Page 1 of 13

SAVE

RESET

EMAIL

PRINT

DATE Name: Address Telephone Occupation

ONE STOP WIDE AWAKE CARPAL TUNNEL DECOMPRESSION INTERACTIVE PATIENT CENTRIC DOCUMENTATION AND CONSENT FORM HARLEY STREET HAND CLINIC / / Date Of Birth : Email

Handedness

R/

L/

Ambidextrous

Step 1:
Watch OSWA Carpal Tunnel Information Video available on android, you tube & our websites

Step 2:

Fill Out This Interactive Carpal Tunnel Assessment Form Please tick if you have any of the following medical problems and give details of anything else you wish: Do you have any allergies?(if yes specify) If female- might you be pregnant? Are you diabetic? Do you have thyroid problems? Do you have any chest/heart problems? Do you have a bleeding disorder? Do you take anticoagulants? Other (please specify) Please list your current drugs

Tick and inform Mr Bismil if you take any of the following drugs: tricyclic and monoamine oxidase inhibitor antidepressants digoxin thyroid hormone (thyroxine) sympathomimetics (weight control or attention deficit disorders) stimulant drug abuse, eg, cocaine Page 2 of 13

Step 3: Hand Diagram- You Are Suitable For OSWA Care If Your Problem feels like this: If the problem feels different book a clinic appointment at Harley Street Hand Clinic

Tick here to confirm that your symptoms are like this

Step 4: Please fill out the Carpal Tunnel Questionnaire below The assessment centres upon a validated scoring system for carpal tunnel syndrome which has been published after peer review1,2 Question Has pain in the wrist woken you at night? Has tingling and numbness in your hand woken you during the night? Has tingling and numbness in your hand been more pronounced first thing in the morning? Do you have/perform any trick movements to make the tingling or numbness go from your hands? Do you have tingling or numbness in your little finger at any time? Has the tingling and numbness presented when you were reading a newspaper, steering a car or knitting? Do you have neck pain? Has the tingling and numbness in your hand been severe during pregnancy? Has wearing a splint on your wrist helped the tingling and numbness? TOTAL SCORE Yes +1 Yes +1 Yes +1 Yes +1 Yes 0 Yes +1 Yes -1 Yes +1 Yes +2 No -1 No 0 Score No 0 No 0 No 0 No 0 No +3 No 0 No 0 N/A 0 N/A 0

Page 3 of 13

If score 4 or less book a clinic appointment 00 44 7581 369 015, wear a splint to keep the wrist straight (in neutral) and commence these exercises

Figure 1 Cycle through these positions holding each for 3 seconds

Page 4 of 13

Figure 2 Cycle through these positions holding each for 3 seconds

Page 5 of 13

If score 5 or more continue with One Stop Wide Awake Pathway and sign and print here: I understand that the surgery offered is Limited Open Carpal Tunnel decompression3 I realise that there are three possible courses of treatment- exercise, surgery and injections. By continuing I confirm I have tried: o exercises o and also tried splinting the wrist in a neutral position eg. at night If I prefer an exercise approach I will advise Mr Bismil immediately I can contact Mr Bismil o who will facilitate this is if appropriate. I understand that the scientific logic of this pathway is that: o CTS is a clinical syndrome o It cannot be proven or disproven by tests such as nerve conduction studies o My own subjective assessment (completed above) and the surgeons confirmation of this and further clinical tests will add weight to the diagnosis of CTS which has been made above o I am proceeding because on balance I would like to consider surgical treatment o I understand at surgery the transverse carpal ligament is divided and the pressure on the nerve is relieved and therefore further damage to the nerve due to the CTS should be prevented o Before I attend for my OSWA care I will read the surgical consent form carefully and sign this form prior to surgery

Patient Signature Print Name Date

References For Carpal Tunnel Assessment And Patient Education 1. Kamath V, Stothard J. J Hand Surg Br. 2003 Oct;28(5):455-9. 2. Bridges MJ, Robertson DC, Chuck AJ. Hand Surg. 2011;16(1):39-42. 3. Crpar M, Ar M, Trker M, Ekiolu MF, Cetik O. Eklem Hastalik Cerrahisi. [The efficacy and safety of limited incision technique in carpal tunnel release]. [Article in Turkish] 2011;22(1):33-8.

Page 6 of 13

SURGEONS ASSESSMENT PAGE TO BE COMPLETED BY SURGEON AT OSWA Date: I have scrutinized the above document and the patient is suitable for OSWA carpal tunnel care. The patient complains of sensori-motor symptoms emanating from the median nerve in the form of pain tingling and numbness I have explained to the patient the only absolute contraindication is local anaesthetic allergy which is rare and on the basis of the patient history there are no concerns regarding this. Rather than true allergy patients are more likely to experience fainting or to react to adrenaline (either their own or administered- adrenaline is a beta-1 adrenergic agonist.). In our experience with wide awake hand surgery 15 years we have not encountered a patient who was confirmed to have local anaesthetic allergy. THE PATIENT DOES NOT GIVE A PAST HISTORY OF RELEVANT OR CONFOUNDING ALLERGY / CONTRAINDICATION TO WAHS

Sensory deficit median nerve CTS? Motor deficit median nerve CTS ? Tinels test Carpal Tunnel? Scratch collapse test Carpal? Biro test Carpal? Evidence of double crush?

RIGHT Yes / No Weakness APB/ Wasting APB/ Other (specify) Positive / negative Positive / negative Positive / negative Yes / No

LEFT Yes

/ No

Weakness APB/ Wasting APB/ Other (specify) Positive / negative Positive / negative Positive / negative Yes / No

ANY OTHER INFORMATION Eg. Nerve conduction studies performed/ results There is no clinical evidence of treatable or non-surgical problem such as pregnancy, hypothyroidism or diabetes.

Page 7 of 13

DIAGNOSIS Median nerve entrapment: site: carpal tunnel Severity left Mild /right /Moderate /bilateral / Severe

Diagnosis and risks versus benefits of treatment options fully discussed. I have explained to the patient that limited open wide awake carpal tunnel release is offered for moderate-severe CTS: a. clinically confirmed moderate-severe carpal tunnel syndrome (tick) b. with objective evidence of neurological dysfunction of all three components of nerve dysfunction: a. Motor i. thenar weakness and/or ii. thenar wasting (tick) b. Sensory (objective sensory deficit) (tick) c. Autonomic (biro test) (tick) I have discussed with the patient the management plan including any staged treatment (specify) Injection and exercise treatment has been offered as an alternative if CTS is mild or if the patient on the balance of pros and cons and risks and benefits wishes to avoid surgery in the first instance and understands the pros and cons and risks and benefits of injection detailed overleaf. Overall, I have explained to the patient that with limited open carpal tunnel decompression: [ ]s carpal tunnel syndrome has [ 90% ] 5% ] % riskof chance of significant improvement versus a [ worsening after surgery and the balance as no improvement.

Name:

Signature Of Surgeon

Date

MR QMK BISMIL

Page 8 of 13

Name: Corticosteroid Injection Information Side Effects of Corticosteroid Injectionto be minimised by using minimum effective dose Local side effects: 1. pain flare post-injection 10-20% range, (controlled with simple analgesia and activity modification) 2. Skin/fat changes a. the skin can change colour or the fatty tissue may atrophy 4% 3. Less common local side effects (around 1% level or less) for significant problems: a. Bruising/bleeding- usually minor b. Steroid chalk-paste- as it sounds; not harmful as far as we are aware c. Soft-tissue calcification- as it sounds; not normally painful or problematic d. Steroid arthropathy- inflammation and wear of joints due to steroid. A study by Roberts et al published in the Journal of Rheumatology in 1996 concluded that corticosteroid injection in rheumatoid arthritis does not increase the rate of joint replacement. As at 2013, there is little good quality convincing evidence that steroid causes significant arthritis in joints. 4. Tendon rupture and atrophy- uncommon, well below 1%; doctors should not inject directly into tendons. 5. Delayed healing of soft-tissues- doctors will not routinely use these injections in acute injuries 6. Infection- very low risk with aseptic technique- summary of published literature 1/17000 range 7. Rare local side effects (significantly less than 1%) such as nerve injury, blood vessel injury or needle fracture Systemic Side Effects (significant side effects 1 % level or less unless specified)to be minimised by doctor using minimum effective dose of corticosteroid Cushings syndrome is the medical term applied to how the body will respond to systemic high levels of cortisol/corticosteroid. It is very rare for a minimum effective dose local corticosteroid injection to cause this syndrome, and because of the small doses injected locally this should be a transient problem. On the basis of a literature search as at 2013: the possibility of local minimum effective dose musculoskeletal corticosteroid injection, used sparingly, causing significant and long-lasting systemic effects is very low- in the 0.1% region or less. Rare systemic side effects- 0.1% region or less (on the basis of Pubmed search): Analphylaxis/ Cataracts/ Complex Regional Pain Syndrome /Myopathy /Pancreatitis/ Psychosis Patient To Sign And Date Here If They Wish To Proceed With Injection Treatment For CTS Before Any Surgical Treatment Signature Of Patient Countersign By Surgeon Date Page 9 of 13

PATIENT AGREEMENT TO LIMITED OPEN CARPAL TUNNEL DECOMPRESSION Date: Name: Date Of Birth CARPAL TUNNEL DECOMPRESSION RIGHT LEFT STATEMENT OF WIDE AWAKE HAND SURGEON AND PATIENT: The Wide Awake Hand Surgeon has explained the risks and cons and potential pros and benefits of the procedure to the patient as above and below; and the patient has signed above and below to enter into this care contract with the treating surgeon. The intended benefits: To relieve entrapment of the median nerve in the carpal tunnel. To improve/reduce the symptoms of your carpal tunnel syndrome. Improve the function of your hand as much as possible. Serious or frequently occurring risks:
1

NAME OF PROCEDURE

If the median nerve has been compressed for a long time some of the nerve fibres may have been severely damaged and hence there will be either partial recovery or possibly no recovery. It may take several months for the nerve to make the optimal recovery. There is a 1-2% chance of established infection. The scar may be painful for several months in some patients depending on how the body reacts to surgery. The most severe form of scarring is a keloid scar which is a possibility after this or any surgery. Furthermore there is a 48-7%2 chance of pain due to the division of the deep tissue (pillar pain) ; which should improve with time and rehabilitation (exercise) but may be permanent. There is a 5-10% chance of short-medium term recurrence (condition coming back); which is a separate issue from failure of an already damaged nerve to return to normal (see above) There is a less than 1% chance of nerve damage, tendon damage, bleeding or damage to any local structures. In addition to the complications above there are other possible complications which are not common (less than 1%) in one stop wide awake carpal tunnel practice1 e.g. Complex Regional Pain Syndrome Page 10 of 13

And other reported complications3 of carpal tunnel surgery include neuroma of the palmar cutaneous branch of the median nerve, hypertrophic scars, dysaesthesias, joint stiffness, failure to relieve symptoms and neuromas of the dorsal sensory branch of the radial nerve.

There is an inherent risk to all surgical treatment. The patient has been advised preoperatively and agreed to watch the OSWA Carpal Tunnel Video visit the service website for a detailed consideration of pros and cons and risks and benefits of this operation. In addition to the specific and most relevant risks detailed on this document the consultant has given the patient individualised specialist advice concerning treatment of their condition; and by signing this form the patient declares that they wish to proceed with surgery on the basis of their perception of the balance of pros and cons and risks and benefits in their case. Anonymised digital photographs and/or video of your hands are routinely taken for clinical and educations purposes if this is not acceptable please inform the doctor and tick this box 1. Bismil M, Bismil Q, Harding D, Harris P, Lamyman E, Sansby L. Transition to total one-stop wide-awake hand surgery service-audit: a retrospective review. JRSM Short Rep. 2012 Apr;3(4):23. Epub 2012 Apr 16. 2. Yung PS, Hung LK, Tong CW, Ho PC. Carpal tunnel release with a limited palmar incision: clinical results and pillar pain at 18 months follow-up. Hand Surg. 2005 Jul;10(1):29-35. 3. Louis DS, Greene TL, Noellert RC. Complications of carpal tunnel surgery. J Neurosurg. 1985 Mar;62(3):352-6. We have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment, injections and exercise) and any particular concerns of those involved. The patient has completed their stepwise self-assessment document Signed: Date: STATEMENT OF PATIENT: I agree to the procedure described above. I understand that there is no guarantee of recovery and that reasonable complications may occur. I understand that the procedure will involve local anaesthesia. Signed: Name Of Patient (PRINT): Date: Page 11 of 13 MR QMK BISMIL Consultant Orthopaedic Surgeon

Name: OPERATION NOTE Date of Surgery / /

Operating Surgeon Signed: MR QMK BISMIL

Mr

QMK Bismil

Standard Technique As Follows For OSWA Limited Open Carpal Tunnel Decompression Wide Awake Anaesthesia with 5ml 2% Xylocaine with low dose 1:200 000 adrenaline Curvilinear incision over carpal tunnel Sharp and blunt dissection to site of entrapment Nerve released in tunnel No intraoperative complications unless specified below, anyspecific relevant findings also documented here: Non-dissolving interrupted skin sutures, mepore dressing, wool & crepe. POST-OPERATIVE REGIMEN 1. Elevate/ sling 72 Hours 2. Reduce Dressings After 3 Days 3. Post-operative exercises and return to activity explained 4. Removal of sutures 10-14 days Page 12 of 13

DISCHARGE DOCUMENTATION PROVIDED TO PATIENT PATIENT SHOULD FORWARD TO GENERAL PRACTITIONER Harley Street Hand Clinic Queen Anne Street Medical Centre Wide Awake Hand Surgery 18-22 Queen Anne St, London W1G 8HU Patient Details Name:

Dear Doctor Date / /

Your patient had wide awake hand surgery today in the form of carpal tunnel decompression. The surgery proceeded uneventfully and the median nerve entrapment was relieved. The post-operative regimen is as follows: POST-OPERATIVE REGIMEN 1. Elevate/ sling 72 Hours 2. Reduce Dressings After 3 Days 3. Post-operative exercises and return to activity explained 4. Removal of sutures 10-14 days Specific Requests

Yours sincerely,

Quamar MK Bismil MBChB(Hons) MRCS DipSEM MFSEM DMSMed FRCSEd(Tr and Orth) advice@quamar.biz 07581 369 015

Page 13 of 13