Wide Awake Local Anesthesia No Tourniquet: An Alternative Approach to Carpal Tunnel Surgery

RESEARCH ANALYSIS

Wide Awake Local Anesthesia No Tourniquet: An Alternative Approach to Carpal Tunnel Surgery

John J. Czarnecki, BS

Sidney Kimmel Medical College at Thomas Jefferson University

SUMMARY POINTS

-       Wide Awake Local Anesthesia No Tourniquet (WALANT) is a technique used by orthopaedic hand surgeons to perform basic operations without the need for general anesthesia.

-       Compared to general anesthesia cases, WALANT patients spend less time in the hospital/surgical center which ultimately leads to a decrease in total medical costs.

-       The complication rate of WALANT compared to general anesthesia operations of carpal tunnel release (CTR) shows no increase in the rate of infection or necrosis, with a clinically insignificant difference in bleeding.

-       WALANT patients showed a decreased visual analog pain score and decreased usage of postoperative opioid injections with an inconclusive difference in postoperative opioid usage.

-       Due to a decrease in OR time and cost with no clinically significant increases in complications, WALANT procedures provide a way to increase the efficiency of CTR surgeries.

ANALYSIS

Background

Wide awake local anesthesia no tourniquet (WALANT) is a technique used by orthopaedic hand surgeons that combines local anesthesia with a vasoconstrictor to complete basic surgeries. The typical anesthetic used in WALANT is 1% lidocaine combined with 1:100,000 epinephrine (1). In a survey conducted in 2020, surgeons indicated that a median of 50% of carpal tunnel surgeries they completed were done using WALANT (2). Due to the high usage of the WALANT technique for hand surgery, it is important to understand the benefits and drawbacks of using WALANT compared to general anesthesia for carpal tunnel release (CTR). The goal of this analysis is to assess the potential benefits and drawbacks of using the WALANT technique for CTR, specifically related to efficiency, cost, complication rate, pain, and opioid usage postoperatively.

Findings

WALANT patients tend to have less time in the OR and PACU than general anesthesia patients, which leads to decreased medical costs. A study published by Okamura indicated an average operating room (OR) time for WALANT of 46 (5.7) minutes compared to 59.5 (6.8) minutes for intravenous regional anesthesia, demonstrating a decrease in OR times for WALANT even when compared to other local anesthesia techniques (3). Furthermore, Segal reported that WALANT leads to decreased time spent in the PACU and a decreased need for preoperative testing for anesthesia, which may include blood work, an EKG, or a chest radiograph (4). This decrease in time for WALANT patients implies greater procedural efficiency and a decrease in cost as well. The cost saved due to WALANT CTR surgeries was demonstrated in a study by Alter, who revealed a range of $1,320 to $1,613 saved throughout the entire episode of care for a WALANT CTR patient compared to a patient undergoing IV sedation (5). 

Table 1. Cost Comparison for Intravenous Sedation versus Wide-Awake Local Anesthesia. Reprinted from Alter TH, Warrender WJ, Liss FE, Ilyas AM. A Cost Analysis of Carpal Tunnel Release Surgery Performed Wide Awake versus under Sedation. Plast Reconstr Surg. Dec 2018;142(6):1532-1538. doi:10.1097/prs.0000000000004983

WALANT procedures tend to have similar complication rates compared to other anesthesia methods, which emphasizes their utility within CTR. A study published by Avoricani in 2021 demonstrated 0% 14-day and 0.37% 30-day surgical site infection rates for WALANT CTR procedures done in a minor procedural room under field sterility (6). This illustrates that, in addition to having low complication rates, WALANT surgeries do not require an OR, which could potentially lower costs even more. In addition to low infection rates, blood loss of wide-awake CTR procedures with and without a tourniquet demonstrated an estimated blood loss of 3.16 mL with a tourniquet and 4.25 mL without, which is not a clinically significant number. This demonstrates the effectiveness of WALANT at limiting blood loss (7). In addition, the concern for epinephrine-induced necrosis related to WALANT anesthesia is something that concerned the medical community. However, Denkler’s study reviewed medical databases between 1880 and 2000 and found zero instances of epinephrine-induced necrosis with the usage of lidocaine and epinephrine combined as an anesthesia product (8). As a result, this concern should not drive physicians to refrain from using WALANT for CTR.

The WALANT technique has also been demonstrated as being less painful for CTR compared to local anesthesia, with mixed results related to opioid usage postoperatively. Utilizing a visual analog score, Kang and Gunasagaran found that compared to general anesthesia (Kang only) and/or other local anesthesia patients (both Kang and Gunasagaran), WALANT patients had a lower visual analog score of pain (9).⁹Furthermore, Kang also found that 12% of WALANT patients required opioid injections postoperatively compared to 35% of general anesthesia patients, indicating a lower level of pain postoperatively (10). When comparing oral opioid usage postoperatively, Chapman concluded that gender and age were the more significant factors correlating to opioid usage than the technique of CTR (11). While Chapman found other variables to be more indicative, Davison found that “narcotics” were used by 66% of IV anesthesia CTR patients compared to 5% of WALANT patients (12). As a result, more research must be done to further investigate whether WALANT CTR has an impact on opioid usage postoperatively.

Figure 1. Postoperative analgesics. a Distribution of postoperative analgesic medications used by patients in the wide awake cohort. b Distribution of postoperative analgesic medications used by patients in the IV sedation cohort. Reprinted from Davison PG, Cobb T, Lalonde DH. The patient's perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). Mar 2013;8(1):47-53. doi:10.1007/s11552-012-9474-5

Discussion

Due to the decreased costs and OR time without increased pain or complication rates, WALANT can be a beneficial alternative to general anesthesia for carpal tunnel release procedures. While it may be beneficial for many, patients who have anxiety from being awake for a surgical operation may still consider general anesthesia instead of WALANT (12). As mentioned previously, the lack of significant complication rate differences between WALANT in a sterile procedural room compared to an OR indicates the ability for these operations to be done on a larger scale in lower resource areas of the world. In a 2020 study, Holoyda investigates the implementation of procedural rooms being utilized in Ghana to save money while allowing for surgical sterility (13). As physicians continue to adopt WALANT for smaller operations, they will be able to serve a broader patient population, regardless of economic background.

REFERENCES

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2.     Grandizio LC, Graham J, Klena JC. Current Trends in WALANT Surgery: A Survey of American Society for Surgery of the Hand Members. J Hand Surg Glob Online. Jul 2020;2(4):186-190. doi:10.1016/j.jhsg.2020.04.011

3.     Okamura A, Moraes VY, Fernandes M, Raduan-Neto J, Belloti JC. WALANT versus intravenous regional anesthesia for carpal tunnel syndrome: a randomized clinical trial. Sao Paulo Med J. 2021;139(6):576-578. doi:10.1590/1516-3180.2020.0583.R2.0904221

4.     Segal KR, Debasitis A, Koehler SM. Optimization of Carpal Tunnel Syndrome Using WALANT Method. J Clin Med. Jul 3 2022;11(13)doi:10.3390/jcm11133854

5.     Alter TH, Warrender WJ, Liss FE, Ilyas AM. A Cost Analysis of Carpal Tunnel Release Surgery Performed Wide Awake versus under Sedation. Plast Reconstr Surg. Dec 2018;142(6):1532-1538. doi:10.1097/prs.0000000000004983

6.     Avoricani A, Dar QA, Levy KH, Kurtzman JS, Koehler SM. WALANT Hand and Upper Extremity Procedures Performed With Minor Field Sterility Are Associated With Low Infection Rates. Plast Surg (Oakv). May 2022;30(2):122-129. doi:10.1177/22925503211003840

7.     Sasor SE, Cook JA, Duquette SP, et al. Tourniquet Use in Wide-Awake Carpal Tunnel Release. Hand (N Y). Jan 2020;15(1):59-63. doi:10.1177/1558944718787853

8.     Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. Jul 2001;108(1):114-24. doi:10.1097/00006534-200107000-00017

9.     Gunasagaran J, Sean ES, Shivdas S, Amir S, Ahmad TS. Perceived comfort during minor hand surgeries with wide awake local anaesthesia no tourniquet (WALANT) versus local anaesthesia (LA)/tourniquet. J Orthop Surg (Hong Kong). Sep-Dec 2017;25(3):2309499017739499. doi:10.1177/2309499017739499

10.  Kang SW, Park HM, Park JK, et al. Open cubital and carpal tunnel release using wide-awake technique: reduction of postoperative pain. J Pain Res. 2019;12:2725-2731. doi:10.2147/jpr.S210366

11.  Chapman T, Kim N, Maltenfort M, Ilyas AM. Prospective Evaluation of Opioid Consumption Following Carpal Tunnel Release Surgery. Hand (N Y). Jan 2017;12(1):39-42. doi:10.1177/1558944716646765

12.  Davison PG, Cobb T, Lalonde DH. The patient's perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). Mar 2013;8(1):47-53. doi:10.1007/s11552-012-9474-5

13.  Holoyda KA, Farhat B, Lalonde DH, et al. Creating an Outpatient, Local Anesthetic Hand Operating Room in a Resource-Constrained Ghanaian Hospital Builds Surgical Capacity and Financial Stability. Ann Plast Surg. Apr 2020;84(4):385-389. doi:10.1097/sap.0000000000002196