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"Fat Pad" and "Little Finger Pulp" Signs Are Good Indicators of Proper Release of Carpal Tunnel.

To the Editor: We read with interest the article by Proubasta et al. (2). Several reviewers commented on various aspects of this study. However, we would like to offer further commentary on 2 points. The first point regards the photograph that illustrates the fat sign. The authors mention in the article that this fat sign is important, and to make sure to cut the most distal fibers of the transverse carpal ligament (TCL). Unfortunately, this fat is seen in the proximal part of the TCL in the photograph. The second point regards their evaluation of patients with carpal tunnel syndrome (CTS); little information is provided concerning the diagnosis of the patients. The authors do not mention how they selected their patients as surgical candidates for carpal ligament section. We wonder how many of their patients underwent magnetic resonance imaging (MRI) or magnetic resonance neurography of the wrist before surgery. We think that conventional electromyography and clinical evaluation are inadequate and inconvenient for comparison of the results of carpal tunnel surgery. Preoperative electromyographic findings only show the location of involvement but not the cause of this syndrome. CTS cases are a common disabling condition and generally result from the compression of the median nerve from different pathologies such as tenosinovitis, ganglion cyst, or excess muscle or fat in the carpal tunnel (1). Considering the hand’s function in one’s everyday life, we stress the importance of wrist MRI, although it is not as widely accepted as MRI of the spine or brain, for the evaluation of the patient with CTS. Wrist MRI and magnetic resonance neurography can easily be performed in any MRI unit, and they can show us both the location of the entrapment of the median nerve and the differential diagnosis of CTS. These techniques can also identify the cause of treatment failure. Without knowing the underlying cause of the syndrome in each case, comparing the results of carpal ligament section will lead us to misinterpret the results of the surgery. We have always focused on how we could minimize the incision and how we cut the carpal ligament totally. If we do not have wrist MRI and we do not know the underlying cause of the median nerve entrapment, we need to examine the nerve to see whether there is any other pathology causing this entrapment. If we are operating without the information from wrist MRI, a longer incision is needed for this procedure. The authors’ incision looks rather long, but they mention that they used a short palmar incision. Otherwise, during the follow-up period, we could not state that the patient’s complaints after surgery are due to incomplete release of the TCL. The authors also mention, as a limitation of their study, that they had no control group.