Doing carpal tunnels and cubital tunnels at the same time is simple. Start with a 30-gauge needle at the elbow and inject 5 cc's without moving the needle at all. Then 3 cc's just under the skin in the carpal tunnel without moving at all. If you alternate injecting between the carpal tunnel and the cubital tunnel, when you reinsert the needle, the patient doesn't feel anything at all. And the less you move the needle, the less likely they are to feel any other pain at all. So really, all they feel is the first poke in the elbow and the first poke in the hand. And then they never feel any of the needle reinsertions. I like to tumesce until I have at least 2 centimeters of visible and palpable local anesthesia anywhere that I'm going to dissect. We wait at least a half an hour before we cut. And while we're waiting, we operate on two or three other carpal tunnels that have been previously injected. Doing them in a minor procedure room and avoiding transposition has really simplified these operations and decreased the morbidity greatly. I stopped transposing in 2018 because the evidence showed that the results were no worse if you just decompressed it. And I found that to be true. If you don't transpose, you don't divide all these little sensory nerves that I now preserve to decrease morbidity. I also used to wait for nerve conduction studies to be positive before I would do ulnar nerve surgery. Often, that was too late. Now I do them much earlier, even if the nerve conduction studies are not positive. I go by symptoms because there's so little morbidity to doing these in a minor procedure room. There I am releasing the forearm fascia just over the nerve distally. And inside the forearm fascia, there's a little band right there that you sometimes see inside the muscle. So you need to check that. I think distally is more important than proximally. Proximally, there's almost never anything obstructing the nerve. And so you don't need giant incisions proximally. You don't need a giant incision distally. Just enough to get underneath that forearm fascia. And here I am showing that proximally, there's nothing when I spread my scissors. And I can even put my little finger up in there. And there are just no impingements proximally. Most of the action is actually at the forearm fascia level and in the cubital tunnel itself. So a short incision, a minor procedure room is nothing to add to a carpal tunnel if you have ulnar nerve symptoms.

carpal tunnel syndrome

cubital tunnel syndrome

minimal needle movement

nerve decompression

forearm fascia release