MODES OF ANESTHESIA

There are three high quality and six low quality studies that suggest local anesthesia alone can be used for carpal tunnel release. Three randomized controlled trials evaluated local anesthesia as compared to intravenous regional anesthesia (Nabhan 2011, Okamura 2021, Sorensen 2013). One study demonstrated decreased tourniquet time and OR time in the local anesthesia cohort with no differences in patient reported outcomes (Nabhan 2011). Another study demonstrated lower intraoperative and postoperative pain and analgesic use in the local anesthesia cohort (Okamura 2021). Sorensen et al, demonstrated that patients in the local anesthesia cohort reported less postoperative pain and analgesic use. Lower quality studies have demonstrated adequate and/or improved pain control in the local anesthetic cohort (Kang 2019), low or no increased risks of complications (Rellan 2021, Wellington 2021), and similar patient reported outcomes as compared to other anesthetic modalities (Tulipan 2017, Tulipan 2018).

Benefits/Harms of Implementation
There are potential benefits and harms associated with local anesthetic and intravenous regional anesthesia that should be discussed with patients. For example, local anesthetic may allow for flexibility in procedure location (e.g., office-based surgery) and ability to drive oneself home, however it may be anxiety provoking for some patients. A shared decision-making approach on the use of local only for surgery may be beneficial.

Cost Effectiveness/Resource Utilization
Cost effectiveness and resource utilization were not primary outcomes of this review, and costs and resource utilization vary based upon context, however in general, carpal tunnel release with local anesthetic results in lower costs and resource utilization compared to other forms of anesthesia (e.g., monitored anesthesia care) (Carr 2019, Kamal 2019).

Acceptability
Based on descriptions in the literature, local anesthesia has been adopted by surgeons and patients in multiple countries as an acceptable approach for carpal tunnel release.

Feasibility
Local anesthesia is readily available and feasible as it does not require any additional medications or changes to the surgical approach.

Future Research
Future investigation can focus on the development of tools to help understand patient preference and guide patients in understanding the benefits, risks, and costs associated with available anesthetic techniques. The financial advantages of local only anesthesia may be further explored in future cost effectiveness analyses.