20 patients evaluated, the 
Altissimi and Mancini technique was found to produce complete 
analgesia in all of the patients compared with the Gale technique, 
in which 30% of patients complained of intraoperative pain.20 
Similarly, a nonrandomized prospective interventional trial 
reported in the Journal of the Institute of Medicine by Sigdel et al19 
concluded that the Altissimi and Mancini technique provides 
reliable intraoperative analgesia. Neither of the studies reported 
the incidence of median nerve injury with infiltration of the 
carpal tunnel.19,20

Lidocaine is most commonly reported as the local anesthesia 
agent of choice for minor hand surgery procedures owing to its 
safety record compared with other local anesthesia agents.10,11 

The addition of epinephrine to lidocaine serves to extend the 
block duration, acts to provide hemostasis, and raises the toxic 
dose limit, thus allowing for a greater volume to be used.10,11,15 The 
average duration of 1% lidocaine with 1:100,000 epinephrine is 
4 to 5 hours, adequate to provide analgesia for the intraoperative 
and postoperative period for BCTR procedures.10 An upper limit 
of 7 mg/kg of lidocaine with epinephrine is widely accepted as a 
safe toxic dose limit allowing for ample volume of 1% lidocaine 
with 1:100,000 epinephrine to be used.10,11 The use of lidocaine 
with epinephrine is reported extensively as a safe local anesthesia 
throughout the dental and plastic surgery literature.10,11

Modifications to reduce pain on injection related to the initial 
needle stick and stinging affiliated with local anesthesia 
infiltration were identified in the literature reviewed. Such 
modifications included using a small 25- to 27-gauge needle 
for injection, introducing the needle perpendicularly to the skin, 
advancing the needle slowly behind the field of existing local 
anesthesia, and buffering the lidocaine with sodium bicarbonate 
to achieve pH normalization.21-23 An original study by Frank 
and Lalonde22 concluded that 1% lidocaine with 1:100,000 
epinephrine has an average pH of 4.2 to 4.7 and is reliably 
normalized to a target tissue pH of 7.38 to 7.62 with the addition 
of 1 mL 8.4% sodium bicarbonate to every 10 mL of local 
anesthetic (10:1 ratio).
Hands-on: Performing the Injection
For successful performance of the Altissimi and Mancini 
injection technique, the literature stresses the importance of 
reviewing the median nerve anatomy to avoid intraneural injury 
with a carpal tunnel injection. The median nerve becomes 
superficial at the distal forearm proximal to the wrist.24 It 

traverses the carpal tunnel, medial to the flexor carpi radialis 
tendon, and deep and radial to the palmaris longus (PL) 
tendon (Figure 1).24 The median nerve innervates the palmar 
surface of the thumb, index, middle, and the lateral half of the 
ring finger, including the nail beds on the dorsal surface.24 An 
atraumatic injection of the carpal tunnel can be accomplished 
with familiarization of median nerve anatomy (Figure 1),24 and 
utilization of a 45-degree radial and distal needle angle just ulnar 
to the PL tendon (Figure 2).19,20,24

Figure 1. Cross Sectional Anatomy of Carpal Tunnel.
Illustration Credit: Debar Varela, 2017. 

 Figure 2. Modified Altissimi and Mancini19,20 carpal tunnel 
injection as described by Farhangkhoee et al25 in line with the 
radial border of the ring finger at a 45-degree radial and distal 
angle. Superficial landmarks for infiltration: radial border of the 
ring finger from the proximal palmar crease to the distal wrist 
crease. The diagonal line depicts Kaplan’s cardinal line, the distal 
most extent of an open or endoscopic carpal tunnel release, 
sparing the superficial palmar arch from transection.26 Image 
credit: Debra Varela, 2016.



A modification of the Altissimi and Mancini technique, termed 
the “hole-in-one” technique, has been described and utilized 
extensively by Lalonde.27 Reliable replication of the technique 
was highlighted in a study conducted at Dalhousie University in 
Canada by Farhangkhoee et al25 in which 25 consecutive medical 
students (36%) and residents (64%) observed the injection one 
time and then independently demonstrated the technique on the 
next patient. Pain score data were collected immediately after the 
demonstration by asking the patient how many times pain was 
felt during the injection utilizing the “hole-in-one” technique.25 

Of the 25 patients injected, 66% felt pain on only the first stick, 
termed a “hole-in-one,” while 24% reported feeling 2 needle 
sticks, which was termed an “eagle.”25

Technique standardization of the hole-in-one technique included 
the following. A total of 20 mL of 1% lidocaine with 1:100,000 
epinephrine and 2 mL of 8.4% bicarbonate for each carpal tunnel 
injection was prepared.27 A 27-gauge needle was first introduced 
in line with the ring finger at the distal wrist crease, at a 
45-degree radial direction, and 10 mL was injected into the carpal
tunnel for the median nerve block.25,27 The remaining 10 mL was
infiltrated into the palm in line with the radial side of the ring
finger (Figure 2),26 with care given to advance the needle within
the field of existing local anesthesia, avoiding needle contact with
unanesthetized tissue.25,27 Kaplan’s cardinal line as depicted by
the transverse palmar line (Figure 2) provides a reference point
to the superficial palmar arterial arch. The Kaplan’s cardinal
line landmark is referenced as the distal most extent of an open
or endoscopic CTR by hand surgeons and ensures that the
superficial palmar arch is free of transection.26 The intersection of
the palmar lines serves as a reference point for local infiltration
for the incision site.26

Pain level was described by the volunteer patient population as
less than the pain experienced with local dental anesthesia by
84%, and 64% rated it as less pain than with the insertion of a
20-gauge intravenous needle used for providing sedation.27 While
the researchers conceded that the study may have been skewed by
patients feeling obligated to support students, the technique was 
found to be easily replicated.27

SUMMARY
The literature selected for review included descriptive 
nonexperimental, observational review, and case-control studies. 
The data supporting BCTR versus SCTR revealed cost and time 
savings for patients and surgeons.1,4-6 Documentation of the desire 
to perform BCTR in a simultaneous fashion and the limitations 
of certain anesthetic techniques with bilateral upper extremity 
surgeries validate the need for an efficient, evidence-based 
anesthesia plan.7-9

The acceptance of epinephrine-containing local anesthetics in the 
hand surgery literature has made performing hand procedures 
such as CTR without the use of a tourniquet possible, thereby 
negating the use of a pneumatic tourniquet and associated 
tourniquet pain.10-12,14,15 Much of the recent literature reviewed 
has cited or been authored by Lalonde and his associated 
researchers on the use of WALANT for hand surgeries including 
CTR. The cost- and time-effectiveness of WALANT has been 
documented in studies that compared cost, safety, and patient 
satisfaction.11,14,15,27 Lalonde et al have proposed that most CTR 
procedures can be performed with WALANT with resultant 
high patient satisfaction, improved safety, and decreased 
cost.10,11,15,21,25,27 CTR procedures in Canada are performed 
90% of the time with local anesthesia only and no tourniquet.27 

In contrast, most CTR procedures in the United States are 
performed by use of a tourniquet either with sedation or with 
general anesthesia.27

A gap in the literature was found to exist in the comparison of 
patient satisfaction with local anesthesia only with the same local 
anesthesia technique with sedation with regard to decreased 
anxiety and increased satisfaction with simultaneous BCTR 
procedures. Additionally, studies designed to quantify the level 
and type of sedation as related to patient satisfaction with CTR 
surgery were lacking. While expense and efficiency are important 
driving factors, patient comfort and psychological well-being are 
equally important considerations. Factors increasing anxiety in 
patients undergoing local anesthesia were addressed in a study by 
Caddick et al,16 who found that aside from obvious factors such 
as fear of pain, the use of “surgical jargon” and the operating room 
environment itself contribute to anxiety. Caddick et al16 suggested 
that an increase in patient anxiety during the perioperative period 
has an overall negative impact on patient recovery. Attempts 
to reduce the stressful aspects of the operative process could 
therefore result in a positive psychological and physical response 
to surgery.16

As local and regional anesthetic techniques are used more 
frequently with outpatient surgical procedures, consideration of 
factors beyond analgesia having an impact on patient comfort is 
required.17,18 Each patient is an individual, and a simple procedure 
in the eyes of one patient may result in emotional distress in 
another.17 Formulation of the anesthesia plan and preoperative 
consultation should be individualized according to the patient’s 
physical health and psychological needs.17,18 Future research 
into the effect of local anesthesia and median nerve block with 
sedation on anxiety and satisfaction with BCTR could add 
valuable information for anesthesia providers caring for these 
patients.

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