"Hole-in-one" local anesthesia for wide-awake carpal tunnel surgery.

Properly injected local anesthesia can be almost painless with attention to a few simple details that have been published in a previous Plastic and Reconstructive Surgery video1 (see Video 3, which demonstrates injection tips for “hole in one” local anesthesia, available in the Related Videos section of “The Safe Management of Anesthesia, Sedation, and Pain in Plastic Surgery” CME article in the October 2010 online issue of the Journal, at www.PRSJournal.com). The purpose of this new video is to provide simple instructions for almost pain-free carpal tunnel surgery in which there is no need for sedation or tourniquet. As can be seen in the video, all that the patient feels is one poke of pain (a hole in one) with a fine 27-gauge needle in the wrist, and then no pain at all for the rest of the local anesthetic injection and the operation (Figs. 1 through 4). Epinephrine2–4 injected with the lidocaine provides hemostasis and eliminates the need for a painful tourniquet. The technique is reproducible, as almost all medical students and residents who rotate through our service are able to achieve a “hole in one” in local anesthetic injection, as they are all scored by our patients, and must learn how to do this as part of their rotation. In Canada, more than 90 percent of carpal tunnel operations have moved to being performed with the surgeon as the only anesthesia provider with pure local anesthesia, or with the patient wide awake.5 In contrast, in the United States, the majority of carpal tunnel operations are still performed with a tourniquet and with sedation, blocks, or general anesthesia provided by a nurse anesthetist or anesthesiologist. One of the reasons for this is the commonly held feeling that “My patients need sedation.” When the sedation-free alternative is offered to patients in a positive manner, many if not most prefer this choice for several reasons. For the patient, no sedation means no postoperative nau-